99080181 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PGR MIT
BUILDING DIVISION APPLICATIONIPERMITPLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS SANITARY NO. APPLICATION SUBM UA1E
Aft Rtsr OR, cv 6kTinlo CA 9501LI
R' NAME: PHp :�'J_/�� ONTRACfOR'S NAME: LIC NO:
OY JKJ VL N/C CONE ROLp
' A CHIT. /EN a �� I11 : AUURESS: ❑
CONTACT: /j
'HONE: /�o BUILDING PE MIT INFO
L44li t✓r K6 %'B�— ']r33-66 T/ ❑ Cons iltant Fm Paid by Applicant(Initial) BLDG / ELE PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm out 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
IFOZ wfItS fame an"tfecDivision 3oftha Business end Professions Coda and my license, RESIDENTIAL,
O i PERMIT ISSUANCE
ul= '" ❑SFDWL ❑KITCHEN REMODEL
�FUZtFt]] License Class Contract
APPLIANCES-RESIDENTIAL ❑ADDITION C1 PLUMBING RE-PIPE
N 6 4 Date I'S DE L
As shall he use DECLARATION []MULTI-UNIT EI STRUCTURAL
F m !understand my plans Shull he used as public records PANELS MODIFICATION
o°z �
UP To 200AM1'g [I INTERIOR El CHIMNEY REPAIR
Licensed Professional ` n gQLPWAMPS IMPROVEMENT C]SWIMMING POOLS
OWNER-BUILDER DECLARATION
y�y C a I hereby off.Nat 1 am exempt tram the Comsactor's License Low for t e El BATH REMOUEV AIR DEMOLITION
X 36 U fallowing reason.(St 7011.5,Business and Professions Cade: city m county SIGNS L'LECTRICAL^ - — ❑OTHER
4a^77 LL LLO which requires a pemtit m coosamic alms improve,demolish,or m - a - n
prior to its issuance,also requires the applicant for such permit to Ne SPEC UIT/N
$ } that he is licensed pursuant to the provisions mf the Comrxmr's Licm w
,�G7 (commencing with Section7000yof Division 3oftha Business and COMMERCIAL
iLq m pt; that he is exempt therefrom and the basis for the alleged exemptin . ti of ❑NEW BLDG/ADDITION ❑DEMOLITION
i�
Section 7031.5 by any applicant for a permit subjects the applicant to a civil pamItyof POWER DEVICE ❑TENANT ❑FOOD SERVICE
F. R' not marc than five hundred dollars(S5001.
Z P IMPROVEMENT
6 01,rix owner of the property,or my cmplo,es,with wages as their sole compensation, SWIMMING 11001.ELECTRIC
O will Jn the work.and the svucmre iv nm lmm�dcJ nrndercd fa...Ic vv.9a44.Busluesn ❑OTHER
and Prolessions Cade:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
pmpeny who builds or improves immon,and who does such work himself,r through
his own employees,provided!that such improvements am not mtendal or oRcrcd for NEW RPSIDENT1AL ELECTR SQ FT.
rule.If.however.Ne building or improvement is sold within one ycor of completion,the SQ.FT.FLOOR AREA $/SQ,PT.
comer,builder will have are border of proving that he did not build or improve for our-
...stasownerofthe property,, exclusively contracting with licensed
ntrachmss i. TOTAL:
conewa the project(Sec.9049,flusinass and Professions Code:)The Canummr'e Li-
censeLvwdoesnotapplyto an owner of property who builds or improves thereon,and QTY PLUMBING PERMIT FEE
who contracts for such limiters with a co mu nom s)licensed pursuant to the Contractor's
Licansa Lim. PERMIT ISSUANCE
_ lam exempter Sec. .B&P C for this reason
/ tar Date ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORT .MS COMPI� ATION DECLARATION BACK FLOW PROTECT.DEVICE 2-0 060
I hereby affirm under penalty of pe jury ane of the following declamrimm: f
❑I have and will maintain a Cadfcate of Cmnsenuoself-inure for Workcr's Compen. DRAINS-FLOOR,ROOK AREA,COND. STORIES TYPE CONSTRUCTION
sauna,as provided far by Section 3900of the"For GNe,for Ne performance of the
work for which this permit is issued. FIXTURES-PER TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section
39W of the labor Code,for the performance of the work for which this permit is issued GAS-EA.SYSTEM.I INC.4 OUTLETS OCC.GROUP �OPN Z�
My Worker's Compensation Insurance carrier and Policy number art: ��soa
Cartier: Policy No.: GAS-EA.SYSTEM-OVER 4(PA)
CERTIFICATE OF EXEMPTION FROM WORKERSO
COMPENSATION INSURANCE GREASFJINDUSTRL WASTE INTERCEPTOR
- I11111.UING DIVISION FEES
(This section need not be completed lfthe permit is forms,hmmdred dollom 0,Its)) GREASETRAP -
or less) PLANCHECK PEE
I certify that in the performincemihe work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner m as to become subject to the Worked Cmmpen. ENERGY FCC
O Z inion Laws of California.Date WATER HEATER W/VENT/ELECTR GRADING FEL
2 Applicata
y NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTEM)REATING
become mbjat to the Workers Comparison,.provisions of Ne labor Coda,you must SOILS FEE
forthwith comply with such provision or this permit shall be deemed revoked. WATER SERVICE
aQ
� z. CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,FT. PAID « [k
IJ pI hereby affirm thatthem is a construction lending agency for the performance of
Na work Gn which this permit is issued Eget.30s)9,CivC.)
F' Leader's Name b TOTAL:
Lv Lender's Address TOTAL:
I certify that 1 have read this vpplicinkm send state that he above information is BUILDING E
rr Tap correct.l agree to comply with all city and county ordinances and state laws relating to QTY MECHANICAL PERMIT FEF.
(,) z building construction,and herebysuthorire representatives of this city to enter upon the SEISMICIE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
We)agree to save,indemnify and kcep hnmtlem the City mCupertino against ELECTRIC E
Iiabiliries,judgmants,costs and expenses which may in any way recoup against said City ALTERORADDTOMECH.
in consequence of the granting of this Permit. PUUMHING FhE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,IX0 CFM) `
SOURCE REGULATIO S. ME11 11 CAL FEE
J A^
AIR HANDLING UNIT(OVER IO,WCFM) 11
CON CTIONTAX
Slgnamrc of—Appl Cn nrrr///111 rector Duto EXHAUST HOLD W/DUCT) + HOU ITIGATION ME
HAZARDOUS MATERIALS DISCLOSURE
Willtheapplicant m far..building occupant store,(handle haamdo.,nort id HEATING UNIT(H)1 ly), (1 BTU)1I ..
as define by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety s
Cee,Section 25532m)? HEATING UNIT(OVER I00,00)1374) 'i
--::,7—
E]yes [J No VENTILATION FAN(SINGLE RESID) r„ PAID
Data R«eipt p
Will the applicant or future building occupant use equipment or devices which -
axon harad,us air contaminants m dented by the Bay Area Air Quality Management BORER-COMP(JHPOR 100,000 BTU)
81�1
"---- A .
Diann^
FI Yes ❑N, BOILER-COMP(OVER 100,000 BTU) Ir
Ihme read the hvamdom materials requirements under Chapter 6.95 of thAIR CONDITIONERe Cali. � ISSUANCE DATE
farm Health&Safety Cade,Sections 25505,25533 and 25534.1 undersand that if the NEW RESIDENTIAL MF.CH. SQ.FT. ,� 2 / o(DQ
building docs not currently have.tectum,thin it is my responsibility w holly the occupant Cita
r NIF ulminims hick must he mer prionnlrrmnce of.CcnlOcnm of Occupancy.
Ow r u u to eased agent Dote TOTAL-. ISSUED BY:
OFFICE