99090012 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBINGMECHANICAL
,.BUILDING PROJECT IDENTIFICATION
LUINGADDRESS: SANITARY NO. LIGATION SUB=L DATE
aaas� Lod0 �wAj
_
OWNERS IS E PHONE: CONTRACTOR'S NAME: LIC NO:
OI /1 $ q 3� N/C CONTROL#
ARCHITECT/ENGINEER. V LIC NO. AD RESS: i a. C `t ❑
to Flr=IJO� C - oSc U+
CONTACT. PHONE: `,=BUILDING PERMIT,INFO'-,
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
Dg-
LICENSED CONTRACTORS DECLARATION QTY I,. .ELECTRIC PERMIT FEE ❑ El
I hereby affirm tit t 1 I' sed and pr 1' n. f Chapter 9(armmenc ng , ,i s _ _ JOB DESCRIPTION
Z with Section 7000)ofpi Islas 3 ofthe Business I Professions Codemnd my license is RESIDENTIAL'
C'
CZ,
in full farce and effec •_q I I I PERMIT ISSUANCE ❑SFDWL El KITCHEN REMODEL
mZ� License Clas - - L Lic.b Y gPPL1ANCES-RESIDENTIAL El ADDITION [I PLUMBING RE-PIPE
(�i Date Con[racmr
I„p w ARCHITECT'S DECLAR ION PANELS ❑MULTIUNIT Ll STRUCTURAL
Z O P2 2. l endersmnd my plans shall be used as public records MODIFICATION
OZ�-1Q UPT02MAMPS L1 INTERIOR El CHIMNEY REPAIR
F4r"j Licensed Professional 201-EXIOAMPS IMPROVEMENT E3 SWIMMING POOLS
aye OWNER-BUILDERDECLARATIONCLARATION OVER 1000 AMPS ❑BATH REMO UREPAIR ❑ EMOLITION
a Q I hereby officiation 1 um exempt from the Cnnlmcrooa License l,. far the
followinguires a(Section]u in t,after
and improve.
diminish,
i Code:Any city or county SIGNS ELECTRICAL ❑OTHER
W 3 Bs y which requires a permit to construct,elms lmpnrve,demolish,or repair any sweture
car prior to its issuance,also requires the applicant for such permit to File a signed statement SPECIAL CIRCUIUMISC.
�yi° that he is licensedpursuantlatheprovlsionsoftheContractorsLicenseLaw(Chaner9
X00 (Commencing with Section 9000)ofDivision 3 ofthe Business and Professions Code)or TEMP.METER OR POLE INST COMMERCIAL:
LL p,m y that he is exempt therefrom white basis(oche alleged exemption Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W m Session 701 IS by any applicant for a permit subjects theappliennt to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
not more than five hundred dollars($500). IMPROVEMENT
C Q ❑ I,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
X2 will dothe work,and the structure is not intended or offered for sale(Sec.90,14,Business ❑OTHER
d � and Professions Cade:File Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
properly who builds or improves(harder,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT
sale.If,however.the building or improvement is sold within one year of completion,the SQ.FT.FLOOR AREA $/SQ.FT
e,builder will have the human of proving that he did not build or improve for pur-
pase occur.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL: -
construct the project(Seo.7044,Business and Professions Code:)The Contractor's Li- t -
.e Law does not apply to an ownor of property who builds or hold vas mereon,and QTY; PLUMBING PERMIT FEE _
onwaets fo...ch projects with a contiactor(s)licensed personal to the Conductive,
"s"Law. PERMIT ISSUANCE
I am exempt under Sec. ,B&pCPorthisreamn
Owner Date ALTER-DRAIN&VENT-WATER(EA) VALUATION
• WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE O
1 hereby aRrm order penalty of perjury one of the following deciamnons:
❑(have andwill mtllnmrn tlCeniOwleof Camsem In self-insure for Workcis Campeu- DRAINS-FLOOR,ROOF,AREA,COND, S RIES TYPE CONSTRUCTION
,mien,as provided for by Section 37M of the Labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
I have and will maintain Wader's Compensation Insurance,as required by Section
IXlof the Labor Code,forthe Performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCCGROUP APN
My Worker's fie Nsurance caner and Policy nu raR:- �Q^
Grtier: C �� RA91h LV(1=N.Policy No.: r -1/ GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS �ANoO
COMPENSATION INSURANCE GREASFANDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(Tiwafich need nal mpld d if thepermil is foronehundred dollars($100)
le beco
or leas) GREASE TRAP PLANCHHCK PEE
I certify that in the performance ofthe work forwhich this permit is issued,I shall SEWER-SANITARY-STORM EA.214 FT.
not employ any person in any manner so as to become subject m the Workers'Compen- ENERGY FEE
zZ salon L.awsor California.Date WATER HEATER WNENTT..LECTR
Q Applicant GRADING FEE
y NOTICE TO APPLICANT If,after making this Certificate of Exemption,you should WATER SYSTEM/TREATING
E
SOILS FE
r4 become n contsubject y the Worker's Compensation provisions hal of the Leber Code,you maul
!� forthwith comply with such provisions or this permit hall be deemed revoked. WATER SERVICE
P A
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.PT. PAID
`� z (hereby affirm rico there isaconswmion lending agency for lheperromlanscof Date Rcceipl#
C)P the work for which this permit is issued(Seo.3097.Civ.C)
W F Lender's Name TOTAL:
LE Lender's Address TOTAL:
>" 0. 1 rt fy lit t i have rend tit s apple I a J.tm Nal the above-nforlraf is I BUILDING FEE
.Fi 0
correct.I agree to comply wilt all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT' PEE
L) build g Inn,end hereby mnM1onz p t i of this city to enter up the " ' r ' SEISMIC FEE
above-mentioned property for inspection ponsews. PERMIT ISSUANCE
(We) perm save,indemnify and keep hamtless the City of Cupertino against ELECTRIC FEB
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in consequence 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.FEF.,.
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,000 CPM) CONSTRUCTION TAX
Signature of Applicant/Cotnraetor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEAGNO UNIT(TO 100,000 BTU)
defined by the Cupertino Mnm armscl Code,Chapter 9.12,and the Health and Safety
Code,Sectio"25532(x)° HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RESIDE PAID
Date Rwciptp
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-GGMP(3HP OR 1010,000 BTU) TO
District^
F-1 Yea No BOILER-COME(OVER 100,000 BTU)
I have read the hazardous materials requirements units i Chapter 6,95 of the Cali AIR CONDITIONER ISSUANCE DATE
famla Health&Safety Code,Sections M503,25533 and 25534.1 understand Thal if the NEW RESIDENTIAL MECH. SQ.PT.
\ huilding does not currently have.boanWhal it is myrespornbilily tonotil,the occupam
of the refmarments which must bit mm priors,issuance of a CeriOeate of Ceremony
r Owner or amhorizeJ agent Date TOTAL ISSUED BY'.
A_ AA OFFICE