99080001 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-'USE BALL POINT PEN ONLY -
CITY OF CUPERTINO IIUILDING-(:LRC'MECHANICAL I. PE
APPI.ICATIONMERMIT I'INGPROG-MN.CENTIFIC
BmLDlrvc mesion 50001
BUIIAtN4'1'RO.IEf-T IDENTIFICATION
BOLDINGA S ������ �� SANITARY Is APPLICATION SSUBMIT-I'ALDA'I'I
OWNrB'S NAM PI ON[i: CO RA D 'S ALE: 11 L1CN :�� 2 g
(//V'K'e NIC CONTROL#
CHITECIENG1NEER: LIC NO: A E 5: ❑
y Q
CONTACT: PHONE: - BUILDING PERMIT'INFO
�f/ T J� ❑ Consultant Fees Paid by Applicant(initial)' BLDG ELECT PLUMB MIZ01
F W Z in l'Il I hx,,bd effect. QT'Y PERMIT ELECTRIC PERMIT FCE JOB DESCRIPTION.
LICENSED CONTRACTOR'S UECLANATIfIN
I hcrchy edam don 1 am licensed under provisions of CI'rpmr 9lennmencing
adoZ with Seninn7(XNB of Division)of the Business end Pmfuninre Cnd undmylicemeis - - RESIDENTIAL
T ISSUANCE
aUU~k3 Licennc Cluas G LiL.M /� ❑SI'UWI. ❑KITCHIiN.RCh10Dlil.
FZyI Dam Contractor APPLIANCCS-RESIDENTIAL ❑ADDITION [I PLUMBING NIiPII'li
w6a ❑MULTI-UNIT ❑STRUCTURAL.
NCHfI'ELTS DECI.ARA ON
'0 rro Z L understand my plans shall he used as public records PANELS MODIFICATION
OZ14- UPTO20n AMPS ❑INTERIOR E3 CHIMNEY REPAIR
h•�FW Licensed l'rnfesaional 101-100(IAMPS IMPROVEMENT C]SWIMMING POOLS
901 OWNER-BUILDER DECLARATION OVER["AMPS ❑RAI REMODELREPAIR [I DEMOLITION
C e Law for the
xLxpaQ I hereby afrm that I am exempt from the Convenor's LicensU following reason (Section 703 L5.Business and Professions CMc:Any city or county SIGNS ELECTRICAL ❑Ofl¢H
W 31a F which requires a permit m construct,alter,improve,demolisil repair any structure
prior to issuance,also requires the afflicted for such permit o lilcu signet statementSPECIAL CIRCUI FIMISC. 01
that he is licensed pursuant to the provisions of no Contractors License Law(Chapter 9 COMMERx
(commencing,with Section 7")of Division 3 of the Business and Profusions Code)or TEMP.METER OR POLE INST.
ILpi�,c oL that he is exempt therefrom and the basis for the alleged exemption,Any viNmion of ❑NEW BLDG/ADDITION ❑DEMOLITION
W^m ScUiun70315 by aryappdicam fora permit subjects the applicant u civil penalty of POWER DEVICESd�q
❑TENANT ❑FOOD SERVICIi
0 I amnralhml fvehundreddollars($500). I DVI'MENT
�I,asnwne,oI hopropcny,or my cmployeu with wngcs us'huirsnlc cnn'pemvtion, SWIMMING 11001.PLEC'TRIC
vett Ao the work.vest the swcmre is not imended fir nRercd lirr sole ISec.7W4,liusiness 'THBR
and Professions Cede:The Contractor's License Law aces not apply to an owner of OUTLETS-SWITCHES-FIXTURES
Or
n'a prop<•ny who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECI'11 SQ FT.
sale.11,however.the building or improvement is sold within ma yeurofcompletion,the SQ.71uY
S/SQ.IT.
owner-builder wil I have the burden of proving that he did not build or improve for put-
pe.ofsale.). f
❑h as owner of the properly,am exclusively contracting with licensed con'rumors m TOTAL:c:mzwet the project(Sec.7014,Business and pndessions Cool The Contractor's Li-
c set.awdoesnotapplytoanownerofpropertywhohuildsorimprovesthereon,and QTYPLUMHINGPFiRMIT FEF; 1999
who contracts for such projects with a comeactions)licensed pursvanuo the Contractor'sLicenx Low. PERMITISSUANCE
1 nm exempt under Sec. .B&I'C for this reason
ALTER-DRAIN&VI?NI'-WATER(EA) VALUATION
Owner - Date '
WORKER'S COMPENSATION DECLARAI ION .BACK FLOW PRII17(71'.DEVICE —• ---
1 herchy affirm under penalty of perjury one of the following dalandinns:
I hnvvandwilin i onto a Cvnineamor Consanuo sel f-hom.for Workers Ccousle- DRAINS-FLOOR.ROOF,AREA,GOND. ORIliS TYI'H CONS'1'ItUC'I'I(lN
mtinkn�,�`x�s provided for by Section 37W of the Lubar Cndq liu Cha Iurinrmmmce of the
work�'yV which on,permit is isxucd., FIXTURES-PER'['NAP
(O.Th and will mmmuld Worker's Compensation Insurance,as required by Section
37411 of the Lismi-Code,far the performance alone work Car
which
'his
sfardanit is iissued. GAS-EA.SYSTEM-1 INC.40U'f1.ETs OCC,GROUPMy
C mcrr n ns I uncc aPolcy No.' CEZ%=?w GAS-EA.SYSTEM OVER 4 OW
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASF/1NDUSTRh W'AS'Ri1NTENCEPTOR
COMPENSATION INSURANCE BUILDING DIV] FEES
(This sectiotmed not M completed done per
mu-is furore hundred dollars($100) GREASETRAP -
or less.) PIANCII[CK IIiE
I cmify that in the performance ofthe work forwhich this Permit is issued.I shall SEWER-SANITARY-STORM EA.210 FE -
act employ any person in any manner sec a to become subject it)the Workers'Corrpen- ENERGY FEE
Z motion laws of Califnrniv.Date WATER HEATER W/VIiNT/ELECfR
Q Applicant 1 GRADING FEE
N NOTICE TO APPLICANT':If.after making this Cenificam of Exemption,you should WATER SYSTEM/I'REATING -
hecome.wh'ect to the Worker's Compensation f the LaMa Code,You must SOILS FEE
pe provisions c
!' fonhwi'h comply with such provisions ser this permit shall he deemed revoked. WATER SERVICE, -
W
CONSTRUCTION LENDING AGENCY NEW R1iSID1iN'I'IAl.1'LMO. SQ.FT ('AID
V �. Iherehy aflirtn lhauhereisnconstmction lending tlgency lir the perfnnllanco of
Date ReceiptN
F the work for which this permit is issued(Sac.3097,Civ.C.)
Q 'fOTA 1.:
Lenders henna
U
1.endcr'x Address 'TOTAL:
BUILDING PER
[r 1 agree
that 1 have read anis application and stare ordinances
the ahrve information is
fA esuem,logreemcomply hwith erth, city and countyyotatives of and city
it) ocretiongm QTY. MECHANICAL PHKh11T FEE
U rZ•I building amstmction,and heathy authorize representatives of this city uumer ulwn the SHISMIC PER
ahrvun crismad limpcny for inspection purposes. PERMIT ISSUANCIi
(We)agree to se,indemnify and keep harmless the City of Cupenino against ELIiCr111C FEE
save,
Iiahilities,judgmems,costs and expenses which may in any way acerae against said City ALTER OR ADDLD MECIL
in PLUMBING FEE
msequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILT.COMPLY W I'I'If ALL NOWPOINT AIR HANDLING UNI'['(TO IOIKO CFM)
MIfCIIANICAI.FEF.
SOUR7REGULATIONS.
f AIR HANDLING UNI'1'(OVI?N 10,0010 CPM) CONYTRUCf1ON'fAX
Signvm¢of Applicam/Cnnvacmr Date EXHAUS'fHOOD(W/IIUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplimml orfumrc building occupant store fir handle hazanlous imiedul HI3ATING UNH'TfO 100,(000 OJO
vs defined by the Cupertino Municipal Code.Chapmr 9.14,find the
' Iculth and Sufcty
IG i21fCade,Svion 25532a! N0(0 if I'U)
❑Ycs - VEND ILATION PAN(SINGLE RFS1D) PAID Il:nc Receip
Will the applicant or future building«cupvut use equipment or devices which
nil hazardous air comamiranu as defined by the Bay Area Air Quality Management BOILER-COMP(3HP ON 10JW BTU) TO 1.
1
Distrior!
❑Yee BOILER-COME()VER 100.000 BTU)
1I baxallous ¢pals rcyuircmenu umkr Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DAT
E
fair Heath&Safe S« o s 25505,25533 ami 25531.1 understood than if the NEW RESIDENTIAL MECIL SQ.EL.
buildin6 docs nm cu a t,thaduismymspmsoolo I on 'he«$pant
of Wercyuire . sesta etpriormissua«cofuCenificmeo Quf p�pgy., �S
amA[
Owner oro thnrizcdacm U e TOTAL: ISSUED HY:�
OFFICE.— --