991201431
1
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY q e4- / 2 0/ q,?,
CITY OF CUPERTINO BUILDING - ELECTRICALERMIT
i" BUILDING DIVISION APPLICATIONIPERMIT PLUMBING - MECHANICAL.
' I BUILDING PROJECT IDENTIFICATION
NO.,p
S00ot � ��T'T7
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BUILDINGADDRESS:
!9333 tlA 1-60 oa+v,Atway GerrPAQ este-e
&— do 3
SANITARY NO.
APPLICATION SUBMITTAL DATE
2_z�_gp
OW R'SNAMU PHONE
7MA �AI�7EYL
/CjpNTRACTOR'S NAME: LIC NO:
//��� /'1�M 61`6-_7.00
NIC
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CONTROLk
R HITECT/ENG PER LIC NO:
oX�a� GS yo 3
ADDRESS : 40*07l
e3eyL.yd8B6Woo0 Ao, tum
'ONTACT: PHONE:
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECT PLUMB MRECCHH/
❑ ❑ ❑ L
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I .m licensed under provisions of Chapter 9 (commencing
wilM1 Sedinn9(g10)nf DivisionJof theBminesa and Pmfessions Code; and my license is
in full force and effect. -26 LiaN 616 7 8
License Class
Date Con
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
❑ SFDWL EI KITCHEN REMODEL
❑ADDITION ❑PLUMBING RE -PIPE
El MULTI -UNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR El CHIMNEY REPAIR
IMPROVEMENT []SWIMMING POOLS
❑ BATH REMODFUREPAIR ❑ DEMOLITION
11 OTHER
PERMITISSUANCE
APPLIANCES—RESIDENTIAL
DECLARATION
DELL
AR hall be used
I understand my plans shall be used as public records
PANELS
-
UP TO 200 AMPS
Licensed Professional
• OWNER -BUILDER m the Continuum's
1 hereby affirm thin I am exempt from the Contractor's License Law recent
following reason. (Section 90315, Business and Professions Cade: Any city or county
which requires u permit m comumm, alter, improve, demolish, or repair any structure
poor to its issuance,.!,. requires thcappliciat for such permit to file. signed dempeem
that be is licensed pursuant to the provisions of the Contmemrs License Law (Chapter 9
(commencing with Section 9000) of Division 3 ofthe Bminessand Pmfersima Cede)or
thin he is exempt therefrom and the basis far the alleged exemption. Any violation al'
Section 90315 by any applicant for a permit subjects the applicant to a civil penalty of
not mere than five hundred dollars(S50AT
❑I, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the stmcmm Is not attended or offered for sale (Sec. 9044, Business
and Professions Code: The Cmarpvtor. License Law does not apply to as owner of
property who builds or improves thereon, and who does 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 winds one year ofcampletion,the
owner-huilder will have the burden of proving that he did not build or improve for pur-
pose of sale.).
❑ I, as owner of the properly, am exclusively contracting with licensed contracmm to
construct the project (Sec. 7044, Business and Professions Ced J The Contractor's Li-
use Law does not apply to an owner of properly who builds or improves thereon, and
who contracts for such pr jests with a roc metor(s) licensed pursuance the Contractor's
License Law.
FlTam exempt under See, , B & P C for this meson
201-I00IIAMPS
OVER IOW AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUITIMISC.
TEMP. METER OR POLE INST.
COMMERCIAL,
❑NEW BLDG/ADDITION ❑DEMOLITION
ANT ❑ FOOD SERVICE
PROVEMENT
THER
Q
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS — SWITCHES— FIXTURES -
NEW RESIDENTIAL ELECTS SQ FT.
S .FT.FLOOR AREA
-
-
S/SQ. FT.
TOTAL:
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER —DRAIN & VENT— WATER (EA)
Owner Dam
VALUATION
7 (mss O
V
WORKER'S COMPENSATION DECLARATION
T hereby off under penalty of e orrjuryoncofthefollre for orker' Co
(have and will maintain. Certificate of Consent In self -insure for Worker's Confirm-
cion, as provided for by Section 3900 of the Labor Code, for the performance of On
work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as required by Section
3900.Rhe Labor Code, for the performance of the work for which this permit is issued.
My Wor en's Com��eensationlnsuranSG conformal Pali $�y� r
Grie /M!'IIL�Y. e0a rsoicy No�kw&',7903.#
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCEGREASE/INDUSTRL
(Thissection need not be completed ifne permit is future hundred dollars (51FOR
Thr less.)GREASE
I really that the perfurmanceofthe weakforwhi.h this permit is issued, l shall
not overlay any person in any manner ac as m become subject to the Workers' Compen-
cation Laws of Califomia, Dam
Applicant l
BACK FLOW PROTECT. DEVICEJ
DRAINS — PLOOR, ROOF, ARCA, GOND.
STORIES'TYPE
CONSTRUCTION
FIXTURES — PER TRAP
GAS—G. SYSTEM -I INC. 4 OUTLETS
OCC. GROUP
AP[� O
O �.
I GAS- EA. SYSTEM -OVER 4FA)
WASTE INTERCEPTOR
BUILDING DIVISION FEES
y'RAP
PLANCHECK FEE.
SEWER — SANITARY — STORM EA. 2001T.
ENERGY FEE
WATER HEATER W/VENT/ELECTR
GRADING FEE
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
subject 1. the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions at this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a constmction lending agency for the performance of
the work for which this permit is issued (Sec. 3099, Civ. C.)
Lenders Name
WATER SYSTEM/TREATING
WATER SERVICE
SOILS FEE
PAID
Dam Receipt#
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
Leaders Address
TOTAL:
BUILDING FEE;
1 certify that I have read this application sad state that the above information is
cornier. [agree to Comply with all city and county ordinances and state laws relating to
building consumption. and hereby authorize representatives ofthis city to enter again the
dince-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities,judgments, costs and expenses which may in any way accme against said City
in .... egamen of the granting citrus permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1, NON -POINT
SO kCBll _ REGULATIO d5.
i1r-t8-99
QTY. MECHANICAL PERMIT FEE
$FPIMIC FEE'-- \�
PERMIT ISSUANCE
t �.
ELECT
LUM E f' If IZIJ,4
ALTERORADDTOMECH.
AIR HANDLING UNIT ('1'O IO.OW CPM)
M�J ECHANICAL PLG
CONSTRIICrION TA%
IV
AIR HANDLING UNIT (OVER 10,000 CFM)
4A/�/I(,oyKA✓,
Signature of Applicantonto rV Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or rut.. building occupantstereor handle Inverters material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(.)7
❑Yes ❑No
Will then applicant or future building occupant use equipment or devices which
pp g oo pan a Air
mit rnzallous air comaminanre as defined by the Bay Area Air Quality Management
memct7
❑Yes ❑N0
Ihave mail the hazmdeusmaterialsreyuirementsunder Chapter 6.95 of the Cali-
Terms Health & Safery Code, Sections 25505, 25533 and 25534. 1 understand That if the
building it. not curently have. tenant, thin it is my responsibility m sonify the eacupant
of the rx,mumnents which most be met gado,to issuance of. Certificen of Occupancy.
EXHAUST HOLD(W/DUCT)
HOUSING MITIGATION FEE
HEATING UNIT (TO 100.000 BTU)
HEATING UNIT (OVER I0Q000 BTU)-
-
PAID --
Date ReceipJTMAU
VENTILATION FAN (SINGLE RESID)
BOILER— COMP (3HP OR 100,000 BTU)
,
BOILER—COMP (OVER IOLO(s) RTU)
AIR CONDITIONER
-
ISSUAN ED
2. e 2 9
ISSUED BY:
NEW RESIDENTIAL MECH. SQ. FT.
r
- TOTAL:
Owner or authorized agent Date
OFFICE