99080065 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDKNFIFICATION
BUILDINGAItlPRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
7141 i kA-q1oLy.e_r- WAV C LA_ 'i ;
OWNER'S NAME: PHONE: I CONTRACT'OR'S NAME: NO:
49 L g n \ , CNIC CONTROL x
RCI HTECT/ENGINEER: IC No ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ 1" ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
(Can't ditfI Ism 1 am licensed holeorder provisions.(.Cadres an(commencing JOB DESCRIPTION
X00 with Section 70W)ect. inn 3ofthe Business end Yofessions Cade,and myliccnx is RESIDENTIAL:
O PERMIT ISSUANCE
m u Li en farce and effect.
IY F GSFDWI. El KITCHEN REMODEL
aUzU License Class Com APPLIANCES-RI!SIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
atI10. D91e Conlmclar
ARCHITECTSPANELS DECLARATION ❑MULTI-UNIT El STRUCTURAL,
Z O nZ I understand my plans shall W used as public records MODIFICATIONOZ—o UP'I'02W AMPS El INTERIOR DCHIMNEY REPAIR
t,1_1 1 Licensed Professional 2BI-I00DAMPS IMPROVEMENT E]SWIMMING POOLS
9 Fc� OWNHII-BUILDER DECLARATIONCacwpyhg III(IBAMPS D BATH RI?MOD.UREPAIR D DEMOLITI
rCa C4 re I heathy affirm th91 I um cxempl frons the Contractor's Llwnsc Law rte the
X 3 LL F fallowing reason.(Section 7131.5,Business and Pmficaorns Codd Any city or county SIGNS ELF.CTRICAI. - D OTHER O
which requires a permit w cnnnwn,alter,improve,demolish,or rtpair any mmcmre
FEOt3 prior to its issuance,also requires the applicant for such Permit to file a signed statement SPECIAL CIRCUIT/MISC. 9�T rUkb
} that he is licensed pursuant n the provisions of the Contractor's License Law(Chapter 9
al QO (canteen leg with Section 7").f Division Sof lite Bminessrmd Professions Code)nr 'TEMP.METER OR POLE INST. JF COMMERCIAL:
11❑y o y that Int is exempt therefrom and the bnsis far the alleged exemption,Any violation of D NEW BLDG/ADDITION D DEMOLITION
Section 70315 applicant by any applicant far a permit subjects the applicano a civil penalty of POWER DEVICES DTENANT [IFOOD SERVICE
FSCnot mare limn five hundred rhdlam(8500). IMPROVEMENT
I,aaowacrOf the propcdy,or my employees with wagcsas ani"we comfamosa er. SWIMMING POOL I1LEMIC
F will do the work,and the structure is not intended oroRered forsale(Sm.71)44,Business DOTHER
3 and Professions Code:The Conbanors License Law does nm apply to an owner of OUTLITS-SW ITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or though
his own employees,provided Thal such improvements we not intended or offered for NEW RESIDENTIAL ELECTR SQ IT.
sale.If,however,the building or improvement is sold within one year of completion.the .FT.
av
nes-builder,will he the burden of poring that he did not Wild or improve for par-
D1,p cto w'sale.l. 7AUG
as owner of the property,am exclusively contracting with licensed comradom wTOTAL:
nstram the project(Sec.70,14,Business amt Professions Gdc:)The Coatrooms',L- 0 ���
come Low, m does not apply an owner of property who builds or improves thereon,and QTY PLUMBING PERMIT' FEE
whocontracts for such projects with a conlractons)licensed pursuant la the Conlmemr's '
License Law, PERMIT ISSUANCE
D 1 am exempt under See B&P C for this reason
Pi " AI.TRR-DRAIN&VENT-WATER TA) " VALUATION
Own Dnw_ J
WORKER'S OMPENSA'II )ECLARAPON - BACK FLOW PROTECE DEVICE
I hereby affirm under pe ally of perjury one of the following doela rations:
I have and will maintain a Certificate of Consenttovelf-insure for Workers Comped- DRAINS-FLOOR.RODE AREA,COND.
kscion,as provided!for by Section 37M of the Labor Code,for the performance of the STORIES TYPE CONSTRUCTION
work for which this p mot is issued. FIX'fIJRES-PER TRAP
D I have and will maintain Worker's COmpanscdon Insumnw,us rcyuircd by Sort a
3700ofthe Labor Code.for the Performance of the workforvIdelnhis permit is issued. OAS-EA.SYSTEM-I INC.4 OUTLETS DCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number we: ��� 'VO�
Cartier Pad P No.: GAS-EA.SYSTEMOVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMP17NSATION INSURANCE GRI!ASE/INDUSTRL WASTE INTERCEPTOR
(Thi ,.,cion need net be completed 11 the permit is rnrrnm hundred dollars(S LIN)) BUILDING DIVISION FEES
or less.) GRP.ASETRAP PLANCHECK FEE '
Loy any thin inlhe any wromero theas
work for subjech t to permitWrker'Contion-ssued,I but[ SEWER-SANITARY-STORM EA.200 FT.
not employ any penun in any manner to as m become subject the Wnrkcrs'COmpcn- ENERGY FEE
C)Z cation Laws of California.Date WATER HEATER WNFTT/ELECTR
7 C) Applicant I GRADING FF,13
q r� NOTICED APPLICANT.If alter asking thls Certificate of facloplow,You should WA'1'HR SYSTEM/TREATING
FFa�I become salyen to the Workers Compensation provisions of the Lahor Code,you must SOILS FEE
forthwith comply with such provisions or this Permit shall be deented revoked. WATERSERVICE
Cl.
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.17 PAID
L) 0 T hereby wifrm that them iso constmetionlendingagency for the performeacrof Date Receipt#
4L the work fur which this permit is Issued(Sec.3097,Civ.C)
Q h Lenders Name TOTAL:
U Lenders Address TOTAL:
Fy I codify that l have read this application and store that the above information is BUILDING FEE
ti fA correct.l agree to comply with all city and county ordinances and state laws relining to QTY MECHANICAL PERMIT FEE
V Z building contraction,and hereby authorize representatives of this city In enter upon the SEI SMIC IEE
alave-mentional property Far im,ml on purposes. -
(Wo)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
liabililiesjudgments.costs andexpenses which may in anywayaceme agadwasaid City AM ER OR ADD TO MECH.
in consequence of fee granting of this permit. PLUMBING FEE
APPLICANT UNDERST DS AND WILL COMPLY WITH ALL NON-MINT AIR HANDLING UNIT('r01 l.isaf PM)
JRCF.REGULATIONS MECHANICAL FEE
^ Ow S Alit I IANDLING UNIT(OVER I II,0(m CFM) CONSTRUCTION TAX
gnaw Of p,, a Com no Dore EXHAUST HOOU(W/DUCf) HOUSING MITIGATION FEE
HAZA OUS MATERIALS DISCLOSURE
Will the applicant or!mare building receptor score or handle hazardous mmerial ((EATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Smtinn 25532(a)7 HHATING UNIT(OVER 100,000 If GH
El Yet VNn PAID VENTILATION FAN(SINGLE RESID)
Dale Racipl x
Will the air emeer orfuta a Wilding bee he ard Bay useequipmentvice which BOILER-COMP IMP OR 100.0(10 BTU)
tit hamrdons sir contaminanu a de0ncd by the Bay Arta Ail Quality Menegcmcnl TOIA
isvid7 HotLER-COMP(OVER IW,MOBTU)
❑Yes �t No
Ihevc rw0 the hazardous materials requirements under Chapter 695 of the Cali AIR CONDITIONER ISSUANCE TE
Forms Health&Safety C ,Sections 25505,25533 and MM.I worprond that if the NEW RESIDENTIAL.MECH. SQ.FT.
ingdoesnotcumently aveatonant Natiiismymsponsibiliiymm0fythemcupant
fN ireme which tso pe me leu ' -ua of a Cedmfcnteaf Me ancy.
1
Ck
vanereat in
agem pat TOTAL: ISSUED BY:
OFFICE