99070036 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY Q
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERNUT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: 40 SANITARY NO. PPLICATI ITTAL DATE
5 7 L ,va�'• f j r 7-23-99
OWNERS NAME: PHONE: CONT ACTOR'S NAME: LIC NO:
(Up )�'A aV U q`t6�q�8f� O +� s. La.I.. 6/w L� NIC CON ROLX
't HITECT/ENGINEER: LIC NO: USE S: v G ❑
o.�ox 36-Z Sae A
CONTACT: PHONE: BUILDING PERMIT INFO '
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR order p DECLARATION QTY ELECTRIC PERMIT FEE
1 om 70(n or mat L am fmc B ander provisions ofChapter9(noylimm is _ 10B DESCRIPTION
pp�'Z with Secdon]IXN17 of Division3o(the Business and Profec inns Code,and,. I' n
p 1= I y me se. PERMITISSUANCE RESIDENTIAL:
H in full force end rp t.
Q4—l- ``=7jL 1�Ip CSFDWI. ❑PLUMBINREMODEL
Q V U License Coca Lin.X
y�Wa Date—Z;�� Cnntraclor APPLIANCES-RESIDENTIAL CADDD70N ❑PLUMBING RE-PIPE
ARCHITECTS UECL ATIO PANELS C MULTIUNIT C STRUCTURAL
Z O'z'z 1 understand my plans that be med ss public records MODIFICATION
OZ4p UPT02MAMPS C1 INTERIOR [I CHIMNEY REPAIR
W l.ieensed Professional
OWNER-BUILDER DECLARATION W ❑
201-IOAMPS IMPROVEMENT SWIMMING POOLS
)d F.
G tY W Q 1 hereby affirm that 1 am exempt from the Convector's License Law for me OVER I"AMPS ❑BATH REM DEUREPAIR Q DEMO}.ITION
x(06 V following remain.(Section 7031.5,Bumness and Professions Code:Anycity inerrancy SIGNS ELECTRICAL OTHEfi
W a F wIt
hich require..permit to construct,olmn improve,dnmrrlixh,or repair any structure
� prior,.its issmnce,alw requites the applicant for such permitto fair signWnatemem SPECIAL CIRCUITIMISC. a
} mat be is licensed pursuantrom
toahe pvisioof the Contractors License Law(Chapter9
�� (commencing with Senion](XXI)af Division of the Business and PnffessionsCWe)or TEMP.METER OR POLE INST. COMMERCIAL:
d a c that he is exempt therefrom and the basis for me alleged exemption.Any violation of C NEW BLDG/ADDITION C DEMOLITION
Saban]031.5 by any applicant fora permit subjects the applicant m a civil penalty of POWER DEVICES
^tri C1 TENANT ❑FOOD SERVICE
ZF..} notmore than five hundred Dollars($SW).
Sp ❑ Lothe .rofthc the smyter myemntendes wim wagessea are
c(M,B ,mes. SWIMMING POOL ELECTRIC IMPROVEMENT
F will do the work,and the strocwrcis nm imm�dW or offered for sale(Sw.]fM4,Business ❑OTHER
u�l and Professions Coale:The Contractors Licenu law does not apply m sn owner of OUTLET'S-SWITCHES-Fi f ES
property who builds or improves thereon,and who does such work himself or through
his own employee.,provided that such improvements arc not intended or offered for NEW RESIDI?NTIAL ELECT SQ PI'.
sale.IL however,malmildingar improvement is sold within one yearofcompletion,the SQ.IT.FLOOR AREA S/SQ.FT.
emnenbuilder will have the burden of proving that he did not build or improve for pur-
pose rrf sadc),
C 1,a.owner of the propeny,am exclusively contracting with licensed contractors to
convect the project(Sec.7014,Business reit Professions Crae:)The Connors Li-
u law does not apply to an owner of property who builds or improves Neeson,and QTY. PLUMBING yC FEF.
who contracts for such projects with a comm un(s)licensed pursuant o the Contractor's
License Use. PERMIT ISSUANCE
I am exempt under Sm. ,B&P C for this reason at
ALI 17R-DRAIN&VENT-WATER(EA) VALUATION
Owner Data
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of Perjury one of the following declaretime,
_]I haveund willmaiamin a Certificate of Consent or self-insure for Wrrfker's Camper. DRAINS-FLOOR,ROOF,AREA,COND.
sation,as parricidal for by Section 37W of the Labor Code,for me p:Aormance of the STORIES TYPE CONSTRUCTION
work for which this Parent is issued. FIXTURES-PER TRAP
C 1 have and will maintain Worker's Compensation Insurance,as required by Section
370l Labor Csrde,fortheperformunceofthe work for which thispermiris issued. GAS-EA.SYSTEM-I INCA OUTLETS OCC.GROUP �Jy APN
My Carne:rkers Cp nmn in
E Policy No.yAe `ft2.988-173 GAS-EA.SYSTEM OVER 4 EA)
❑."HTC F.OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASF/INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
This action nW n
eot hecomW rm
Pleifthe Peit is(Drone hundred Dollars 151 W)
or lase) GREASE TRAP PLANCHECK FEE
I certify that in me peltionanceafth,work forwhich this permit is issued.Lshall SEWER-SANITARY-STORM EA.2W FT.
not employ any person in any manner so as to become subject o me Workers'Cramer- ENERGY FEE
Qz smote Lows of Califorrin Dote WATER HEATER W/VENUBLECTR
O Applicant GRADING FEE
rjJ NOTICE.TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM?RHATING
abecome subject to the Worker's Compensation provisions of the labor Code,you must SOILS FEE
Lkl forthwith comply with such provisions or permit shallM deemed revoked. WATER SERVICE
DQ PAID
CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PCMB. SQ.FT.
U 0 lhereby ichaffirm his
thanhererssued(Sm.30 lending agency(Doha ped'ormance of
Date ReceipX
fL the work Ibr which this permit is issued(Sec.7(19],Ci,Cd
Q tender's Name TOTAL:
W Lenders Address TOTAL:
IL 1 certify that 1 have read w
this application and state that the alee information is BUILDING FEE .
rFi
In ciiomm I agree to comply with all city and amnty ordinances unit same laws oclating to QTY, MECHANICAL PERMIT FEE
V Z building construction,and hereby authons representatives ofthis city to enter upon the SEISMIC FEE
almove-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree tai save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any waymemeagainstsaid City ALTER OR ADD TO MECH.
in consequence of the printing of this permit PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NOPOINT AIR HANDLING UNIT(TO IO,IXIB CFM)
MECHANICAL FEF.
SOURCE REGULATIONS. ♦ AAq
64—t-, Lj (•tom/ AIR HANDLING UNIT(OVER IO.000 CFM) CONSTRUCTION TAX
gnamre dApplicanV muraaor Date EXHAUST HOOD(WIDUCf)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Willtheapplicamm,forum Wilding oceupam store or handle haxallous material HEATING UNIT(TO I00.000 BTU)
as def ted by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code•Seaton 25532(x)] HEATING UNIT(OVER 1ILIM,)BTU)
p ya: FIN. VENTILATION FAN(SINGLE RESID) PAID --
Will the applicant or future building t use equipment or devices which Dau Receipt X
pp dby the
qu it Qu BOILER-COME DHP OR IW,IIW BTU)
emit haxsrdous air contaminant as retired by the Bay Arca Air Quality Management
TOTAL: x
District?
❑Yes -1 No BOILER-COMP(OVER 100.000 BTU)
I have read the havrdnus materials per 6.95 of me Cali- AIR CONDITIONER ISSUANCE DATE
requirements under Cha
forms Health&Safety Cade,Smoons 25505,25533 and 25534.1 understand that if dm NEW RESIDENTIAL MECH. SQ.ET. -3—
T. 3_ Q
huilding does not currently hove o tenent.that it is my responsibility to nmify the overprint z
of the requirements which must be met poor to issuance of a Certificate of Occupancy.
Owner or authooxed agent Date TOTAL: ISSUED BY:
OFFICE