99080149 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '7 )4? t '7
BUILDING-ELECTRICAL PE MIT NO.
riTY OF CUPERTINO PLUMBING-MECHANICAL,
BUILDING DIVISION APPLICATIONIPERMIT
BUILDING PROJELT IDENTIFICATION
SANITARY NO. APPLICATION SUBMITTA ATE
BUILDING ADDRESS:
96 (2011*3y"4y Set1 PHONE: CO ACTOR'S NAME: LIC NO: N/C CONTROL p
aco'IfRE'CT GINE R: LIC NO: ADD;97 a-�u n/ f t ED
CONTACT: PHONE: BUILDING PERMIT INFO
a ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
6 513-_o(ol8 ❑ ❑ Q— ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT PEE JOB DESCRIPTION
I hereby affirm that l .licensedunder pnwlsi am ol'Chapter 9(commencing _
gzt1'ZwithSmion JtlW)ofDivieion3ofNc Businessman ProfessionsCode,andmy license is RESIDENTIAL,
F�-�� is full force and affect PERMIT ISSUANCE 0SFDWL ❑KITCHEN REMODEL
.tuu License Clans Lic.# APPLIANCES-RESIDENTIAL ❑ADDITION MBING RE-PIPE
yam Dam Conlmeor - ❑MULTI-UNIT ❑STRUCTURAL
ARCHITECTS DECLARATION PANELS MODIFICATION
nemmnJmyplansshallbCmsedaFpuhliamemdl, UPT02gAMPS
DZ- 0 [I INTERIOR [I CHIMNEY REPAIR
m F-Iy Licensed Professional 201-IWOAMPS IMPROVEMENT ❑SWIMMING POOLS
�y�; OWNER-BUILDER DECLARATION OVER IM)AMPS ❑BATH REMODEVREPAIR El DEMOLITION
C W st I hereby nation that I am exempt from the Commences License law for the ❑OTHER
?;O y UF following maiice (Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL
which require..a N,md to consumer,alter,impmve,demolish,or repair any stmcture
prior wits issuance.also requires the applicant for such Permit o file o signed statement SPECIAL CIRCUIT/MISC.
F, } that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
C 4C (Commencing with Section 70Vd of Division 3 oflhe Business and Professions Crack)or TEMP.MET OR PULP,INS'T. COMMERCIAL;
i e o Oy Not he is exempt therefmm and the basis for the alleged exemption.Any violation of ❑NEW BLDGIAODITION ❑DEMOLIt10N
it m lr. Section 7031.5 by any applicant for a permit subjects the applicantto o civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
F_-Z y not more than Ove hundred dollars(8500). IMPROVEMENT
MING POOL ELECTRIC
R6� 0hazowner of Ne property,ur my cmployttswith wages as their rete compensation, SWIM0 ER
will do the work,and thesmucture is not inandedor Offered for sale(Sec. Business OUTLETS-SWITCHES-FIXTURES
W'-' and Professions Cide:The Contractor's License law does not apply to m owner of
W 3 property who builds or improves thereon,and who dors such work himself or through NGW RESIDIiNTIAI.ELECTIt SO FT.
his own employee,,provided that such Improvements are not intended or Orated for SQ.FT.FLOOR ARCA —$/SQ.FTr.
sale.If,however,the building or improversn is sold within one year of completion,the /�
ser-Wilder will have Ne burden of proving Nat he did not Wild or improve fu par 79
pose of sale.l. TOTAL:
❑L as owner of the property,am exclusively contracting with licensed contractors to
Conswd Ne project(Sr.7044.Business and Professions Code:)The ucmmclm5 Li-
se Law does not apply to an owner of property who builds or improves Hereon,and QTY. PLUMBING PERMIT FEE
who contracts for such Ium eels with a conmanar(s)licensed pursuant to the Contractors
License Law. PERMIT ISSUANCE
I am exemptunder Sec. ,B&1'C for this reason
ALT12R-DRAW&VENt-WATER(EA) VALUATION
Date
net
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby arms under pemlty of Perjury one of the following declarations: ryY
I have and will mainmina Certificate mComamon,dFinsure for Workers Compen- DRAINS-FLOOR,ROOF AREA,COND. STORIES 'TYPE C♦` STRIJL'f10N
scion,az provided for by,Section 37M of the labor Code,for the performance of the / W
ark for which this permit is strait. FIXTURES-PER TRAP
I have and will maintain WmkCT's Compensation Insurance,as required by Seen.. 1 lNC.4 OUTLETS
37Wofda LOW,
Cale.teethe performance ofthe work GAS-EA.SYSTEM-
for which thixpetmit is issued. OCC.GROUP A�
My Wo Co a alt n i d Policy GAS GAS-EA.SYSTEM-OVER 4(EA)
Currie ahe,No.: Zt 6
CERTIFI ATE OF EXE [ION FROM WORKERS' GREASFIINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING UIVISIO FEES
(This section need no W eplopleard iflhe permit is for one hundred dollars($Hsh GREASE TRAP YPLANCHECKFEE
or It,,)
Loy any Natinthe anymannro as to Cakbecome
for which?to ferthe Workers'
Compin0 SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as to become subjce to the Workers'Compen- ENERGY FEE
Z action laws of California.Data WATER HEATER WNENTIELECTR GRADING FEE
Applicant
i NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTLICVTREATING SOILS FEE
become subject to Ne Worker's Compensation previsions of the Labor Code,you must
forthwith comply with such provinme,or this permit shall W deemed revoked. WATER SERVICE
Q
d
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PUSH. SQ.ET. PAID
Date Receipt#
I hereby shim that them is a construction lending agency for the performance of
F F the work for which this permit is I...ed(Set.3097,Civ.C.) TOTAL:
O U Lenders Name TOTAL:
r W Lenders Address BUILDING FEE
1 ceAfy Not I have rival this application red aline Nat the above information is
r Ineme"It.Iagree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE SEISMIC FEE
U 7 building cotwmuction,and hereby andprom representatives of this city to enter upon the
,j nve-mentioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE
(We)agree to save,indemnify and keep hamtless the City of Cupcnino against
liabilities,judgments,Costs ad ex s which may in any way azcrat against said City ALTER OR ADD TO MECH. PLUMBING FEE
ircoosequcnceof elr plat ie brit.
APPLICANT . DF TAN D WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0d100 CFM) MECHANICALFEE
DO U IONS.
-�r,�fy10 AIR HANDLING UNIT(OVER I0,000 CFM) CONSTRUCfIONTAX
Si are fAl ''ani/Cos Ctar ^t/ 1Data EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding ottupant store or handle hinardous material HEATING UNIT ITO I00.01M BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,"BTU)
Coda Section 25532(a)4 _
�Y°a I-)N° VENTILATION FAN(SINGLE RESID) - PAID Date Receipt#
Will the applicant or future Wilding Occupant use equipment or devices which BOILER-COMP(3HP OR IWAOOBTU) rl
tit hamrdous air comernam nts as defined by Ne Bay Am.Air Quality Management 'TOTAL: ' L
District? BOILER-COMP(OVER Hah"BTU)
❑Yes (:J No
Alit CONDITIONER ISSUANCE DATE
I have rad the Lamrdou,at Cmd,requi¢muns undo Chapter 6.95 Of the Call-
Nmia Health&Safety Code.Sped e.25505.25533 and 25534.I uMersWtd thatd the NEW RESIDENTIAL MECH. SQ.FT.
buildingNcc not currently have.tenant,that it is my responsibility,to manly the Occupant
Owner 0f eui�ODT24 401DMC TOTAL: ISSUED BY:
1 OFFICE