99110136 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 9T J I
CITAI OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. I APPLICATION SUBMITTAL DAD
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OWNER'S NAME: PHONE CONTRACTOR'S NAME: LIC NO'.
` .�� NIC COM'H(yLa
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InNCill'1'ISC'I'111N IlliR: LIC N('. ADDRELit-
ISS ❑
CONTAM PHONE: BUILDING PERMIT INFO
s ❑ Consultant Frxs Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
Lo&Q- l ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION e OTY ELECTRIC PERMIT FEE
I hereby afford On 1 am licensed under provisions of chapter 9(commences JOB DESCRIPTION
Q=Z with Section 700B)of Division Lifthe Bminexsand Professions Code.and my license is RESIDENTIAL:
WO C) ntfull li,rcc send r PERM SSUANCE
C-f- L.1 (� OSFDWL ❑KITCHEN REMODEL
GUU IArense CLrss Lic.M ��^ APPLIANCE. RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
y¢LLl Halc CS DFCL
GG ARCIII'I'IiCI"S UIiC1.A1tAT10N —� ❑Mlj a'1-UNIT ❑STRUCI'Ario
F+N Z 1 understood my plum.shall be used os public records PANELS CHIMNEY
§CATION
OZ4-` UP]'02W AMPS El INTERIOR ❑CHIMNI:Y RI3PAIR
,,I-W Licensed Professional 201-1000AMPS IMPROVEMENT (]SWIMMING POOLS
Zyf� OWNER-BUILDER DECLARATION OVER IIMMIAMPS ❑BATH REMODpgIJREPAIR C3 DEMOLITION
I hereby affirm that 1 am exempt from the Contractor's License Law for the \`
3=U following reason.(Section]031S,Business and Professions Cade:Any city or county SIG NS ELECTRICAL ❑O11�"iEN FSG
y which requires a permit m construct,alter improve,demolish,or repair any slm<turc r l a .Q i�DC_P_
gnome its issaznce.also requireathe applicant for such permit 19 fl,, M,ned,mmmem SPECIAL CIRCUIT/MISC.
that he is licensed pursuant to the provisions of the Couturiers License Law(Chapter 9
ad Cc (conmmncing with Section 9BBf1)ofDivision3 nfthe Businea and Prolexsiam'CnJc)or TEMP.METER OR POLI:INST. COMMERCIAL'
d q o W thin he is cxnnpt therefrom and the basis lira the alleged exemption.Any violation of ❑NEW BI.DG/ADDITION ❑DEMOLITION
Section 7031.5 by any appllcunl for it I,onnit subjects the applicant in a civil'Nualiy of POWER DEVICES
U^� rat nwrvihun live hundred dollars(55(0), ❑TENANT FOOD SERVICE
[-• J. IMPROVEMENT
G Q I.as owner of the progeny,or my croployces with wages as their sole comgensrtion, SWIMMINGPOOLELECfR1
S will do be wk,and th-bucmre isnot intended-offered ferrule(See [I OTHER
or
h
DI"m and popery
who
Code:The oicsi cmr's Licence Law does not apply himself owner of OUTLITS-SWI'TCHF_S-Fl
3 progeny who builds pr improves thereon.and who Joe,such work dedoror through
sal own employees.provided that such mem is
ov an,not intended or offered for NEW RESIDENTIAL ELE $TOTA
sale.IL bsnvcvcr.the building ur impravcmcm is sold within one year ofrompininn.lhe SQ.FT.BOOR AREA LSQ.Ff.
cr-builder will have the burden of proving that he did not build or improve for pur-
"w of wle.).
M I,as owner of the progeny,am exclusively contracting with licensed contractors to .
instruct the project(Sec.7034,Business and Professions Code:)no Conwmor's Li
cc m Law docs mol apply in an owner ofprapid,who build,o,lmprovue mercum,kit QTY. PLUMBING PEFQJFr E
Moo contracts for such projects with a enntra't to I irensed paauant ,,th Commaml
Lice s,Law. PERMIT ISSUANCE
❑ 1 our exempt under Sas .B&11 C for this reason
ALTI:R-DRAIN&VENT-WATER IEA) VALUATION
Owner Uzne
Wm under Penalty
DECLARATION B, KFi.OW PROTECT DEVICE 1
I herebyawill mm tain a pennity of Perjury one of theelf following decWorker's
❑Ihave and forbinaction3ae of the Labor
Cs ,far the Wodds Compo- DRAT\'-FLUOR.RWEAREA,CORD. STORIES TYPE CONSTRUCr10N
scion. r prich his
for by Section 3]10 of the labor Code.for the performance of the
work for which th'n permit vistaed. FlXTURES 'T:H TRAP
1 have and will maintain Worker's Conigcosarom Insurance.as required by Section
3 oft ofthe Labor Codc.forrhopml rancrorihuwotk fnrwhmhdtis lc..it is issued. GAS-EA.SYS' 1-I INC.40U`pLETS OCC,GROUP N'N
My WSonour hu' ranee tunic,and Policy nun tier, 14 G t
Carrih.y.l�s'YVI'[I(�C Policy No.:� .^ lj�I GAS-EA.SYS'IFM- VER 4(EA) �;�y�CAC jS
CLIO IFICATI?OF EXHIAPI ION FROM WORKERS' GREASEJINDUSTRL WA :INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(]his section need not he conipincd ifthe permit is forone hundred drllan(SIM) GRI:ASE TRAP
or le"d PLANCHECK FLE
I cenify that in the perfannunce ofthe work for which this permit is issued.lshall SEWER-SANITARY-STORMS 10)IT.
not employ any Person in any manner m subject as to become subjeco the Workers'Counted-
0Z
omped- ENERGY PEE
0 Z sunion Laws of California.Dae WATER HEATER WNENT/ELECTR GRADING FEE
Z O Applmam
N(H ICE T(1 APPLICANT:If,after making this Certificate of Excmpbon,you should WATER SYS rEM/TREATING SOILS FEE
newbjwl m the Worker's Cnngwnsation provisions of the Labor Calc,you mast
{ra Iurdwithr up,with sueh prrokirnsor this permit shall be decmedrevoked. WATER SERVICE
Q
UZ CONS m isrRuca c ION LENDING INGAGENGY NEW RLSIIliiN1'IALYhMR SR I'll LAID Dine ReceiptM
U O If hereby affirm lM1auherc is o ud(Sri.nn lendingagency for the gerhammpcc of
E"' Llot ework far which this permh is issued(Sri.31W],Co.iv.CJ
U. 1<nJcr's Name TOTAL:
LBUILDING Igili
U61 Lender's Address TOTAL:
y 1 vend,then I have read this agg.icrow and stem that the above information is
t: 0.
correct.l agree to comply with all city and county entrances and same laws relating to QTY. MECHANICAL PERMIT FEE
U Z building construction.and hereby authorize representative of this city to enter upon the SEISMIC FEE
aMivo-mcndonN pmpcny for insgcction Purposes. PERMIT ISSUANCE
(We)agree to save,Indemnify and keep hatmle,the City of Cu xinino against ELECTRIC FEE
in
Iiahiliticn,juJgmems,astsand exhorts w
hichmre
ay in any wrynmc.,uu,l,md City ALTER OR ADD'1'OMECII.
nsequvtec of the granting ill this permh, PLUMHIN[11)F'E
APPIACANT UNDERSTANDS AND WILL COMPLY WITH ALI,NON-POINT AIR HANDLING UNIT(TO 10,DO CFM) MECHANI6AL'IFEE �'Y L L Irl
O CIi REGUL TIONS.
AIRHANDLINGUNIT(OVER 10,000CFM) CONSTR (iT1ON
Cc p k o0 � G
Signamrcnl Applicani7Coihr tr Date EXHAUST)OCD(W/DUCT) ;
11
HOUSIN RIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE t
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO IMdM0 BTU)
as defined by the Cupertino Municipal Codes Chapter 9.12,and the Hcuhh wd Safety
Code.Section 25532(x)'! - / HEATING UNIT(OVER 100,000 B0'6 By
❑Yes '�4P1' VEND LATION PAN(S INGLE REMD) PAID
Date RccciPtp
Will the... ..canl m.inure bending nccuguB y A ea Air 0.m nr devisee whish
atoll huaurdnus alt conlanununB ns Aulinal by the Bay Area Alr Quality Manugummot tl011.1!R-C(1MP(711YUN IIMI,fXMI BTU) TOTAL'
11i.caicl'! f
C1 Yes ROIIJ:N-COME(OVF.R IIMI,UIU B'N)
1 have read the haeardnu,m:ncnals reyuimmm
es under Chapter
CON IM PION ER,6.45 of the Cali- ISSUANCE DATE
forma Health&Safety Cute.Section,25505.25533 and 25534.1 undmmnd then if the NEW RESIDENTIAL MECH. SQ.FT.
M1u SJriesnon conically have' iro.that it is my rc,pamibiliry toramify thenccapznt
f requit, is which mush�e vin gonna issuance ofa Cenlf ateof(ker,mg,
to CALM
t4�1 t ga _ `c1.t14 CJC
Owner to authorized agent Dae TOTAL: ISSUED BY'.
OFFICE