99090128 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLYC' O ()1-7
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CITY OF CUPERTINO BUILDING-ELECTRICAL PER
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION. —.—�
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL UATE
l D 45'6 Lina W ✓, Co •
OWNER'S NAME: 1. PHONE: ZSS_ CONTRACTOR'S NAME: LIC NO:
I NIC CONTROL#
CHITE '/ENGINEER: LIC NO: ADDRESS. ❑
CONTACT: PHONE: ,BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG FLE.CT PLUMBB MECH
ElJ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I herby i fbm that I am licensed under provisions of Chapter 9(commencing -� _ JOB DESCRIPTION
with Section700(f.fDiviston 3ofthe Business and Professions Code,and my license is RESIDENTIAL•
O O PERMIT ISSUANCE
W.. in full fore eeffect. [_1SFDWL [I KITCHEN REMODEL
V E'
License Class
Lac.N
+ZV APPLIANCES-RESIDENTIAL El ADDITION LJ PLUMBING RE-PIPE
ai Date Contractor
CC ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
Z C v,4 I understand my plums shall be used as public remNn PANELS
MODIFICATION
pz- UPTO200AMFS El INTERIOR El CHIMNEY REPAIR
F� Licensed Foressional 201-IMIJAMPS IMPROVEMENT C]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER like)AMPS ❑BATH REMODFUREPAIR ❑DEMOLITION
C 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
,k 0 Y V following reason.(Section 7031.5,Business and Prrms,ionv Code:Any Eby or eouary SIGNS ELECTRICAL []OTHER
W W WO y which requires a permit to construct,alter,improve,demolish,or repair any structure
Fyl' prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC. Ar
mp that he k licensed pursuant w the provisions afthe Contractors License Law(Chapter 9
� qp (commencing with Sedinn7W01 of Divisinn3of the Business and pre[eslonsCWe)mr TEMP.METER OR POLE INST COMMERCIAL:
d e C that he is exempt therefrom and the bells for the alleged exemption.Any violation of ❑NEW RLDG/ADDITION ❑DEMOLITION
'^ Sectio 7031.5 by any applicant fur a permit subjects the applicant to a civil penalty of POWER DEVICES
y ❑TENANT ❑FOOD SERVICE
y not more lhao lift hundred
Progeny,or my em). PROVEMENT
60Lasnwwork,andthnperty, rmyemplendes with wages mtheir(Sce.eompenactlom SWIMMING POOL ELECTRIC
C andwill do the dessm s C d e The Cont is for attended or Law do for et apply 704T Boniness OTHER
and Professions Cade:The oyes then' License Law does not apply s an owner of OUTLETS-SWITCHES-FIXTURES
property who builds pr improves thereon,and who does such work himself or through
his own employeesprovided Nat mch improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.lf,however,the
building or improvement is sold within one year of completion,the SQ.FT.FLOOR AREA $ISQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pur-
Zsesale).
owner ml the progeny,am exclusively command,with licensed contractors to TOTAL:
conffiact the project(Sea 7144,Bethel,and Profession,Code:)The Cmumemu'n Li
cruse Law does not apply to an owner of property who builds or improves Iheretn,and QTY. PLUMBING PERMIT FEE
who contracts Fireman projects with a tmam,nuPd licensed pursuer to the Comment's
Licence Law, PERMIT ISSUANCE
❑I am exempt under Sec. B&P C for this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner111, 171—
Date
WORKER'S COMP EN SATIONDECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one ot'the following declarations:
I have and will..;bruin a Certlfcaleor Coastal o self-insure for Workers Cempetr DRAINS-FLOOR ROOF,AREA,GOND. STORIES TYPE CONSTRUCTION
,mine,as provided for by Section 37W of the Labor Code,for the performance of Ne
work for which this permit is issued. j FIXTURES-PER TRAP
E] 1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,I..the performance of the .,it for whichthis permit is issued. GAS-EA.SYSTEM-I INC,4OUTLETS OCG GROUP APT', p
My Worker's Compensation Insurance carrier and Pulicy number are: � Y
Carrier: Policy No,: GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERSQ• 3
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR
BUILDINQ DIVISION FEES
(Kris action need tribe completed if Ne permit in become hundred dollars(Sled) GREASE TRAP _
arm' I
rles ) PLANCHECK PEE
I county that in the performance ofthe work forwhich this permit is issued,i shall `
not employ any person in by manner so as to beem r,subject to the Workers'Compen- SEWER-SANITARY MEA. DP.0 .,, ENERGY FEE
.action Laws of California.Date WATER HEATER W/V ECfR
zApplicant Ii��GRADING FEE
'7..iI( NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMliRE 1 �I
became subject to the Worker's Compensation previsions of the Labor Cede,you mum SOILS FEE
SEP
ti forthwith comply Ih mch provisions or this t shall be deemed revoked. SERVICE
W,Q pywi p perm; WATER
z;tz CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PIIMB. SQ.FT. `PAID Date Receipt#
I hereby affirm that There in a construction lending agency for the performance of
f
U the work for which this permit is issued(Sec 3097,Civ.C.) �--
4'' F Lender's Name TOTAL:
U Lender's Address TOTAL
W
I certify that 1 have read this application and stain that lite about information is BUILDING FEE
n.iy correct l agree to comply with all city and county ordinances and state laws miming In QTY. MECHANICAL PERMIT FEE
C.7 Z huilding cmmrieion,and hereby authore
rize repsentatives afthi,city to enter upinthc SEISMIC FEE
above-mentioned property far inspection puryoses. PERMIT ISSUANCE
(Wt)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities.judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
consequencein of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER I(thin CFM) CONSTRUCTION TAX
rgnmare of AppllcaM mancemr Dnte EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HBA'i'INO UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)? HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID Date Receipt#
Whi the npplicant or Fannie building tecupant use equipment or devices which
Flt hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP CHP OR 100,000 BTU)
O AL
;,,Her? BOILER-COMP(OVER 100,000 BTU)
❑Ye, L]No
1 have read the hazardous materials earimmarems under Chapter 0.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
Exam Health&Safely Cade,Sections 25505,25533 and 25534.1 understand Net if the NEW RESIDENTIAL MECH, �� �/ Q
building does net currently have a tenant,that it is my msprnsihility,to notify the occupant /
e mqu mons which ems be ton ppor m issu nceof a Cci ificate or Occupancy.
Owner or authnmed ager ��/ Date TOTAL ISSUED BY:
OFFICE