99080098 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY CUPERTINO BUILDING-ELECTRICALP
BUILDINC.DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION' 'i;
BUIkOiNG ADDRESS: SANITARY NO. APPLICATION SUBMITTAI.DATE
o ��S ��Lr �r,/ 12; /A/ �'ASSO/t-_ f' / 8 9
OWAN/B/jt'S NcgMBr� PEON /' CONTRACTORS NAME: LIC NO:
NIC CONTROLN
`CHITECT/ENGINEER: LIC NO: ADDl
CJ/�
V
CONTACT: PHONE: _ , r; BUl DING PERIv1lT[NFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELEC PLUMB MECH
LICENSED CONTRACTORS DECLARATION QTY „
,* ELECTRIC PERMEl El
IT i FEE ,'.
C=Z I hereby.corm m l am r d e p ons or Chupar 9(summa g JOB DESCRIPTION
WQp with Section 700(firfDrIwitar 3afthe Business andPofessions Code and my license is PERMIT ISSUANCE RESIDENTIAL:
F in buil force ane elfeu.
o
WmFLicense Class Lic.M ❑SFDWL ❑KITCHEN REMODEL
Dae_ Cunoaclor APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING REPIPE
ARCHITECTS DECLARATION ❑MULTI-UNrr ❑STRUCTURAL
PANELS
Z O ZI understand my plans shall be wed as public records MODIFICATION
0--4-0 UP TO 2M AMPS
Q [I INTERIOR ❑SWCHIMNEY
MINGPREPAIR
OL
C4 � Licensed Profescionel 2111-1000 AMPS IMPROVEMENT
C6L „"�j OWNER-BUILDERexempt
from
mDECLARATION
❑DEMOLITION POOLS
OVER ItifNIAMPS ❑8 HREMODEVREPAIR ❑DEMOLITION
Q I hereby.(lino that 1 am exempt from the Contractors License Law for the
g d V followwhich re reason.Permit
9(1315,Business imp Professions Code:Any city or county SIGNS ELECTRICAL HER
which regtdres n permit a oonamct,.her,improve,demolish,or repair any swcmre l W L,2 N SN-,:7p
net 0 its issuance,also repriessthe.pplicant for such permutes,file.signedstatemem SPECIAL CIRCUITIMISC.
d£ that he is
nepursuant it,the provisions of the Contractor a License Law(Chapter 9
❑C (mmmeneing wi[hSdalton 9000)uf ilivisirn JoRM1e Business and pmfeRinns Code)or TEMP.MET ER OR POLE INST. COMMERCIAL:
6 q q that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
0 Section 7031.5 by any applicant for a permn sub car,the applicam m a civil penalty of POWER DEVICES
toe than Bveoaddreddollars(85W). ❑TENANT ❑FOODSERVICE
1Z
ow net ofrhe property.or my employees with wages as theirsole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the amen a is not intended m s,lYerW far sale(Sec.tall Banner, ❑OTHER
m and Professions Cade:The Contractors License Law does not apply to an owner of OUTLETS-Stoll CHES-FIXTURES
.. property who builds or improves thereon,and as he deed such work himself or through
his awn employees,provided that such improvements are mr intended or offered for NEW RESIDENTIAL ELECTR SQ FT. PC
sale.IL however,the building or improvement is sold within one yearofcompletion,the SQ.FT FLOOR AREA $/SQ.FT,
ovmer-hrildzar will have the burden of proving that he did not build or improve for put-
paseof y TOTAL:
Lilaollisirefter of the property,am exclusively contracting with licensed eom
ntemrs to
construct the project(Sec.7044,Business and Professions Core:)The Contractor's Li-
e
nse Law docs not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT ' ` FEE "
who contractsfor such projects whb uconhnmor(s)licensed pursuant o the Contractor t"
License Law, PERMIT ISSUANCE
❑I am exempt under Sea ,B&PCferthisreasn.
Owner - - Dare ALTER-DRAIN&VENT-WATER(EA)
VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
I hereby affirm under penalty of perjury,one of the following declarations: 0 -0
I have and wil l maintain a Cenificale of Consent o self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA COND. S RIES TYPE CONSTRUCTION
saint,as provided for by Section 3900 of the Labor Code,for the performance of the
work for which this pennir is issued. FI%TURES-PER TRAP �N�c �.✓OJ 7�
❑I have and will maintain Worker's Compensation Insurance,as required by Section
37Mofthe Labor Code,for Ne performance of the work for which this permit is issued. GAS-EA.SYSTEM-]INC.4 OUTLETS OCCGROUP APN
My Worker's Complemental Insurance carrier and Policy number are: T �/
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA) r17
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSTRL WASTE INTERCEPTOR
(This section need not be completed lfthe poont is marine hundred tire.(SI00) - BUILDING DIVISION FlIa
or less.) GREASE TRAP
PLANCHECK FEE
Ioy any
ythatper int he frof anymnoncenerofine s to orkbecome
for which this perthe it is WokersCmpenl SEWER-SANITARY-STORM EA. FT.
nor employ any oho in any manner so as to became subject to the Workers'Compen- ENERGY PEP.
,Z Annan Latae of C.Ilforni..Dote
y� O Applicant WATER HEATER WNENT/ELECTR GRADING FEE
G h NOTICE TO APPLICANT:If,after making Nis Certificate of Exemption,you should
a became mbirri m the Worker's Compensation WATER SYSTEMITREATING
p Provisions of the Ladd Code,you must
W forthwith comply tai@.such provisions.,,his pennir shall be Jcemed revoked. WATER SERVICE
� Q t i
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PENCE. SQ.IT PAIDL
V Q I hereby affirm that there is a construction lending agency for the performance of �'�' Date Receipt If i'
LT. F
the work for which this permit is issued(Sec.3097,Civ.Co EUI]
U Lender's Name is 19NAI,t ,,
.ti {Ie, Lenders Adduce, TOTAL',
a I certify that I have read this application and state that the above information is BUILDING PEE
rN. Osl correct I mor,m comply with all airy and county ordimodw and same lawn relating m QTY. MECHANICAL PERMIT I� FEE
S
V a bottom,const..tear,and hereby authorize representatives of this city as,color upon the r ''t EUSM
7 IC.FEE
above-mentioned property for ml purposes.
PERMIT ISSUANCE
(We)agme to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way acerae against said City ALTER ORADD TO MECH.
in asequence of the granting of this permit. PLUMBING FE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. MECHANICAL
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TA%
its
i'mattor.fApPlicaMCintrarbr nm EXHAUST HOOD ONMUCT) HOUSING MITIGATION E
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store car handle hazardous material HEATING UNIT(TO 100,000 BTU)
as dented by the Cupertino Municipal Carlo,Chapter 9.12,and the Health and Safety
Code,Section 25532(.)^ HEATING UNIT(OVER 100.000 BTU)
❑Yes E]No VENTILATION FAN(SINGLE RESID) PAID
Dam Receipt#
Will the applicant or furore building occupant B yuse A co Air Qua of devices which BOILER-COMP(3HP OR 10(1,1100 BTU)
n b.zmdau.c air cnntamin.nt.'as defined by the Bay Area Air Quality Management TOTAL:
U
Yes ❑No BOILER-COMP(OVER Will"BTU)
I have react the hevNous mcrouls requirements under Chapter fi95 of the Cali- AIR CONDITIONER ISSUANCE DATE
m in He.lth&Safety Core,Sections 255115,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
buildrodces mercenarily have a mm [,that ii is my responsibility ro notify the occupant _� 3_ 9 9
ofWe.epaj¢atems leh moa ace ora i0c eol'Ocu ancy.
authnriea,agent Dam TOTAL: ISSUED BY:
OFFICE