99070062 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY qq O 0
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJF ENTIFICATLON
BUILDING ADDRE.S$: SANITARY NO. APPLICATION SUBMITTAL DATE
ER's N � PHONE: CO ACTOR'S NAME: LIC NO:
If _vf �' �� NX CO ROLA
RCHITECT/ENGINEER: LIC NO: A ESS ❑
CONTACT: PHONEBUILDING PERMIT INFO
U19 ❑ Consultant Fees Paid by Applicant(Initial) BLDG , ELECT PLUMB MECH
ff ❑ ❑ 0� ❑ .
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
OC'Z with Section 000foof Division 3 of the Business and Professions Code,and my license is RESIDENTIAL,
W O O PERMIT ISSUANCE
�F U U full force and effect ❑SFDWL ❑ HEN REMODEL
U License Class LION
APPLIANCES—RESIDENTIAL
Dam Contrnaor El ADDITION LUMBING RE-PIPE
F�yhy
ARCHITECT'S DECLARATION PANELS ElMULTI-UNIT ❑STRUCTURAL
,O O-❑ 1 understandmy plans shall he used as public records MODIFICATION
O Z-+O UP TO 200 AMPS
F E' Licensed Professmnal ❑INTERIOR ❑CHIMNEY REPAIR
qq 2111-1000 AMPS IMPROVEMENT
OWNER-BUILDERDECLARATIONthe Commerce's
❑DEMOLSWIMMING POOLS
C CC Q 1 hereby affirm chat 1 am exnnpt from the Comramor's License Law fm the OVER I"AMPS El BATH REMODEIIREPAIR El DEMOLITION
XO d U following reason(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL —1 OTHER
W 3 W mF¢ which requires a permit to construct,aper,improve,demolish,or repair any structure
�O.i prior to its issuance,also requires the applicant for such oro file a signed statement
permit g SPECIAL CIRCUIT/MISC.
a;!(d (cothat heiscing it pursuant to the provisionsof the eBusiness License Law(ChapterCode)or
y a��� -hat he is
(commencing Section 7000)and theof basis or of the alleged
Business and Professions Code)or TEMP.METER OR POLE INST. COMM .R .IA :
that io is exempt therefrom.,the gas for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION [I DEMOLITION
W w Section 0031.5 by any applicantfor u permit stbjecs the applicanno ncivil pcnalry of POWER DEVICES ❑TENANT ❑FOODSERVICE
F J+ of more than five hundred dollars($500).
�G I,ns owner of the IMPROVEMENT
O ❑ property,or myemee with wagesrsalei(Sec.compensation. SWIMMING POOL ELECTRIC
andwill do Pimhmwmk,and the he Corals not intended License offered wows of apply to an.Business - OT R
and Professions Code The C e.o damns License Law rices not apply to if owner of OUTLETS—SWITCHES—FIXTURES
'3.. property who builds or improves thereon,and ve who does such work himself of through
his own employees,provided or improvement
such improvements are not intended or offered for NEW RESIDENTIAL ELECIR SQ FT.
solo.
erIf,howev will
have
he burden
of proving
that he did none year of
improve
SQ.FT.FLOOR AREA $/SQ.Pf.
merf-0�tiIlder will have @e burden of proving that he did not build or improve for pur-
i9et'as owner of the property,am exclusively contracting with licensed contractors to TOTAL: ---_--•-u/
construct the project(Sec.9044,Business and Professions Cale.,Tha Camranor's Li- L L,
cense Law does not apply to an owner of properly who builds or improves thereon,and QTY PLUMBING PERMIT FEE
who contracts for such projects with a contioctons)licensed pursuant to the Contractor's
License Law. l der ,
❑lm1c.Znp , re
_ ,B&PC for his as _on PERMIT ISSUANCE j� JUL 2 1999
ALTER—DRAIN&VENT—WATER(EA) VALUATION
wren Dare
WORKER'S COMP ON :CLARATION BACK FLOW PROTECT.DEVICE -
I h rchy affirm under penalty of perjury,one of the following declarations. By
❑IhaveandwillmaintainaCenificamofConsenlloself-insurefor Workers Compen- DRAINS—FLOOR,ROOF,AREA,COND. STORIES
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued. 5 FI%TURES—PER TRAP
❑I have and will maintain Workers Compensation Insurance,as required by Section
3900 ofthe Labor Code,for the performance ofthe work for which this permit is issued. GAS—EA.SYSTEM-]INC.4 OUTLETS ACC GROUP pPN
My Worker's Compensation Insurance carrier and Policy number arm / O 3
Carrier: Policy No.: GAS—EA.SYSTEM-OVER 4 RIA) `P C
CERTIFICATE OF EXEMPTION PROM WORKERS' GREASF/INDUSTRL WASTE INTERCEPTOR O
COMPENSATION INSURANCE BUILOINGDM$If1NF8
or leas)(Thiasamiad product len completed ifthe permit is forooehundred dollars($110d) GREASETRAP
PLANCHECK FEE
I sonify that in the performance of the work for which this permit is issuedlshall SEWER—SANITARY—STORM EA.2110 FT.
not employ any person iia any manner sn an to hecnme subjecuo the Workers'Compel- ENERGY FEE
O Z sation Laws of California.Doe / WATER HEATER WNENVELECTR
Applicant - GRADING FEE
y NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/TREATING a become subject to the Workers Compensation pmvisions of the Labor Cade,you mist SOILS FEE
W forthwith comply with such provisions or this permit shall be deemedrevoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FT. PAID
V.0 Ihercby affirmthanhere is acOnswmion lending agency fonhe performance of Reis ceipt#
LL Fy the work for wbiehthis permit is issued(See.3099,Civ.C)
O Lenders Name V TOTAL:
V Lenders Address TOTAL:
1 certify that I have read this application and state that the above information is BUILDIN P
ti y correct.1 agree to comply with all city and county ordinances and state laws relating to Q•ry, MECHANICAL PERMIT FEE
V building construction,and hereby authorize representatives of this city to enter upon the SEISMIC FEE
alarve-mentioned property for inspection purposes.
(We)agree in me,indemnify and keep harmless the City of Corporally against PERMIT ISSUANCE ELECTRIC FEE
liabilities.judgments,conn and expenses which may in any way accrue agalnstsaid City ALTER OR ADD TO MECH.
in consequence of the grouting of this Permit PLUMBING
APPLICUNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURC R -U ATIOfjl9. MECHANIC E
AIR HANDLING UNIT(OVER 10,000 CFM)
CONSTRUCTION AX
Si of ApplicanUCmiturttor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTIL
as defined by the Cup r into Municipal Code,Chapter 9.12,and the Health and Safety `
Code,Section 25532(a)'f HEATING UNIT(OVER 100,000 BTU)
71 Y'., ON. VENTILATION FAN(SINGLE RESID) PAID --
Date Receipt
Will the applicant or future building occupant use equipment or devices which tl01LER—COMP(3HP OR IW,r%10 BTU)
emit hazardous air contamimams as defined by the Bay Arca Air Quality Management
Disnin4 BOILER—COMP(OVER 100,000 BTU) T
Yes No❑
I have rend the Immrdlyue mumrials mquiremens under Chapter h95 of the Cali- AIR CONDITIONER ISSUANCE DATE
to
th&Sarety C Sections 5.25533 and 25534.1 understand Nat if the NEW RESIDENTIAL MECH. Sp,PT.
b it ng sm cone oveamn ,t al it is responsibilirytonotiry the acopam ••�
oft equine encs who Host t or m is a a of a Certifiate of OavpOuc
A f
O m oriz sem ` Dam TOTAL ISSUED BY:
OFFICE