99090029 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING ELECTRICAL PER 1
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING.MECHANICAL
s t BUIIIDINGPROJ&CTIDENTIFICATION'' 2^ `
BUILT-1NiTADDRE55: SANITARY NO. APPL -BMrr=ATE
WNER'S NAM PHONE COAVIACTOWS NAME: LIC NO,
IW
CHI I EUI7EN EE LIC NO: ADDRESS: /� ` ❑
CONTACT: PHONE: $T (p.@SI al " `t ',BUILDING PERMIT INFO'
c
[V Pk°I^•ti. ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATIONQTY -, ELECTRIC PERMIT` 'FEE
I hereby affirm th t 1 licensed d p . m
of Chapter 9(coma g + • I JOB DESCRIPTION
QZZ with Section ofdvision 3 of(be Business and Professions Cale,and my license is - RESIDENTIAL:
l" in fall tome and eDBli O PERMIT ISSUANCE. ❑SFDWL [_1 KITCHEN REMODEL
U U Loacr m Olass Lic.M
yaa DateaCnnlracmr APPLIANCES-RESIDENTIAL ❑gUUITION ❑PLUMBING REPIPE
ARCHITECTS DEC ARATIDN PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z O w Zy I understand my plans shall be used as public records MODIFICATION
OZ- UP TO 200 AMPS 1-1 INTERIOR El CHIMNEY REPAIR
Licensed Professional
OWNER-BUILDER DECLARATION 201-1000AMPS IMPROVEMENT (]SWIMMING POOLS
YayT OVER IWDAMPS ❑BA MODEIJREPAIR ODEMOLITION
pp,a U 1 hereby affirm that 1 am exempt from the Contractor's C License Law for the
W 3 w F fallowing requires
a.(Section]antra Business and Professions Code:Any city as county SIGNS ELECTRICAL R
F O which requires issuance,permit re construct,aper,improve,demolish,or repair any swment
prat he islts enseprm requires the
ovisio ant Far provisions
Permi0ofiles Law statement SPECIAL CIRCUIT/MISC.
a� (com fn6i g,edpuf(ion7 )ofDjssioi ofihe Contractor's License Law Em
pa'O O (cat he is exempt heefr m and of D osis n r oRhe a ed exe and Professions Cade)or TEMP.METER OR POLE IN
l 000" 00 CONIMmUn
a ry,o Sec he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW ''
random
omtoo by any hundred
for($500)permit subjects the applicant toacivil penalty of POWER DEVICES QT�NA -I I�(� F rIC
mut ate than Bvehundfedty,ormyempl. IMPROVEMENT U6}
(]I,as owner oRhe properly,or myemployeeswith wages as their sale compensation, SWIMMING POOL ELECTRIC
will do the work,and the structure is not Intended or offered for sale(See, 044,Business ❑0??
¢] and Professions Code:The Contramor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES / (F ,
1 property who huilds(ir improves thereon,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,Imweven the building or improvement is sold within one year ofcomplaien,the SQ.FT FLOOR AREA $/SQ.ff.
on,mobadder will have the burden of proving that he did not build or improve for pnr-
Pose of sale.), -
❑1,as owner of the property,am exclusively contracting with licensed contraanm In TOTAL.
construct the project(Sec.70,14.Business and Professions Cade:)The Contramors Li-
m Law does not apply to an owner of property who builds or improves thereon,and QTY, 'PLUMBING PERMIT FEE'
who contracts for such projects with a eontramons)licensed pursuant to the Contractor's `
License Law. PERMIT ISSUANCE
❑ I am exempt under Sec. ,B&P C tar this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Dale
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby amren under penalty of Perjury one of the following declarations.
I have and will maintain a Certificate of Consent toself-imine fur Workers Compen- DRAINS-FLOOR,ROOF,AREA,CONE. STORIES TYPE CONSTRUCTION
,.lion,.s provided for by Section 37M m the Labor Code,far the pcompro ace of the
work for which this parboil is;sued, FIXTURES-PER TRAP
I have and will maintain Worker,Compensation Insurance,as required by Section
3700 of the Labor Cade,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC 4OUTLETS OCC.GROUP �API�/^
My Worker's Compensation lnsuranw prrrierand Polio,numberare: (I� Ce NN
Carrier: Polley No: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSTRL WASTE INTERCEPTOR BUILDINGDIVISIQ FSE$
(This rection need not hewmpleted ifthe permit is for etre hundred doll.rs(6100) GREASETRAP
or IeesJ PLANCHECK FEE
I certify thatlnthe pcomanereciddre work forwhichdox,and,is issued,l shall SEWER-SANITARY-STORM EA.200 IT
noremploy any e m y manners n hecnme suhjeci m the Workers'Copper- ENERGY FEE
,ratan Law o tCa my�. to - WATER HEATER WNENT/ELECTR
z V) APPhcam IC NT If, _ GRADING FEE
ti N NOTICG�ct Lhe Work.If,after making this Cemhcam of Exemption,you should WATER SYSTEM?REATINC
SOILS P8 '-"'•'-'�
a ; become subjecttothe Workers Compensation or this provisions nTthe Labor Com,you most
_F.E--
L1J F.t forthwith comply with such provisions or this permit shall be deemed revoked WATER SERVICE
Q `
U O CONSTRUCTION LENDING ngagerAGENCY NEW RESIDENTIAL PCMB. SQ.FT. - PAID Date Rod
I hereby affirm that thea is.wntSar.30 lending agency Torthe perl'ormnneeof
the work for which this permit is issued(Sex:.3092 Civ,CJ
4Tr ULenders Name
U Lenders Adal TOTAL:
1 certify that 1 have read this application and state that the above information is I BUILDING PEE
Tcorrect.I agree m comply with all city and county magnitudes and state laws relating m QTY: MECHANICAL PERMIT -FEE
U❑ building construction,and hereby authorize representatives of this city to enter upon the
7 O *'. SEISMIC FEE
abovemendonad pmpeny for inspection purposes. PERMIT ISSUANCE �'
(We)agree to save,indemnify and keep harmless the City of Cupertino against - 1:BC'PRIC ll
liabilities,judgments,costs and expenses which may in any way accrue agavistand City ALTER OR ADD TO MECH.
in nseyuence of the granting midpermit. PLUMBING FEE
APPLICANT UNDERSTANDS AN ILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO W,000 CPM) MECHANICAL FEE
S E REGULATIONS.
AIR HANDLING UNIT POSER IO,I)(10 CFM) CONSTRUCTION TA
igroure of ApplicanUConwemr Dote EXHAUST HOOD ry!/UUC<7 HOUSING MITIGATION BE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicam or future building oocopantnoreor handle hazardous mmuial HEATING UNIT(TO 100,000 BTU)
as defined by the presence Municipal Code,Chapter 9.12.and the Health and Safety
Cade,Section 25532(x)7 HEATING UNIT(OVER 100,"BTU)
(]Yes ❑No PAID
VENTILATION PAN(SINGER RESID) Dole ReceipiM
Will the applicant or future budding occupant use equipment or devices which
mit hazardous air contaminants us defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU)
Dl,viat7 MAI t
L]Yea No BOILER-COME(OVER 100,00)BTU)
1 have read the hazardous materials requirementsAIR CONDITIONER under Chapter 6.95 of the Cali- ISSUANCE DATE
humid Health&Safety Cade,Sections 25505,25533 and 25534,1 understand that if the NEW RESIDENTIAL MECH. SQ.FI.
bni s not currently love ateoant ll is myarpme,falitym notify the oocapant
the yue ms hich ngtst be met // issuance ofa Certifieam of Ocwpancy.
''�l ,�nn
UAmemeMsifiaturs,rat TOTALISSUED BY
OFFICE