99110079 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY O
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECIIANICAL Ql
J' BUILDING PROJECT IDENTIFICATION
BUILDING ADORESS: SANITARY NO. APPLICATION SUBMITTAL DATE
19-7 14 E, ES _ 4/' 11-1(e _
R' N ME� HON :g��� CONTRACTOR'S NAME: LIC NO:
N/C CONTROL It
ARCHII'ECI'IENGINEER: LIC NO ADDRESS: ❑
coNTACI': PHONE: BUILDING PERMIT INFO
❑ Consultant Foes Paid by Applicant(Initial) BLDG ELECT PLUMB ECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY, ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Coupler 9(commencing JOB DESCRIPTION
WOO won Section 700E. haision 3ofthe Business and Prvfesslons Code,and my license is RESIDENTIAL:
l- m fiallfor[xandeffect. PERMIT ISSUANCE ❑SFDWL ❑KITCHEN REMODEL
QUO License Class Lian APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
F Q W Date Contractor
t/ ARCHITECTS DECLARATION El MULTI-UNIT ❑STRUCTURAL.
Z p y 7, 1 underomid my plans shall he used us puhlic mcoNs PANELS
MODIFICATION
c Z_a UPT02WAMPS El INTERIOR ❑CHIMNEY REPAIR
Q4F-J Licensed Professional 201-I0Ig1AMPS IMPROVEMENT ❑SWIMMINGPOOIS
OWNHR-BUILDER DECLARATION ..,�,,T(_�
CY -4 OVI7R IWBAMPS *ATH REMODELIREPAIR ❑DEMOLITION
G C W Q 1 hereby affirm that 1 1. exempt from the Conuacmr's Licence Law for the
3 LL F following rusoa(Section]construct,
t,alter. andmp ve,desioas Crda:Any city an or county SIGNS ELF.CTRICAI. ❑OTHER
which requires n permit re etmss the alcor,improve,deummil t file
repair any xwment
FSO
prior to issuonee,also requires the applic rtor such permint rilcasigned statement SPECIAL CIRCUIT/MISC.
E } Nat he is licensed purstanta.the previsions of the Contmcme,License Law(Chapter 9
�COp Immmencing wiNS¢tion]g0)nf DivisionJof the Business anJ Professions Cnle)or TEMP.METER OR PO COMMERCIAL:
6 c C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
o, Section]031.5 by any applicant for a permit subjects the applicant In u civil penult,of POWER DEVICES
not more thou ve hundred dollars S5(N0. ❑TENANT ❑FOODSERVICE.
^ZQ riI,as nwnerof the SWIMMING PO ELECTRIC IMPROVEMENT
�Q ❑ property, remyemplended with for their compensation, ❑OTHER
will do the work.and the strvcwre is not intended erotTemd forsale(Sao]fW,Business
W 3 and Professions Code The Conuacmrs License law does not apply to an owner of OUTLETS-SWI Riig
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not rumored or offered far NEW RESIDENTIAL ELE SQ Er.
sale.If.however,the huddling orlmparcrat is said within one ycar ofeompleJnn,the SQ.PT.F{.OGR AREA $/SQ.FT.
owner-hudder will have the burden of proving that he did not bund or improve for par
pose of sale.).
❑I,as owner of the property.um exclusively commuting with licensed contactors to TOTAL:
conswn the project(Sec.70/ .Business and Professions Code:)The Conuactnr's Li.
const,Lawdoesn apply to minister of property who huilds or improves thereon,and QTY. PLUMBING PERMIT FEE
who eonvu rch"
project,with n timmolor(s)licensed pnmmnrto the Cnmracmr's
Licen w, PERMIT ISSUANC17
m exempt under Ser. ,B&P C for this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
net Dole
WORKER'S CUMPENSAi'ION DECLARATION HACK FLOW PROTECT'.DEVICE
hcrcby offizm under penalty of perjury one of the following declarations:
Ili. sand will mainamr.Carificleof Consent atself-itrume sr Worker's Cmnpen- DRAINS-FLOOR,ROOF,AREA,COND. STXI TYPE CONSTHUCI'ION
station.as provided for by Section 37M of the Latter Code,for the performance of the
work for which this permit is issued. FIMURES-PER TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section
37M of the lalOr Code,for the performance of the work for which this permit is issued GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP
My Worker:Compensation Insurance carrier and Pal icy number am:
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE.OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRFASMNDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FE
(This section necdnat becomplema ifthe permit is Lorene hundred dollars($100) GREASE TRAP
or less.) PLANCHECK FEE
I certify that in the performance ofthe work for which this Permit is issued.)shall SF.WfiN-SANITANV-STORM BA.21N1 Fri.
not mnploy any person many i mater so as to become subject to the Workers'Compen- ENERGY FEB
QZ salinn laws of California.Dae WA'HiR HEATER W/VENT/ELECIR
Z O Applicant GRAD OHFE ^
rN.. NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTEM/TREATING ' L
/'`\
F becomexubject to the Worker's Compensation provisions of the lalan Code.you must SOILS �\
aQ forthwith comply with such provisions or permit shall be deemed revoked. WATER SERVICE tL
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL.PLMB. SQ.FT PAID 1
V Q I hereby uffirrn that hem is a construction lending agency for peRonnance a IF DflU tb
the work for whicb this permit is read IStt.3(0].Civ.C.)
C) U Lemdds Name B TOTAL:
Lemde(s AJdmss TOTAL:
1 certify ohm 1 have read this applustinn and scam that the uMwe information is BUILT NUMB
i..i rn correct.I agree to comply with all city and county ordinances and stale laws rotating to QTY, MECHANICAL PERMIT FEE ^-'^--
V Z huilJing construction.unJ hertby authorize reprtsentatives of this city to enter upon the SEISMICFEE
above-mentioned pmpeny far inspection purpo.ccs. PERMIT ISSUANCE.
(We)agree to save,indemnify and keep harmless the City of Copeman against ELECTRIC FEE
liabilities,judgments.costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECIT PLUMBING FEE
in crmsequence of the granting of this permit.
APPLY NTUNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'1'(TO IQIXNI CIM)
MECHANICAL FEE
SOI 'E REGULATIONS.
AIN HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
ignamreof AEAicant/Contractor Data EXHAUST HOOD(W/DUCD MOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicnm or Wmrm building nectmanimmm or bunAla LumNoaa inateriitl HEALING UNIT(T(3IINI,INI(1 BTU)
as definN by the Cupertino Municipal Code,Chapter 9.12,and the Health and Sam,,
it ode,Section 25532(x)'! 11 EATING UNIT(OVER 100.001)BTU)
E3 Yes ❑No PAID
VENTILATION FAN(SINGLE RESIU) Data ReceiptM
Will the applicant or future building oecupmm use equipment nr devices which
omit bazmdous air contaminants as defined by the Bay Arca Air Qwlity Management BOILER-COMP(3HP ON 100,000 BTU)
District'?
T '
❑Yes ❑No BOILER-COM
C3 IW.00f1 BTU)
I have read the hazardous materials nquimnems under Chapter 695 of the C.B. AIR CONDITIONER ISSUANCE DATUO
fo {ealth&Safety Code,Sections 25505.25533 and 25534.1 understand ohm if the NEW RESIDENTIAL.MECH. SQ.Fri.
Jdiag does not currently have o tenant.that it i,my re,,re billry m notify the occupant
of 0e mr,mmanents which must It,met Prior to issuance of a Cenilicate of Occupancy.
caner or aathodzed agent Data TOTAL: ISSUED BY:
OFFICE