99100134 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLYi�Q J
CT'VV OFCUPERTINO BUILDING-ELECTRICAL PE MIT NO,
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION C
BUILDINGADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
IIIc s-r Z /CN°
OW R'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO.
TI S— — NIC CONTROL#
11
�, C TE /EN INE' : LIC NO'. ADDRESS: I I &3A„L„- ❑
CONTACT: - PHONE: 'BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ Yu
LICENSED cONTfldCTOR'S DECLARATION ElQTY. ELECTRIC PERMIT FEE
I hereby affirm that I am licensed ander provisions of Chapter 9(wmmendng _ -SOB DESCRIPTION
IyQjQO withStromone and
of Division of the Business and Professions Guda and my license is PERMIT ISSUANCE RESIDENTIAL:
�Fly F n full fora and e0 r ❑SFDWL ❑KITCHEN REMODEL
y�UU License Ines L. APPLIANCES-RESIDENTIAL
� Dam C [3 ADDITION ❑PLUMBING RE-PIPE
p.Ow ARCHITECTS DECLARATION ❑MULD-UNIT ❑STRUCTURAL
Z p 2 Z I understand my plans shall be used as blic records PANELS
Pu MODIFICATION
O Z UP TO 200 AMPS
OW Lmensed Professional ❑INTERIOR ❑CHIMNEY REPAIR
201-I000AMPS IMPROVEMENT
Sy0 ,'al OWNER-BUILDERexempt from
❑DEMOLINGPOOLS
y G 1 hereby off rte that 1 am exempt from the Contractor's License Law for the OVER IUIN)AMPS El BATH REMODEL/REPAIR 0 DEMOLITION
{y'3Pollowing reason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
W F
0OyQ which mantisa permit to construct,aper,improve,demolish,of repair any structure
print to its issuance,elan requires theapplicam forsrch permit to fileasigned stammeer SPECIAL CIRCUIT/MISC. +, �I,
if
r, G that he is licensed pursuant to the provisions of the Contractor's license Law(Chapter 9ICISI
aCC (commencing with Section u)(0)or Of vision 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. CO-MMERCIAL:
p�,sa a that he is exempt therefrom and the basis for the alleged exemption.Any violation of - ❑NEW BLDG/ADDITION ❑DEMOLITION
'may Section 7031.5 by any applicant for apermit subjects the applicant toacivil penalty of POWER DP.VICE
F
Z>, not more than five hundred dollars( ay. []TENANT ❑FOOD SERVICE
C� ❑I,as owner of the property or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
GL` will do the work,and the structure is not intended omRered for sale(See.]M4.Business ❑OTHER
4,3 ro and Professions Code:The Coulool ar's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXT E
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvement,are not intended or offered far NEW RESIDENTIAL ELECTR
sale.If,however,the building or improvement is sold within one year ofoompietion,the SQ.FT.FLOOR AREA ii/Ssh PT.
aw ner-builder will have the burden of proving that he did not build or improve for put-
. pace clash.).
❑h as owner of the pmpeng am exclusively contracting with licensed contractors to TOTAL
onsWd the project(Sec.]044.Business end Pndesaions Code)The Contractor's Li-
c 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 c0nnactons)licensed command to the Counsel.?,
License law. PERMIT ISSUANCE
❑ I am exempt under Sec. ,B&P C for this mason
Date
ALTER-DRAIN&VENT-WATER CA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE �S
1 hereby aBirm under penalty of perjury one of the following declarations: d
I have and will maintain a Certificate of Cousenuo self-insure for Worker a Compen- DRAINS-FLOOR,ROOF.AREA,COND.
1Owner . STORIES TYPE CONSTRUCTION
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
k Tnr which this Permit is issued. FIXTURES-PER TRAP
have and will maintain Workers Compensation Insurance,as required by Section
ofthe Labor Cure,for the performance ofthe work for which this permit is issued GAS-EA.SYSTEM-1 INC.4 OUTLETS OCG GROUP APN
My Work�y F�dnyansnti.yb ��rand Policy nAun�er.�eK
Carriesk YSaD Policy Nu OMityl6 GAS-EA.SYSTEM-OVER4(EA) ��ON I'
CERTIFICATE OF EXEMPTION FROM WORKERS' v
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR
(This section need not be completed flow permit is for onehundred dollars(§1007 —BUILDING DIVISION FRES
or IessJ GREASE TRAP PLANCHECK FEE
-
(certify that in the anyPerformanceofthe,1.hickforwhijethis permit is issued,lshall SEWER-SANITARY-STORM EA,200 FT.
not employ any person in any manner so as to become subject to the Workers'Compw- ENERGY PEE
zZ action Laws of California.Data
O Applicant" WATER HEATER WIVENTILLECTR GRPIDIN FEE
pJ NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTENUTREATING
a become value.I.the Worker's Compensation provisions of the Lobar Cade,you must SOI
W Q fonhwithcomply witbwch provisions or this permit shrelbedeemed mocked. WATER SERVICE
U�4CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL TIME. SQ.ET PAI CT 2 6 1999
(2 I hereby affirm that there is a construction lending agency for the Performance of Date Realpt#
w H the work for which this permit is issued(Sec.3197,Civ.C.)
O U Lender's Name TOTAL:
W Lender's Address TOTAL:
aI certify that 1 have rend this application and state fiber the above information is BUILD
y correct.I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
I.) Z building consnumion,and hereby sothonze representatives of this city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes. PF,RMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the
City of Cupertino against ELECTRIC FEE
liabilines,judgmetnx,c fca�dc,},1cnseswhichmayinany way acrneagainst said City ALTER OR ADD TO MECH.
In consequence of th c u i spennit PLUMBING ME
APPLICANT UN RSI DS ND pf OMP WITH ALL NON-POINT AIR HANDLING UNIT(TO 10."CFM) MECHANICAL FEE
SOU REy .A
AIR HANDLING UNIT(OVER 10,0110 CFM) CONSTRUCTION TAX
Sig namreof ApplicanVCop, for Dole EXHAUST HOLD(W/DUCT) HOUSING MITIGATION FEE
Hmat f SMATERIALSDISCLOSURE
Willy the Cupertino
or future Municipal
e,Chapter
9.12, dthandle Health
Noand Safety
HEATING UNIT(TO 100,(NNI BTU)
as defined io the 32Ei)?no Municipal Codd,Chapter 9.12,and the Health end Ssfwy
Coda,Section 25532(0)] HEATING UNIT(OVER 100.000 BTU)
❑Yes 5}No VENTILATION PAN(SINGLE RESID) PAID --
Da¢ Receipt#
Will the a pplicantortuts a building by the Bay
eco Air eutordeviceswhichement BOILER-COME(THE OR I of"BTU)
it,harardeus air contaminates as defined by the Bey Area Air Quality Management TOTAL: 5
't. is
District? -
❑Yes �o BOILER-COMP(OVER 1IXk000 BTU)
I have read the �Adsdous materials requirements under Chapter 6.95 of the Cell- AIR CONDITIONER
re9ui P ISSUANCE DATE
fomie Heaith&S. y Cad t s 255051.5 JJ and 2//2ss��..34.1 understand that if the NEW RESIDENTIAL MECH. SQ.EL
building doe mi eat ani*du' my0ilitym notify the occupant
article uca., un t tpds Certificate of Ovemarnry.
Q
Owns authoriz agent Date TOTAL: ISSUED BY:
OFFICE