99100048 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY innn 4W
CITY OF CUPERTINO BUILDING-ELECTRICAL MIT Ntr.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING•MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
O NF$R NA E: X11 NE: CO ACTOR'S A LI
J
NIC CONTROL#
RCHITECT/N GIlsfffIC ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG EF PLUMB_ MECH
LICENSED CONTRACTOR'S DECLARATION QTY, ELECTRIC PERMIT FEE CEJ/
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
"Z with Section 7000)of Division 3of the Business and Professions Cede,and my liceme s / RF I�phNuAL,
�00 wr f PERMIT ISSUANCE
sy,.. m full force and e ❑SFDWL ❑KITCHEN REMODEL
PZW DasenseC�Cmunwmr 01h -J4_ APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
Foy ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z O y Z I understand my plans shall W used as public records MODIFICATION
pZ4-0 UP TO 2M AMPS C2 INTERIOR ❑CHIMNEY REPAIR
r�2!ZW Licensed Professional 201-10WAMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 1f100AMPS El BATH REMODEUREPAIR [I DEMOLITION
g Q 1 hcrehy M.that 1 am exempt from the Conuacoms License Law forme
gX06V following reason.(Seei..7031.5,Business and Professions Cade:Any city or county SIGNS[LGCTRICAL ❑OTHER
u+3"I" which requires.permit m......ct,alter,improve,demolish,or repair any stmemre
V) prior to its issuance,also rectums the applicant for such permit to file.signed statement SPECIAL CIRCUIT/MISC
} that he is licensed p mmmmme provisions of the Comracmrs License Low(Chapta9
6I�J00 (commencing with Section 7")of Division 3 ofthe Businessand ProfessionsCode)or TEMP.METER OR POLE(NST. COMMERCIAL: ,n
her
a q m K that he is exempt Iefmm and the basis for the alleged exemption,Any violation of ❑NEW BLDG/ADD( N ❑DEMOLITION
W..y
Section 7031.5 hyinyapplicam for.permit subjects Ne.pplicuntm a civil pnnaltyof POWER DEVICES ❑TENANT ❑FOOD SERVICE
.F. y not mart than five hundred dellen(5500). IMPROVEMENT
0 ❑ I,as owner of the property,or my employees with wages as their sale compensation, SWIMMING POOL EL E IC
will do the work,and the structure is not intended or offered for sale(Sec.7040,at
Business ❑OTHER
63 and Professions Cade:The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-FI
proNoy who Wild,.,improves thereon,and who does such wary himself or through
r his awn employees,Provided that such improvements ecru not intended or offered for NEW RESIDENTIAL ELECTR
a sale.If.however.the building or improvement is sold within one yemofcomplaion,the SQ.FT.FLOOR AREA S/SQ.FT.
owner-Wilder will have the burden of proving that he did not build or improve for pur-
pose of saleJ.
Fl 1.ses owner of the property,am exclusively contracting with licensed continuous(a
TOTAL:
construct the project(Sec.7 44,Business and Professions Code:)Th.Commaors Li-
ceme Law does not apply to an owner of property who builds or improves therson,and QTY, PLUMBING PERMIT FEE.
who contracts for such projects with a contrmmds)licensed pursuant o the Contractors
License Law. PERMIT ISSUANCE
❑1 am exempt under Sec. ,B&P C for this moon
ALTER-DRAIN&VENT-WATER(HA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE /J
I hereby affirm under Penalty of perjury one ol'the following declamdons:
I have and will maintain aCertificate of Consent or self-insure for Workers Compen. DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPECONSTRUCTION
ration,as provided for by Section 37M of the Labor Cade.for the performance of the
mk for which this permit is issued. FIXTURES-PER TRAP
I have and will maintain Workers Compensation Insurance,as requited by Section
37004the Labor Cade,for the Performance.f are work for whichthis permit is issued. GAS-EA.SYSTEM-I INC.J OUTLETS OCQGROUP APN
My Works s Comprnsmion I s Iran a carrier and Policy number aIr� / ppp
Cartier: �y'y/Jj�y No.: kzl`7V��3 GAS-EA.SYSTL•MOVER4(FA)
��_��_CERDFICATEOF EXEMPT EXEMPTION FROM WORKERS' GREASEANDUSTR-WASTEINTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not becomplertd if the Permit is for one hundred dollum(SIM) 1jqqq
GREASETRAP
or Icss.) PLANCfIECK FEE
I certify that in the performance ofthe work for which this permit is issued,IshollSEWER-SANITARY-STORM PA.200 FT.
not employ any permn in any manner az m hese bjc i to the Wmkers Compen- ENERGY HE
0 Z ration Laws ofC,1TLomia.Ony — ��—_7'Ij��+-9 WATER BEATER WNENT/ELECIR
Z Z iarara I�/�f��.aT�--.L',. -4 p � f' /q - GRADI_NG.
NOTICE'I'O APPLICANT:If,nit ski g this Cemlica a of Exemption,you shouldWATER SYSTF.MTREATING /.
P
? become subject units,Wmkcr's Cop rwamn provisions of the IoWu Code,you must S E I`),
forthwith comply with such Provisionsar this pernot shall he deemed revoked. WATER SERVICE
U
r CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,I4. PA
U 0 (hereby affirm that there is a construction lending agency for the performance ofLLI !9I REcer t
F the work for which this permit is issued(Sec.3097,Civ.C.)
0 Lenders Name TOTAL.
0 L) Lenders Address TOTAL: _
>' 0. 1 certify that I have mad this application and state that the above information is I
vV) correct
.l agree to comply with all city and county mirtmoces and state lewa In .,to QTY. MECHANICAL PERMIT FEE
U building constmction.and hereby authorise representatives ofthis city to enter upon the SEISMIC E
aMrve-mentioned property for inspection purposes. PERMIT ISSUANCE
r (We)agreenrsare,indemnify.nd mles.keep hmthe City of Cupenmoagalnst ELECTRIC FEE
Iistudities.judgmenls,costs and expenses which may in any way Meme against said City ALTER OR ADD TO MECH.
in consequence ofthe amount of this No .
PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
'0 . AIR HANDLING UNIT(OVER 10,"CFM) CONSTRUCTION TAX
btgn mm ofApphcant/Con for Date EXHAUST HOOD OKMUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building oecupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade.Section M532(a)^ HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID
Date Recti tk
Will the upphinm or future(wilding..pact useegtaymeat or devices which
di mit hazard.....cmentro mems as defmM by the Bay Area Air Quality Management BOILER-COMP(3HP OR 1(10,(100 BTU) TA L:
District?
E)Yea, i]No BOILER-COMP(OVER 100,000 BTU)
I have read the haramdous menials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Gde.Sections 25505.M533 and 25534 I understand Nat if the NEW RESIDENTIAL MECH. SQ.FIE ` A
building does not currently have a tenant,that it is my responsibility to notify the occupant / C//T'
of the umTg hems:;_ lb must be met prior to iswance of a Certificate of cco'r
�l1-.JAY/L1cyPy�/ b-
O'cummiaimmou ant Dam TOTAL ISSUED BY:
OFFICE