99080028 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY nOoC
y CITY OF CUCERTIVOr BUILDING-ELECTRICAL PE
BUILDING DIVISIo.N APPLICATION/PERMIT PLUMBIRFAUTNO
NG-MECHANICAL
BUILDING PROJECT IDENTIFICATION
UILDING Ar,sRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
99�- Ind ;-ak )- y �p
OWNER'SJJAMR: PHONE: CONT CTOR'S NAME: LIC NO:
J, 7u O NIC CONTROLN
Atinkl14- F 71rIx 9P,
CHITEC(ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO'
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
✓✓ 17 o - ❑ �/ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby anhm that I am licensed under provisions of chapter 9(camon ndng JOB DESCRIPTION
Dan with Section 7")of Division 3 turn,Business an mfes'on: ode,and my licenseis RESIDENTIAL
F "�� in foil force end off
B PERMIT ISSUANCE -
m ❑SFDWL ❑KITCHEN REMODEL
aVV Liceme Clan LIEN .APPLIANCES-RESIDENTIAL ❑ADDTUON C3 PLUMBING RE-PIPE�Wh Date Contracmr"
ARCHITECTS DECLAR ❑MULT6UNR� ❑STRUCTURAL
Z O E2 Z I understand my plans shall be used as public records PANELS MODIFICATION
oz-, UPT02MAMPS L1 INTERIOR ❑CHIMNEY REPAIR
FNH; Licensed Professional 201-Ina(IAMPS ,,.s,�,,�IMPROVEMENT SWIMMING POOLS
Sy OWNER-BUILDER DECLARATION OVER 1000 AMPS 04ATH REMODELREPAIR E)DEMOLITION
K 1 hereby (Sect that I am exempt from the Commmoos License city
o for the
6� following reason.(Section 7031.5,Business and ve,demons Conic:Any city or county SIGNS ELECTRICAL El OTHER
Up
0 which itquires a permit re construct,aper,improve,h permit t or repair any swcmrt
0� thior t he its issuance,elalsan to theres the
ovisio sof the sucContractors
Lice se Lawdstaamrnt SPECIAL CIRCUIT/MISC.
sE } (commas licensed pursuant to the of Division 3 the Commam's License LawsCircl(Chapter g
W GAO that he
exempt Section and
of basis or oft he Businessunitmpt ProfessionsCircle)or TEMP.Mli 1'ER OR POLh:INST. COMMERCIAL:
that he is exempt therefrom and the naris for me alleged exemption.Any violation of C1 NEW BLDG/ADDITION El DEMOLITION
m Section 7031.5 by any applicant for a permitsubjects the applicant to a civil penalty of POWER DEVICES sa []TENANT ❑FOOD SERVICE
not mart Nan five hundred dollars(5500).
Z Y IMPROVEMENT
p6 E]I.as owner ofthe propertyor my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
s� mwill Jo the work.and theswcturc is nm imended nr nffcredfor sale lSec.]044,Business El OTHER
and Professions Code:The Contraries License Law does not apply to an owner of OUTLETS-SWITCHES 'IX'NR..
property who builds or improves thereon,and who does such work himself lir through
his own employees,provided that such improvements an,not intend or offend for NEW RESIDENTIAL E SQ FT.
sale.If,however,the building or improvement is sold within one ye a of completion,the SQ.FT.FLOOR AREA f/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pm-
pose of,cle.).
❑ 1.as owner of the property,am exclusively contracting with licensed contractors to
construer the project(Sec.7011,Business and Professions Chet Tha Communes Li-
cense Law does not apply to an owner of property who bull&or improves thereon.and QTY. PLUMBING PERMIT
who contracts for such projects with a commie)licensed pursuant to the Contractor's
License Law. PERMIT ISSUANCE
❑ I am exempt under Sec. ,B&P C for this..,an
Owner Dae ALTER-DRAIN&VENT IE
-WATER A) VALUATION
WORKER'S COMPENSATION DECLARATION BACK PLOW PROTECT.DEVICE / 8 O O
I hereby affirm under penalty of perjury one of Ne following declarations c. (((
Iheve end will maintain eCion 37 m of thexntm Codensurcfer Workdace of the
DRAINS-BOOR,ROOP.AREA,GOND. STOR TYPE CONSTRUCTION
tion,r providW fur mi Section 3]110 of doe Ladrc Cade,for the Performance of tea
work for which this permit is issued. FlXTURFS-PER TRAP
❑ 1 have and will maintain Worker'sante of the
Compensation Insurance,which require)by Section
My artheker Lobar CoJc,fonthsuranc cancer and Poork numramp permit is issued. GAS-EA.SYSTEM-I INCA OUTLETS OCC GNOUP 6 /V1PNn
My Workers Compensation Insurance carrierandPolicy number um: 77 `�
Gorier. Policy No.: GAS-EA.SYSTEMOVER 41EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASFlINOUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thim,retinn ncednot be completed lfthepemtit is Tamm hundred dollars 19100) GREASETRAP
nr less) PLANCNECK FEE
I criifytha sent,perfomunce of the work for whin his permit is Banner.I shall SEWER-SANITARY-STORM EA.2W FT.
not employ any person in any manner so a to hero Ject to the Wmkers'Coati ENERGY FEE
pz saints Lawsppf7�Cnllforms Dae _� WATER HEATER WIVF,NT/F.LECTR
Z APPllcuns Xl a ��9-- GRA '1 —
rN. NOTICE TISIAPI ICA�WVW_mnkin is Certificate of Exemption,you should WATER SYSTEM?REATING
h , become subject m the Worker's Cnmnmu pear provisions of the labor Code,you most SOI
IZ forthwitheomply with such provisions orthis permit shall he deemed revoked. WATER SERVICE
LJJQ
Pro CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
V O l hereby affirm that is a construction lending agency for the performance of Reeetpt
Fthe work for which this permit is issued(Sec.3(19],Civ.CJ
Lender's Name TOTAL:
V Lender's Address TOTAL:
PWi 1 comfy that I have read Otis applleadon and aa¢that the above riumnia,mo is BUIL I T —!,r
r+ fR1 comet.I agree or comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
C.1 Z boldingcreamaionandherehyamhorive representatives cfthiscirym notation the SEISMIC FEE
abrwe"mentioned property for ins seen..puryosn. PERMIT ISSUANCE
(We) men).save,indenmify and keep harmless the City of Copeman.gale- ELECTRIC FEE
I'tahllitics,judgmems,cons and expenses which may in any wayucme against said City ALTER OR AUDIO MITCH.
consequencein of the granting of this permit. PLUMBING FEF.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NOWPOINT AIR HANDLING UNIT(TO 10,000 CFM)
MECHANICAL FEE
SOURCE REGULATIONS.
_ AIR HANDLING UNIT(OVER 10,0011 CFM) CONSTRUCTION TAX
Signnwreo p nn Date EXHAUST HOOD(WIDUCT) HOUSING MITIGATION FEE
IIA DOUS MATERIALS DISCLOSURE
Will by the Cupertinofuture Municipal
e,Chapter
state or handle Health and
HEATING UNIT(TO Ifp.ODI)BTU)
as de,Sect by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Colo.Section 255921u)'I HEATING UNIT(OVER I00,000 BTU)
❑Yes FI No VENTILATION FAN(SINGLE REID) PAID
Dam R iptM
W1"the applicant or fumed building occupant a use equipment lir devices which BOILER-COMP DNF OR 100,000 B'fU3
it havrdous air contaminants as defined by the Bay Area Air Quality Management TGT
unm4 BOILI?R-COMP(OVER 1111/000 BTU)
❑Yes ❑No
1 have read the hazmdous materials"dircmems under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
foram health&Safety Code,Sections 25505,25533 and 25534.1 understand that if Ne NEW RESIDENTIAL MECH. SQ.FT. (� /, /yam
building does nm currently have.mount.that it tarry raponsihllity to notify the occupant jy Y'
of the newiremems w ' oissoetre ofa Cerificme of Occupancy. 0 /
—�"
OwMrir'AMtJtax. s Dam TOTAL: ISSUED BY:
OFFICE