99080030 APPLIG!NTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERM NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
7`I /1 as (a,� �✓a e - Ste/ d'^ y
OWNER'S( MF.: PHONE. ONTRACTOR'S LIC NO:
it _ �3rl ! ® NAME: NIC CONTROL#
CHI GINE R: {7C/ LIC NO, ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
zS5 —35-19 ❑ E;'-- ❑ ❑
LICENSED CONTRACT OR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm Nat I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Wo wish Seddon 7000)of Division 3 of the Business and Professions Code,and my licenseis RESIDENTIAL:
O
F W z m full force and effem. PGRMI'I'ISSUANCE L1 KITCHEN REMODEL
❑SFDWL
-.4_Zh`u License Class Lic.N APPLIANCES-RESIDENTIAL. ❑ADDITION El PLUMBING RE-PIPE
FG R1 Date Contractor
to Q. ARCIIITECT'S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
Z FO y Z I understand my plans shall be used as public rounds PANELS MODIFICATION
024' UP TO 200 AMPS
F at)—W Licensed Professional ElINTERIOR El CHIMNEY REPAIR
201-1"AMPS IMPROVEMENT [I SWIMMING POOLS
X v
OWNER-BUILDER DECLARATION Oylik 1000AMPS ❑B ATH REMODEI/REPAIR ❑DEMOLITION
CL W Q 1 he ,effrn Ihel I am exempt from The Cadmium's Liansa Law for the
0.O LU following reaam.(Section 7031.5,Business and Professions Cade:Any city or action, SIGNS ELECTRICAL ❑OTHER Orvy
W y which mquims a permit Tr consWct,alter,improve,demolish,or repair any structure 1
F O; prior to hs issu.nee,als.eNuires the applicant fnrsuch per mil to file asignedsTntement SPEC IAL CIRCUIT/MISC.
p; That he is licensed puremanl to the provisions of the Contractors License Law(Chapter9
C�+00 (commencing with Section 7000)of Division 3 of the Business and Professions Code)of TEMP.METER OR POLE INET. ITOTAL
COMMERCIAL:
d y e eL the he is exempt Therefrom and the basis for the alleged exemp0on.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section]031.5 by any applicant for a permit subjects the applicant to u civil penalty of POWER DEVICES ❑TENANT ❑FOODSERVICE
not more man five hundred dollars($500). IMPROVEMENT
at 01,as owner of the property,or my employees with wages as Their solo compensation, SWIMMING POOL ELECTRICOOF
ewill rude,work,and lheswemre is an,intended or oReru rorsale(Sec.5044,Bueiness OTHER
tilam and Professions Code:The Contractor's License Law does not apply to an owner of / OUTLETS-SWITCHES-FIXTURES
Cproperty who builds or improves thereon,and who does such work himself or through >2hieown employees,providedthat ommImprovements are nm intnded m oHrel for NEW RESIDENTIAL ELBCTR sale.If,however,the building or improvement is sold within one year of completion,lie -6@�R'FSY8ORAnr'e /SPI'.n nerdbuilder will have the bandenof pmvingtat he did nothuildorilnproveforper1Ems(( r of me pmpeny,vm exdasivdy camreeting with licensed enmractort m �tsuuut the project(Sec 7044,Business and Professions Code:)The Contractors Li-
adir,dLawdoesnotapplytoanownerofpropertywhobuildsorimprovesthereon,and conditionals) QTY. PLUMBING PERMIT FEE AUG 4 egg
who contracts for such projects with a coonals)licensed pursuant the Contractors
License Use PERMIT ISSUANCE
❑ Tomexempmathn Sec .B&PCarm,adom
ALTER-DRAIN&VENT-WATER(EA) By VALUATION
Owner Date [J
WORKii 'S CO sNSNIE&DECLARATION BACK FLOW PROTECT.DEVICE441 -�
I herehy ulfrm under prnnlly of perjury ora of IM1e Lillowmg dealarationa:
I have and will maintain a Certificate of Consent to self-insure for Worker's Cumpen- DRAINS-FLOOR,RODE,AREA,CONI(. STORIES TYPECONSTRUCTION
sation,as Provided for by Section 3700 of the Labor Code,for IM1e performance of the
work for which This permit is issued. FIXTURES-PER TRAP
❑ 1 have and will maintain Worker's Compensation insurance,as required by Section
3710 of IM1e Labor Code,for the performance of the work for whichmis permit is Issued, GAS-EA.SYS'T'EM-I INC.4 OUTLETS OCC.GROUP ! :APN
My Workmna
Worker',Compensation insueuncerand Policy number em'. r0
Cartier: Policy No.: GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEIINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE,
(This section need notbe completed if the pa out Is fintime Int
ne hundred dollars($ l) BUILDING DIVISIONFEES
or lesx) GkEASL TRAP PLANCHECK FEE
I artily that in the performance of the work for which 11a,somil is Lound,I shall SEWER-SANITARY-STORM EA.200 FT.
not employ any persue In any manner,.as to become subject to the Workers Conoco- ENERGY FEE
zZ action l.ewsof California.Date WATER HEAT ER W/VENT/ELECR
Q Applicant GRADING FEE
tr NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMOREATING
F thecomv,cf dot to the Worker's Compensation provisions of IM1e Lane,Code,you mast SOILS FEE
forthwith comply widamch provisioesorthis permitshall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMR. SQ.FT. PAID
L)0 (for nick
tharan ilia issued
Tan Len ding agency Teethe performance of Date Receipt#
(1# H the work for which this permit is issued(See.91197,Civ.CJ
p Lenders Name TOTAL:
WLeaders Address TOTAL.I certify that 1 have reed This applia0on and stem that The above information is BUILDING FHB
tiCO) carat.I agree to comply with a0 city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
C.) building constmetlan,and hereby authorize representatives of this city to enter uponlhe SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep brould s the Cby mf Cupertino against ELECTRIC PEE
liabilities,judgments,costs and expenses which may in any way.cane against said City ALTER ORADD IO MECT1
in consequence of the round,cfmis permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'[(TO 10,1X10 CFM)
MECHANICAL HE
SOURCE REGULATIONS.
C AIR HANDLING ON['I(OVER 10,000 CFM) CONSTRUCTION TAX
Signature or Applicant/ ompoemr Dam EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARD S MATERIALS DISCLOSURE
Will IM1e applicant or future building ooce,am,mmor handle hazardous mamrial HEATING UNIT(TO 100,000 BTU)
as defined by me Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(.)] 1 HEATING UNI'i'(OVER 100,000 BTU)
F1 Yes F1 No VENTILATION FAN(SINGLE RESID) PAID
Data Re pt#
Will the air ricent or future building by the B use ea Air equipment of fjMan.which
it hazardous air comvminanls as defined by the Bay Area Air Quality Munagement BOILER-COMP(3HP OR 100.0310 BTU) its,IOTA I
tptricl?
El Yes rDNo BOILER-COMP(OVER 1110,000 BTU)
AIR CONDITIONER
1 have real the h ode Sea mm,255 5,2553 encs under .1 made rce of the Cali- 1^SDA DATEform.
builds Health&Safety Cada,Sateen 25505,2s my and 255]4.T understand(built the NEW RESIDIiNf1AL MECH. SQ.FT. �—C(
building does not currently haven tenant,that it is my expansibility to notify the occupant
Therequirun Nw1,bmust ha me rinrmies neof a Certificate of Occupancy.
Owner or authoriu ege Date TOTAL; ISSUED BN
OFFICE