99090151 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE MI
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIF'IC'ATION
BUILDING ADDRESS SANITARYNO. APPLICATION SUBMITTAL GATT
IL9A3 wvc',dar cc
NER;S NAME 1'NONE: -IRACTOR:S NAME: LIC NO:
QFC �t �� _ t U NIC CONTROLp
A RCH I I ECI IENGINEER; LIC NO: ADDRES ❑
rOrv'rnCi: ruoNla: BUILDING PERMIT INFO
0e ❑ Consultant Fees Paid by Applicant(Initial) 11L❑DG ELECT PLUMB M[❑C1i
5
LICENSED CONTRACTOR:S DECLARATION QTY. ELECTRIC PERMIT FEE L�
1 hereby affim,that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
MSOZO with Section llNN))of Division B atom Business and Professiotvs Code,and my llccnse is P[RMI'T ISSUANCE RESIDENTIAL
FW_ in full form and effect. ❑SFDWL ❑KITCHEN REMODEL
QUU Lian¢Clas Lic.x APPLIANCES-RESIDENTIAL []ADDITIONUMBING RE-PIPE
N Q W Did Contractor
ARCHITECTS DECLARATION ❑MULTIUNIT E3 STRUCTURAL
Z p y Z 1 understand my plans shall be used as public records PANELS MODIFICATION
OZ=-Z UP 10200 AMPS [I INTERIOR [:1 CHIMN17Y REPAIR
F4tW Licensed Profcesional 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER DHCLARA'HON OVER IIM1U AMPS ❑HATH RFMODF,L/REPAIR ❑DEMOLITION
^yy^C C Q I hcrcby nfiinn that 1 nm exempt timn No CunlmamLr License,
Lvw for the
k3CU fnllowin (Section 903L5.Businces mud l'n,fissions GWc:An I t ❑OTfililt
g rea.on.(, y city art cowl Y SIGNS FLEC'IRICAL
W a Wm which rcaleams o permit to construct..Imr,improve,demolish,or repair any swcmre
�� prior to its ismuncc.also reg^ire,lbcupplica^t lin.uch permiloefile a signed swmmem SPECIAL CIRCUIT/MISC.
Eby that he is licensed punuamto the provisions of the Contractor'¢License Law(Chapter 9
W yrQ,C> (eommencing with Section 7MUof Division Jofthe Bmire,mad Professions Code)., 'TEMP.ME'1 ER OR POLE IYST. COMMERCIAL:
c.a eC that he is exempt Ihereftom and the basis for the alleged exemption.Any violation of [I NEW BLDG/ADDITION El DEMOLITION
X_N Section 9031.5 by any applicant for a permit subject.the applicant to a civil penaltyof POWER DEVICES ❑TENANT ❑FOODSERVICE:
I- sol momtban five hundred d ilims(S500). IMPROVEMENT
=Q ❑l,as owner ofthe property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
will do the work,and the structure is not intended or offered for sale(Sec.704,1,Business OTIIEN� _ -
13 m and Professions Gyle:The Convector's License law does nut apply or an resume of OUTLETS-SWITCHES-FIXTURES
/�� r
Property who builds or improves thereon,and who does such work himself or thmugh w u
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELFCTR SQ ET.
110 sale.If,however,the building or impmvamant is sold within one year ofcompletion,the SQ,FT FLOOR AREA SISQ.FT.
+ er.huRder will have the burvlen o1'proving that he did not build or improve for par- •` EP 2 l 1999 ��
pae•ofsate.). I n
❑ 1,ns uwnar el lie property,um exclusively enntrvctlng with licensed cnm rachers to TAL I
mstrnn the project(See.744.Business and Promssiuns Codes The Convenor's Li- Lr t
cc^.c Law does not apply to an owner of propenY who builds or improves thereon,anJ QTY PLUMBING FsF�/_
who rmanica for such pmjeas with a cnntrunnrf.0 licensed puna.....the Convenors
Lieenw Law. PERMIT ISSUANCE -�-•-
r-1lamesemptunder See .B&P C for this reams
ALTIiN-DRAIN&VENT W'ATEH(EAI VALUATION
net Date
WORKER'S COMPENSATION DECLARATION HACK FLOW PROTECT.DEVICE
I hereby off rat under penalty of perjury one of the following dcclamtionc
` F7Ihave and wil l maintain a Certificate of Consent)self-insure for Workers Comper- CHAINS-FLOOR,ROOF,AREA,CONE). STORIES TYPE CONSTRUCTION
sution,as provided for by Section PW of the Lubin Calc,bathe performance of he
work for which this permit is issued I FIXTURES-PER TRAP
I have and will maintain Worker's Connpsn.alion Insurance,as required by Section
J9110n1'the[.abor Colo,for the pef6ammnmed the work for which t],ispermit is is...d. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP LAINO
My W, kS�.v Cwn ansmi In umncea in-rand I•olicy num '{ O
Cmricr,�p++Ilcy Nu.:41•`•��2-T9 GAS-EA.SYSTEM-OVHR4(EA)
CERTIIBCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIVINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
This sectionnednmbecomplc¢Jifthepened is Intone hundred dollars(SIM) GREASETRAP
or lea.) PLANCHECK FEE
I certify that in the Performance.fthe work far which this permit is issued,l shall SEWER-SANITARY-STORM EA.2000 FT.
not employ any person in any manner so as to become subjecto the Workers Camper ENERGY FEE
O Z station laws of California.Date WATER HEATER WNEN ELEC R
Z O Applicant GRADING 11311
ZI NICE TO APPLICANT.If,after making this Creation,of Exemption,you should WATER SYSTEM1(TREATING
.�-' OTrecountsubject to the Workers Con+penselme provisions of the Labor Code,you must SOILS 14eE
.�j
ruination cenoply with Such provisions or this permit shall he deemed revoked. I WATER SERVICE
4
CONSTRUCI'LON LENDING AGENCY NEW R13SIDF.NTIAL PLMB. SQ IL PAID
hereby short that there is a amsstmeomo lending agency or the perfomemm nl Date Receiptp
U O the work for which hit,pencil is imued(See 3097.Clv.C)
benders Nm
ae IOTAL',
LULcnder'a Address 'TOl'AL:
y I certify that 1 have read this application and slam that the above information ve infoation in BUILDING EEE
F Tqcorrect.l agree to comply with all city and county ordinances and sum laws vl.ti.gm QTY. MECHANICAL PERMIT FEE 12
U Z building ronrvuaiomand hereby amh.riee nPrecanatisee of lhEdry t.error upon the SEISMIC ITE
-' ahose-memiored property for inspection m,ow, PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Criterion against ELECTRIC ME
liubilitim.judgmenls,costs and expenses whirl y in any way acerae against said City ALI'ERORADDTOMECH.
PLUMPING FEE
A APPLICANT
of thegrantingAN ofti pe
APPLICANT UNDERSTAN N 1 PMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO ItI,UNI CI'M)
MECHANICAL PEE
SOURCE RP,GIII. -ON.
O�'Yl L�4 AIR HANDLING UNIT(OVER 10,000CIM) CONS'1'EVICTION TAX'
Slgn.t pplicunl/Cnmm lir ! Date EXHAUST HOOD(WIDUM) HOUSING MI'I IGAT]ON IEE
HAZARDOUS MAI'17RIALS DISCLOSURE
Will the applicant or future building.ccupuntsome or handle hazardous material HEATI NO UNIT(TO I MJ100 B'IV)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Ne,Smtion 255)2(x)9 HEATING UNIT(OVER 100,0N)BTU)
Ycs Na
ut VENTILATION FAN(SINGLE:RFSID) PAID Date Receipt
Will the applicant or furore Idcfim g bccupmn use equipment or dm9ces which
¢mil humrJous air conwninanu as Jcfined by the Bay Arca Air Quality Management BOILER-COMP(BHP OR IOo.IXp BTU)
T
Uistrict9 BOILER-COMP(OVER IBQBIXI B'I'U)
E)Yes ❑Nn
AIR CONDITIONER
I li,ive modthe h rd t JLLLyyyr ,aryI.order Chapter 6.95 ifIli Cal ISSUANCE DATE,
tonnia 11c,1101 de Safety C u.Seri 05,15534 d255941 under,mad'htr''flh. NEW HESIDENTIALMBCH. SQ.FL
nnru<r g +I Art )n then 'hi'p l Trym 'Yp'tol �� D/1
'Ift inl/ ct or oor ef�9`nP�
,f fkcapa ncy 'V
O or amhrvcd agnl S Dm ^c TOTAL: ISSUED BY: t
OFFICE