99090079 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY —10
CITY OF CUPFR'PINtO BUILDING-ELECTRICAL I :RMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
HUILDING ADDRESS: SANITARY'NO. APPLICATION SUBMITTAL DATE
7 LA 00
DR'NERS N E: arlintiqPII(INii: - CONI'RACTOR:S NAME'. LIC NU:
.?SA77 / yJL / 1 1 NIC COMROL4
CHI I'P,CT/ENGINI?Y,R: LIC No, .J O` ADD ESS J�f`J] � ��QD'M /� ❑
CONIACC PHONE, BUIWING PERMIT INFO
qs L a j 0 X03 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
(a V ❑ ❑ ❑ B�
LICENSED CONT'RACTOR'S DECLARATION CITY ELECTRIC PERMIT FEE
I hereby afro mat].,It seemed ander pnovi.iOm orenapter 9(commencing JOB DESCRIPTION
ooz with Section 9G(#potOfv't..on 3ofine Basinesamd Profnsioos Cade,andmy license it RESIDENTIAL
Fw in lull fame and efle" � fS PHRMI'I ISSUANC17 ❑SFDWL El KITCHEN RfiMODIiI.
QzZ.W-,Ul
I)aid Class p (��l.�/ APPLIANCES-RES MENT1AL ❑ADDITION El PLUMBING BE-PIPE
N Q.6 UOC TECTS ECL
'DiA
""ARCHITECTS DECLARATION PANELS ❑MULTI-UKIT ❑STRUCTURAL
ZOyZ l understand my plum shall be used as public records MODIFICATION
OZ—o UPT02MAMPS ❑INTERIOR ❑CHIMNEY REPAIR
F-N F'm Licensed Professional 201.I000AMPS IMPROVEMENT
yYz OW'NFR-RUILDER DF,CLARA'nON ❑SWIMMING POOLS
C=Q I hereby affirm mm I am exempt from me Commcuxs Lmccme Law for the OVER IDN AMPS C:1 BATH REMODEIIREPAIR �DEMOLITION
K 6 V following rtamn.(Section 7031.5.Bus'inece old Pmf—ion.Gale:Any city or county SIGNS ELECTRICAL ❑OTHER A
'3 c v~i which requires u permit it,comlmct.almq improve.dcnudixh,nr repair nor xwewre
ob promo its i,csuancq rNrrrcquill, he applicant bay.ch protium lilea,igncdstatcnerm SPECIAL CIRCUIT/MISC.
E Oji that he is licensed mOunnuu the pmvlsions of the Contmmttd Llcame Lnw(Chapter9
fcummencing with Section 70nd of Division 3ophe Busmen,and l'rdec6m,CodOmo TEMP METER OR POLE INS'I'. COMMERCIAL:
c.6 c C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
X_iISection 7031.5hyanyappheant fora permiteubjcca the applicvd111.Old penaltyof POWER DEVICES ❑TENANT ❑FOOD SERVICE
Spnot more than five hundtnA dollars(5500).
�I,azowner of the pmpeny.or my employees wim wager az their sole mmpcnwtion. SWIMMING POOL ELE IMPROVEMENT
F will do thewofk.and thestmnure is not mended ufuBered for-In(Sev.70al,Rusiac,, DOTTER
63W and and Professions Covell Contractors License law does not apply to an Owner of OUTLETS-SWITCHES I
P
property who builds or improves thereon,and who does such work himself or Enough
his own anployees,provided that such improvements am not intended or offered for NEW RESIDENTIAL ELECTR
,ric.11,noweveq the building On.. rovenwat is sold within one Year A cnmpletiOn,the SO.FT,FLOOR ARF 15/511.11'.
crhuildcr will have the burden el proving that be did not build or improve for pur-
pose Ot-sa1c.)
0 1,as owner of the property,am exclusively contracting with licensed comment,u, TOTAL:
construct the project(SE.9044,liminess and Pmfessions CWc.)Me Contractors Li
ee taw Jon not apply ,,reowocf of pmpcny who builds,,,impmves there... it QTY. PLUMBING PERMIT I FEE
who contracts for such projects with a commcmgs)licensed pursmnt to the Conaachoev
Liceme law. PERMIT ISSUANCE
0 1 am exempt under Sec. ,if R PC for this reason el At:]17R-DRAIN h VENT-WATERVALUATION
�wncr Dv¢ sWDRKIiR'S COMPI?NSATION DECLANATIUN IfnCK FLOW PROTECT'.UEVICHI herehyaffirm under penalty el pcUury one of the follwing decbmttion1m,c nd wil mmnumuCertificulcof Cnnseouo self-itvnre forw', ComS'r0 ?S TYPE CONSTRUCTION
cation,as pmvidcd for by Section 37(Sof the Labor CWcfir the R formance owork tar which mu permit I,issued. TA0 1 have and will maintain Worker's Compensation Insurance,as required by Section
311p Of me labor Cede.for the performance of the work for which this permit is issued. S cOCC.GROUP /�.INMyWorker's Compensation Insurance carrier and PolicynymMM ;� , pA� RO^^//''//AVO Ii lE A' OOC IIIC Tli Ii%T PITON FROM WONKEHS' Q6 O
COMI'IiNSAT10N INSURANCE GIt1iAS� U. i 1 ,
TI'hu section need ern he cutnpinnl iOM1epermit is far one handiest dullan NUILDINC,DIVISION FEES
nr Ices) 0 0 RMIRom PLANCHECK F139
I lertiry that meperiortleave onne woo for hid,tdnperttdt in ia.aad nal
pers
mu umployany on in rtynatnmcrso as m ta
becoe,stor,In the WnAer<Co l ENERGY FEE
O Z sminn Law.,Of California.Date WATERHEATER WNENI'IF.LECTR
Z Q Applicant GRADING FEE
= NOTICE TO APPLICANT:If,after making this Certificate Of Exemption,you should WATER SYSTEMVI'REATING
C > bro me subject m she Worker's CompensationCode,provisions of the Lar Cc,you mint SOILS FEE
14 forthwith comply withsacb pravisinmortbis pcmtit shall be deemed revoked. 4WATER SERVICE
Q
CUN5rRUCcon, LENDING AGENCY iW NESIDEUTIALPLMB. SO.FT. PAID
(� p kbarwyaffirm that there lsvemuuucGonlcnding agency for the performvnm of vt- Receipt#
{w � the work lOr which ihierymdt is issued(Sec 30)].CIv.CJ
U benders Name TOTAL.
>^ U lenders Address TOTAL:
F-' y I certify that 1 have read this application and slate that the above infomtation is BUILDING FEE
rr coma.l agree m comply with all city and county ordinances and sum laws relating to QTY. MECHANICAL PERMIT FEE
(..) Z. building construction.and hereby autbonm representatives offfikeitymenterupon me SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree m erne,indemnify and keep hamtle,,thc City Of Cupertino agaimt ELECTRIC
Iiahiiitie.a.judgmems,coasand expenses which may in any way attme against said City
in conmquence of the granting of this pentad ALTGR UN ADD TO MF.CH' PLUMBING FEE
N'PLICA UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0JXXI CEM)
SOURCE ULATIONS. MECHANICALIEiIi
NRIIANDLINGUNI'1'I OVER 10,IHq CFM) CONSTRUC'HONTA%
Stgnm of ApplicaulComraaor NN I /pate/� li%HAUST HOOD(W/DUM) HOUSING MITIGATION FEE
IIAZARDOUS MATERIALS DISCLOSURE
Will the applicant Or future building oacupa Ohne Or handle h..mdow,material HEAPING UNIT(TO IW.Gtp BTU)
as defined by the Cupertino Municipal Cede,Chapter 9.12,and the health and Safety
Cede,Section 25532(x)? HEA TNG UNIT(OVER 100,0gp BTU)
C]Ne, CNn PAID
VENTILATION FAN(SINGLE RES[])) PAID
Receipt#
Will the applicant or future building occupant use equipment of devices which
mithamNous air mn(unilnan6 as Aufinetl by the Bay Arca An VmJity Manugemenl BORLER-COMP(JIfP OR IIp.IXp R'N)
U'otricYf TOTAL'.
❑Yes CNn MOILER-COMP(OVER Igl01p B'1'll)
I have read the haeardons materials remicarenta under Chapter 695 of the Calf- AIR CONDITIONER
9 ISSUANCE DATE
fitmfa Healhisgdo,,br Safety Cede,Sermons 25505,8533 and 25534.1 understand that if me NIiW NISIDENTIAL MECH. SO.FT ^ _
M1uilJing Jaen not cumnJy It re t.thr livny mspunsihility tnntify Ee wcurym C�(J (1
ofth menrs which mea be et psi tssuonie if en' roof p [/
51
Owt agent ate TOTAL: ISSUED BY:
OFFICE