99090123 (3) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 41 q ()q O
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
RUI LDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
S grJ i I.. L.. 7
OWNER'S NgcME (�
PRONE, - ONTRACTOR'S NAME: ' ` LIC No _L
-tuA J1I1w Tnn.7�S - ] I' r3.CID l Oµkr-gam N/C CONTROLb
HITECfIENGINEER: r LIC NO: ADDRESS: ❑
NTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ EI' Efr ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
��Z with Serine 7000)of Division 3M me Business and Professions Code,and my lin:nse i. RESIDENTIAL:
F W= in full force and effect. PLRMI'f ISSUANCE ❑SFDWL ❑KITCHEN REMODEL
�U License Class Us,it APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
yZ Date TSDEoCommenar
d ARCHITECT'S UECblicreords PANELS ❑MULTI-UNIT ❑STRUCTURAL
2 O r�Z I understand my plans shall he used as public records MODIFICATION
OZ Q UPT02MAMPS 1 11 INTERIOR El CHIMNEY REPAIR
rr ,I ly Licensed Professioml 201-1000AMPS rr1hMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER I(gf1AMP5 P BATH REMODEL/REPAIR El DEMOLITION
0.' 1 hereby affirm that I am exempt from the Commences License Law for the
3 6 F following reason(Section 7031.5.Boniness and Professions Cede:Any city or county SIGNS ELECTRICAL ❑OTHER
ti which requires a permit to construct,alter,improve,demolish,or repair any structure
� print to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC `
a"1y C�' that he is licensed pursuant the provisions of the Contractors License Law(Chapter 9
�rp0a (commencing with Section 9(100)of Division 3 of the Businessnnd Professions Code)or TEMP.METER OR MCI..INST. COMMERCIAL'
Q.�aJ c W that he is exempt thereftnm submit basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION [-]DEMOLITION
Wim Section 70315 by any applicant for apenmhcbjeetathe applicant to a eivilpenalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
n more than five hundred della,,(55!x0. IMPROVEMENT
^ Q Las owner of me properly,ter my employees with wages as theirsole comforter.., SWIMMING POOL ELECTRIC
will do the work,and the structure Is not intended or offered for sale(Sec.7044,Business ❑OTHER
6'3ne and Professions Gale:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or hrough
his own employees,provided that such improvements are not intended or offered for j NEW RESIDENTIAL ELECTR SQ LE
sale.If,however.the building orimprovemem is sold within one year of completion,the .FT.FLOOR AREA $/SQ.CE
builder will have the burden of proving that he did not build or improve for pur-
[P pos sale).
os owner of the property,am exclusively contracting with licensed contractors to TOTAL:
onsVun the project(6,,.9044,Business and pmPoa,mrs C.d,)The Conne am,Li-
se Law does not apply to an owner of property who builds of improves thereon,and QTY PLUMBING PERMIT FEE
whore ace.,for such posters with a iomnmmad licensed proment,,the Contractor,
License Law. PERMITISSUANCE
1 am exempt under Sec. B&P C for this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Date
WORKER'S COMPENSATION DECIARANON BACK FLOW PROTECT DEVICE {\� f1
I hereby affirm under penalty of pujvry one of the following declarations: c lO 0
I haveand will maintain a Certificate of Constant ms,lf-insure for Worker's Crimper- DRAINS-FLOOR.ROOF.AREA,COND. STORIES TYPE CONSTRUCTION
on,as provided for by Section 3700 of me Labor Code.for the performance of the
work for which this permit is issued, FIXTURES-PER TRAP
I have and will maintain Workers Compensation E aminka,as required by Section
3700 ofthe Labor Code,for the performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-I INC.4OUTLETS OCC.GROUP BOk
_ A / ^
My Worker's Compensation Insurance reamer and Policy number area 1G
Carrier: Policy No.. GAS-EA.SYSTEMOVER4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' D
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
This section need not be completed ifinmit is e perforone hundred dollars(8100) BUILDING DIVISION MRS
less) GREASE TRAP PLANCHECK FEE
I certify that in the performance ofthe work forwhich this permit is issued,I shall SEWER-SANITARY-STORM EA.200 FT.
,7. f
not employ any person in any manner so as m feature object to the Workers'Compen- E .kcli"pt
smioa Licvsol Califamis.Data
>Z O Applicmt WATER HEATER WNENT/ELECTR GR�pI GTE _ rj V�
.^-, (j NOTICE TO APPLICANT:If,after making his Certificate of Exemption,you should WATER SYSTEM/TREATING t
a ^' become subject to the Workers Cntnpenaation provisions o[me Labor Code,you must SO 4 ITEtti bachwith comply with-such provisions or this permit shall he favored invoked. WATER SERVICE
Q
Pr
CONSTRUCTION LENDING AGENCY NEW RESIDEN'HAL PLMR. SQ.FT. PAI LJ�
I hereby affirm Ont here is a construction lending agency for the performance of 1 Date Receipt
U
the work for which this permit is issued(Sec.3097,Civ.C.) i
ULender's Name By TOTAL._
Lenders Address TOTAL:
I certify that 1 have read this application and state that the above information is BUILDING FEE
Fr to correct.l agree to comply with all city and county ordinances and state laws minting to QTY. MECHANICAL PERMIT FEE
building,onuranlon,and herebyimthnrize representatives of mistily to enterupanhe SEISMIC ME rill
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless me City of Cupertino against ELECTRIC P
Iiubllides,judgmems,costs and expenses which may in any way aaeme agaivstend City ALTER OR ADD 0)'O MECH.
in onsaquence of the granting of this permit. PLUMBING
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. MECHANICAL FF.
t iQI ('(p 14 P AIR HANDLING UNIT(OVER IO,OCfI CFM) CONSTRUCTI TAX
Signature of AppbcamUControctof 1 Date EXHAUST HOOD(W/DUCT) HOUSING MITIGT FEE
HAZARDOUS MATERIALS DISCLOSURE
Will duappliern or future building occupant store or handle haaardous material HEATING UNIT GO 100,000 BTU)
as de inti by rho Captions,Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(!I HEATING UNIT(OVER 100,(4r)BTU)
❑Vias No PAID --
VENTILATION PAN(SINGLE RESIO) Game Receipt#
Will the it co maniant or here building bytheresonant use A Area
Air Qualitnt or y
Management
BOILER-COMP(3HP OR 100,000 BTU)
it hazardous air contaminants as defined by the Buy Arca Air Quality Mumtgement TOTAL:
suint 111111ssssss
C]Das �N0 NOILF,R-COMP(OVER IIXI,g1I1 BTU)
I have read the hazardous materials counteracts under Chapter 6.95 of the Cali- AIR CONTI'I'IONER ISSUANCE DATE
ams Health&Safety Code,Sections 25505,25533 and 25534.1 understand that lithe NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have a tenant,that it is my responsibility to notify the eeeupant L b
o
here arm tswhielrmustbe tprnrI is ofaCor, roof Oecupone
�_ -9
authorized agent Date TOTAL', ISSUED BY:
OFFICE