99090141 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY l�
CITY OF OUPERTINO BUILDING-ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BU14�I AUDIT�.��� � � O/ SANITARY NO. APPLICATION SUBMITTAL �E
NB 'S NAME: ^CO r PHG E: ONTRACfOR'SNAMF;: LIC NO: 2
••NN\E /O.7y1V-•Jyt�A NIC CONTkOL#
CHITECUENGINE LIC ND: I3j'$$j� ❑
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CONTACT': PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLD ' ELF, T PLUMB MUCH so
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE Lel/
I hereby affirm that I am licensed under provisions of chapter 9(commencing JOB DESCRIPTION
wa0c) with Section]01)(E.Mivlsiml 301hd Businessaad Professions Cade,andmy licensors PERMIT ISSUANCE RESIDENTIAL•
Fyt In full forceand efl'ecl. � /
6UhU" License a Lic.# ` ❑SFDWL Ii7CITCHEN REMODEL
yQ W� Uma Cammcmr APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
ZCtoyARCHIT'ECT'S DECLARATION PANELS ❑MUUpFUNIT ❑STRUCTURAL
) Z I understand my plum shall be used as pithim eradf, MODIFICATION
OZ +A UPT0200AMPS ❑INTERIOR El CHIMNEY REPAIR
F4I"'J Incensed ProRssional 201-I000AMFSIMPROVEMENT L]SWIMMING POOLS
QQ OWNER-BUILDERDECLARATION OVER 10001000 AMPS D BATH REMODEUREPAIR El DEMOLITION
Q I hereby affirm that 1 am exempt fromm the Connector's License Law for the
�qxj O y U following reason.(Section 70315,Business and Pmfmsions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
W 3 w F which regmres a permit it,construct,slice improve,demolesb,m repair any andro re
priorm its issuance,also requirestbcapphomnl forsuch permit to rile a signed statement SPECIAL CIRCUIT/MISC.
} that he is licensed pursuant o the provisions of the Comruclar's License Law(Chapter 9
(wmmermingwiO Section 70c000f Division 3oflhe Businessand PmfirranuCode)ot TEMP.MELEE OR POLL INST. COMMERCIAL:
Gi tL c that he is exempt therefrom Ind the bast,for be alleged exemption.Any violation of
�� Section]03156 an ❑NEWBLDG/ADDITION ❑DEMOLITION
POWER DEVICES
y ynpplieam forapemdr subjects the applieanuo ncivil penahy o[
not mere than rive hundred dollars($500). ❑TENANT ❑POOD SERVICE
^ q ❑ I,asowner of the property,or my employees with wages as theirsole cadhaosmion, SWI MMI NG POOL ELECTRIC IMPROVEMENT
will do the work,and rhesauame is not iblam ed nr offered for sale(Sec.7044.Business ❑OTHER
mit Professions Code:The Commands License Law does not apply to in owner of OUTLETS-SWITCHES-FI ES ---- ---m •.----t
Property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements am not intended or offered for NEW RESIDENTIAL ELECTR r C-V i
sale.If,however.the building nrimpmvemem is sold within one year of completion the ET.FL ORAR A S/SQ,FT.
pcoverhuilder will have the burden of proving that he did not build.,improve for par- 't
a,eaf,ma,. ®
❑ SEP 2 3 199
I,us awnu of the property,am excessively eadinwith licensed wnhacmm TOTAL:
construct tM1c project(Se (144,c.] BusiHolmes, Prof
s unA Professions GtdeJ Ts
'he Commcmr' Li-
se Law does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE
who contracts for such projects with a coronations)licensed pursuance the Convaemh p
y
License Law.
El & B
I am exempt under Sec. ,B
PERMIT ISSUANCE P C for this reason —u...
ALTER-DRAIN&VENT-WATER(EA)
net Data VALUATION
WORKER'S COMPENSATION DECLARATION BACK PLOW PROTECT.DEVICE p O V^
I haebya0m irunder poeoltyaf perjury one of the billowing declarations: U
I huveand will maintain a Certificate of Consent to self-insure for Worker's Compact- DRAINS-FLOOR,ROOF,AREA,COND. S ORIES TYPE CONSTRUCTION
cation,as provided for by Section 3]00 of the Labor Code,for the performance of the
work for which this permit oarsmen. FIXTURES-PER TRAP
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
3100of the Labor Code,for the perfonnanre nflhewmk for which thispermit is issued. GAS-EA.SYSTEM-1 INC.40UTLF,TS OCG GROUP ��APN
My Wnrke' C t Insurance carrier and Polio,nu
Cartier !§WW4AIyD PolicyNa.: � �(y;S7 49_ GAS-EA.SYSTEM-OVCk4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUS'IRL WASTE INTERCEPTOR
(Tussemionnaednar he completed ifthe permit is marine hundred doctors UUP) BUILDINGDIVISIO ES
or IessJ GREASH TRAP PLANCHECK FEE
I.yromythat,comand any romanr,eratorirahe work fmwhich this the Worker,'ssued,l,h.11
SEWER-SANITARY-STORM EA.2010 FT.
not employ any person i a any manner so ns m became abject m the Worker:Compen- ENERGY FEE
Qz saint Lows of California Dae O WATER HEATER WNENVELECTR
GRADING FEE
OTIC rel
N
ti NOTICE TO APPLICANT IL afar making this CeniOcae of Exemption,you should
most WATER SYSTEM/I'RFBTING
a , b rrova subject m the Workers Compensation provisions of the Labor Cade,you mull SOILS FEE
L1a fonhwitM1 comply with such provisions or this permit shell he deemed mvakeJ. WATER SERVICE
0. A
U 0 CONSTRUCTION LENDING le ACENCY NEW RF.SIDENT'IAL PLMB. SQ.FT. PAID
UQ Ifohereby whicaffirm'h thamiti iso add
construction eluding agency forthe performance(if 'Dem Receipt of
[Iw the work far which this permit is issued(Sec.309],Civ.C.)
O Leaders Name TOTAL:
W Lender's Address TOTAL:
ky 1 certify thm 1 M1uva read this application and slam that the above information is BUILDING h
V] correct i agree to comply with all city and county ordinance,and-stale laws mlaling to QTY. MECHANICAL PERMIT FEE
U Z building concoction,and hereby authorize representatives of this city to chair upon the SEISMIC E
abmprepped,.e-mentioned pperty far indeed...purposes. PERMIT ISSUANCE
(We)agree m sever indemnify and keep harmless Ne City of Cupertino against ELECTRI EE
liabilities,judgments.costs and expenses which may in any wayaccrae agar rest said City ALTER OR ADD TO MECH.
in oreeyuence of the granting of his permit. PLUMBING P
APPLICANT UNDERSTANDS AND WILL COM LY WI ALL NON-POINT AIR HANDLING UNIT(TO 10,11(10 CFM)
SO CEyR ULATIONS.s l 1 I�� CONS IT MECHANICAL W�]���( ((�41 q'1}0111' AIN HANDLINGUNIT(OVERIQOOBCUM) CONSTRUCTION TAX
Signature of Appliwnl/Conoaclor � EXHAUST HOOD(W/DUCT) HOUSING MITIGATION PEE
HAZARDOUS MATERIALS DISCLOSUR
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO IOg)00 BTU)
as derided by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety
Code,Section 25532hoo HEATING UNIT(OVER 100,001)BTU)
❑Yes ❑No
VENTILATION PAN(SINGLE RESID) PAID Dae Re
Will the applicant or future building occupant use equipment or devices which Ipt
it hamNnm nir eonmminants e,OeGnW by the Bay Amit Alr Quality Management BOILER-COMP(3HP OR 100,00(1 BTU)
imdn"
]Yes ]Nn BOILER-COMP(OVER 100,000 BTU) L:
I have read the ke Mous natenals requirements under Chapter 6.95 of the Cali- AIR CONDITIONER
ISSUANCE DATE
fomia Health&Safety Code,Sectors 25505,25533 and 25534.I under Innd that if the NEW RESIDENTIAL MFC({, SQ.FT. ��
building doe am cadre d,hi ul nnL thoflfv amibieity to nnlifylh occupant
of ere mmswhich list arnpo my ofacerifi-Infocc or
U rad-mimharizoda,mo re TOTAL: ISSUEDBY:
OFFICE