99090006Aavl_ICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY -�]'/ CI V —1. O V D iii
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMIT NO.
BVIILDINGADDRESS:
1035 T"D u/A
SANITARY NO.
APPLICATION SUBMITTAL DATE
7-6 , ? F
OWNER'S NAME: D #Z A PHONE:!
v
C NTRACTOR'S NAME: QN� LIC NO:
J
NIC
❑
CONTROL M
RCHITECT/ENGINEER: LIC NO'.
ADDRESS
/ E u6 C mP
CONTACT: PHONE:
BUILDING PERMIT INFO
r
❑anFees Consultant FPaid by Apple ant (Initial)
BL❑DO ELECT PLU❑MB SUCH
LICENSED CONTRACTOR'S DECLARATION
I hemby affirm that I am licensed under provisions of Comm, 9 (commencing
QTY, ELECTRIC PERMIT FEE
_
JOB DESCRIPTION
PERMIT ISSUANCE
with Seetion 9000) of Dlvision3 ofthe Business and Professions Code, and my license is
in full force and eIf ac I
License LicH 7
Date Contractor -
ARCHITECT'S DECLARATION
I understand my plans shall be, used as public records
DENTIAL
RESIDENTIAL
❑ADWL [I KITCHEN RF -PIPE
❑ADDITION EJ PLUMBING RB -PIPE
[I MULTI -UNIT El STRUCTURAL
MODIFICATION
[D INTERIOR )�HIMNEY REPAIR
IMPROVEMENT (] SWIMMING POOLS
APPLIANCES -RESIDENTIAL
PANELS
UP T0200AMPSI
Licensed Professional
201-IOWAMPS
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law fur the
following reason. (Section 7031j, Business and Professions Code: Any city or county
[Ill REMODEL/REPAIR ❑DEMOLITION
[]OTHER
OVER 1000 AMPS
SIGNS ELECTRICAL
which require,. permit to construct, idler Improve, demolish, m repair any stmaure
SPECIAL CIRCUIT/MISC.
prior to its issuance, also requires the applicant for such permit o file a signed statement
that he is licensed pursuant to the provisions of the Contractees License Law (Chapter9
H
(commencing with Section TIDO) of Division 3 of the Business and Professions Come) or
TEMP. METER OR POLE INST.
COMMERCIAL:
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
❑ NEW BLDG/ADDITION ❑ DEMOLITION
Section 0831.5 by any applicant for a permit subjects the applicant to a civil penalty of
POWER DEVICES
El TENANT ❑ FOOD SERVICE
not more than five hundred della,, ($500).
01, as owner of the property, or my employees with wages astheir sole compensation,
call I do the work, and the structure is not Imended or uffemd for sale (Sec. 0044. Business
IMPROVEMENT
❑ OTHER
SWIMMING POOL ELECTRIC
and Professions Code: The Contractors License Law does not apply to an owner of
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTIAL ELECTR SQ IT.
property who builds or improves thereon, and who docs such work himself or through
his own employees, provided that such improvements are not intended or offered for
sale. If, however, the building or improvement is sold within one yea ofcorpletien.the
SQ. FT. FLOOR AREA
$/SQ. FT.
caner -builder will have the burden of proving that he did not build or improve for pen,
pose of sale.).
❑ 1, es owner of the property, am exclusively contracting with licemed contractors to
TO'
construct the project (Sec. 7044, Business and Professions Code.) The Contractor's Li-
venseLawdoesnotapplynsanocano, of proper, who bonds or improve, thereon, end
QTY. PLUMBING PERMIT FEE
who contracts for such projects with a nontrachons) licensed pursuant to the Cismair as
PERMIT ISSUANCE
License Law.
lamexemptandet Sec. ,B&PCfrrtu,reason
Owner
ALTER - DRAIN & VENT - WATER (
VALUATION
pa��9I dV
too[ o
WORKERS COMPENSATION DECLARATION
BACK FLOW PROTECT DEVICEI
I hereby affirm under penalty of perjury one of the following declarations:
f i
(have and will maintain eCertifmate of Conserv to self -insure for Workers Compen-
sation, as provided for by Section 3900 of the Labor Code, for the Performance of the
w rk forwbichthi,permitisismed.
DRAINS- FLOOR, ROOF, AREA, COND.
STORIES
-
/
TYPE CONSTRUCTION
FIXTURES - PER TRAP
I have and will maintain Worker's Compensation Insurance, as required by Suiien
9 ofthe Labor Craft, for the performance ofthe work for which this permit is issued
My Worker', Compo ,stern lry� ace ' r and Policy rom oraiwre.�- 1
Cartier. /IIID �FA %a�(GK Policy No.iJa.(p�+w
OCC.GROUP -�
,APN
O
GAS-EA.SYSTEM-IINC.40UTLETS
GAS -EA. gVSTEM-OVER4(G)
GREASF/INDUSTRL WASTE INTERCEPTOR
C TIFIC O OF EXEMPTION FROM R fiRS'
COMPENSATION INSURANCE
'
BUILDING DIVfSi FBS$
(This sectionneed nmbecomplemdifthepumhls foronehundreddollms($100)
or Ices)
GREASETRAP
PLANCHECK PEfi
I certify Natio rhe performance ofthe work for which this permit is issued, l shall
not employ any person in any manner an se to become subject m the Workers' Compen-
SEWER -SANITARY -STORM EA. 200 FT
ENERGY FEE
WATER HEATER WNENT/MEM
GRADING FEE
scram laws of California. Date
Applicant
NOTICE TO APPLICANT If, after making this Certificate of Exemption, you should
become subject co Ne Worker', Compensation provisions of the Labor Cade, you most
WATER SYSMIATIREATING
SOILS FEE
fordwithcomFly with such provisions or this permit shall be deemed revolocal .
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ. PT.
CONSTRUCTION LENDING AGENCY
I hereby affirm that hem is a construction lending agency for the performanceof
P
D t
the work for which this permh is issued (See. 3099, Civ. C)
Lender's Name
TOTAL:
TOTAL.
Lenders Address
B 1 G�P
1999
I certify Nat I have read this application and state that the above information is
comet. I agree to comply with all city and county ordinances and state laws coming to
building construction. and hereby amhorize representatives ofthis city to enter upon the
QTY. MECHANICAL PERMIT FEE
SE With FEE
PERMIT ISSUANCE.
BL TIC PEE
above-mentioned property for inspection purposes.
(We) agree to ,ave, indemnify and keep harmless the City of Cupertino against
ALTER ORADD TO MECH.
PL
liabilities,judgments, costs and expenses which may in any way accrue against said City
in consequence of the gramim, of this permit.
AIR HANDLING UNITOD 10,000CFM)
MECHANICAL FE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SDEREGUI TfONS.
AIR HANDLING UNIT (OVER IB.OUII CFM).
CONSTRU TA
IO
Fi /-rA-�.CONQ� /, L_L!_
EXHAUST HOOD (W/DUCT)
HOUSING MITI G ION FEE
Signature Coutmcmr DamI
HAZARDOUS MATERIALS DISCLOSURE
SquestrRV�1
HEATING UNIT (TO 100,000 BTU)
lo;%f
Ith pplicanl or future building occupam store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Cole, Section 25532(x)9
HEATING UNIT (OVER 100,000 BI Of
VENTILATION FAN (SINGLE RESID)
E] Yea 7 N
PAID "-
Date Receip
BOILER -COMP(3HPOR 100.000131U)
Will the applicant or future building occupant use equipment er devices which
it huxaMous air contaminants as defined by the Bay Area Air Quality Management
TUT
BOILER -COMP (OVER 1 W.OW BI
im,iml
❑Yes ❑Nc
AIR CONDITIONER
1 have read the hazardous materials requiremenu under Chapter 695 of the Cali-
understand that if the
fomes Health &Surety Cady Sections 25585, 255]3 and 'a
ISSUANCE DA'L'E_ ,x
O i/ Y
NEW RESIDENTIAL MECH. SQ. FT.
building not curently have ate n4 that it is my res@msibllilymnotify the occupant
cfthere mens which nmsl tprior to is,umce oiaCertifcate of Occupancy.
a/ v.
TOTAL:
Owner r nt D e
ISSUED BY,
OFFICE