99090043 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL F
BUILDINGyHVIS1ON APPLICATION/PE RMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
RUII.PING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
n S2 /4'/0 Q
OWNS SNrVkIFa )NI'y� AQTpR'S rN 1'E �, hIC N✓ n�
Lha �e)✓ J! L/ NIC CONTROL
ARCHITECTA NGINE1Ut; LI NO: ADURIiS` �,/( �, ❑
CONTACT: PHONE: V BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB METH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby arum that I am licensed under provisions mf chapter 9(eommendng JOB DESCIU ION
OCZ thSeceon 91XN1)of Division3allLo RusinessmW l'mfcssinnxCWe,anJm license's' F IR�aS_DFNIIAL;
x100 wt PGRMII'ISSUANCIi
CµIF in fall tome send ecce �0.�/06�� _ ❑SiDWL [I KITCHEN REMODEL
GFUU lata CI Lic.n APPLIANCES—RFSIDF.NTIAL []ADDITION [I PLUMBING RE-PIPE
N 4 i Dam' Tmmaamr
'7o, A CI TECI';S DECI,ARA'1'ION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z O H Z 1 understand my plane shall be used as public records MODIFICATION
OZ—O UPT0200AMPS El INTERIOR ❑CHIMNEY REPAIR
F.1- Licensed Professional 201-]WAMPS MPROVEMENT (]SWIMMING POOfS
OWNER BUILDER DECLARATIONNT
light AMPS ATH REMODELIREPAIR C1 DEMOLITION
C C 6 1 hereby affirm that I am exempt train the Contractor s License Law for the
�a.0 following season.(Section]031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑QTHER
R131Lh which requires a Permit m construct.aecq improve,demolish,or repair any moisture
o,sc prior to it,isemuac.alo-olmres theapplicamfor such permit to file o signed statement SPACIAL CIRCUIT/MISC.
ELLY that he is licensed parmand to the provisions of the Commi License Law(Chapter 4
fcommencing is ith Section 7011 of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST, OMS MFRCIALo
0. c e' tbut he is esentpt tbertmm and the best,for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Se,t on 9031.5 by any applicant fill it permit subjects the applicant ma civil penalty of POWER DEVICES ❑TENANT ❑FOOL)SERVICE.
Spmadame than five hundred dollen(8500). IMPROVEMENT
❑Las axncr ofthepopeny.or myemployuswith wages as meirsole compensation. SWIMMING POOL ELIiGBT
�Fm will daahewark,audits,suuctarei,irs imumdralm.ffaed lS
hassle ec.]IWI.Business ❑OTHER
µI3 and Professions Code The Commam's License Law docs not apply it,an awncr of OUTLETS—SWITCfiAS—FIXTURES
L pmpeny who builds ser improves thereon,and who Joel such work him.df ser through
his own employees,provided that such improvements ate not intended in offered for NEW RESIDENTIAL HLELTR SQ FT
sale.If,however,the building orimpmvcricnt is sold within one yearofeemplaian,the �8 &SQ'TT'
owner-lander will have(hr,burden of proving that he did not build or improve for par- e
pure of salt.).
0 1,as owner of me propeny,am escl....ely contracting with licensed emarreme,to TOTAL:
construct the project(Sec.VIH4,Business and Professions Gvde)The Conoxetora 1A [S�S�
ionic Law dues nut apply m an owner of property who bends or Improves thereon,and QTY. PLUMBING PERMIT UD J7(v
who contracts for such projects with o centurions)licensed pursuant the Commends C17 3
License Law. PERMIT ISSUANCE
I am exempt under Sec. .B&P C for this reason
ALTER—DRAIN&VENT—WATER IEA) LJ N
or, Date
C
WORKERS COMPENSATION A, h DECLARATION BACK FLOW PROTECT DEVICE --ate
1 hereby anion under penalty n,perjuryoneofthefourefor declarations:
Ihme mA will maintain uCenificam of Cnnem to self-inwre for Worker's Compete DRAINS—FLOOR.HOOF,AREA,COND. STORIES TYPE CONSTRUCTION
wain.,us provided door by Section 370()of the laid, Code.far the pedlnmanec of the
work far which this permit is issued. PIXTURPS—PF.R TRAP 'W/
//
1 have and will maintain Worker's Compensation Insurance,as required by Section (0{p {J
3900 ofthe Labor Code,Gil the pedommnce of the wed ford fithis ttc�c< GAS—EA.SYSTF.M IINC.40UTLEI'S OCC GROUP APN
My Work f:q yr'uy:t�m In J�r lLLc,c:gTjer and No,:
CERTIFICATE
l/!1
Cameo /f•'/7G ��Z(/4�eJ Pand No: GAS—ITA.SYSTEM OVER 4(IiA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCI7 GREASI%INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FT:1'S
('I'hlssection need nm be cntMmit lemdeffic peris for atm hundred dollars(S 11X11 GREASE'TRAP
ser less 7 PLANCH[CK THE
I certify that in the performance afthe work for which this permit is issued.)shall SEWER—SANITARY—STORM EA.200 FT.
nm employ any person in any manner so as m become stbject m the Workers'Carnpen, ENERGY FEE
O Z cation Laws d California.Date WATER 1117AI ER W/VENTLI?CI'R GRADING FEE
z O Applicant
N NOTICE TO APPLICAT:If,afar making this Cenificem of Dampier.you should WATER SYSTEMOREATING
a ; become subject n the Workers p
Compensation mvidine of the Littler Code,you must SOILS FEE
-. forthwith istmply with auc'h provisions or this permit xhnll be deemed revoked. WATER SERVICE,
o. 0
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB, SQ.PT. PAID
U O l hereby affirm that there is a cunswainn lending agency'for the performance of ^ Dao- Rcceiptg
� r. the work for whichthlslxnnit is issued(Sec.3097.Cm C.) TOTAL:
OU Under's Name
} W Lender Address TOTAL'
0.t 1 certify that I have read this application and sus.that the ehave information is BUILDING FEE
.Fat to mnem.l xgrec usaomply with all city send enmty ordinances and Stam laws relating nt QTY. MECHANICAL PERMIT FEE
U building otmsWobn,and firomyunthotim representatives of this city to enter upon the SEISMICFEE
aMwe-memimtW property for inzpection Lump . PERMIT ISSUANCE,
(We)agree m suve,indemnify a cep hh7ucss the City of Cupertino against ELECTRIC FF:f:
luhidicajml......,contu.addsp .es rich m"in city way accrue against said City ALT ER OR ADD TO MECH. PLUMBING FEB
en ccof the g reit.
'.ICaNTUN S )S is
ILL COMPLY WITH ALI, ON INT AIR HANDLING UNIT(TO 141X10 CFM) MECHANICAL FEE
U I?G' O
T
AIR HANDLING UNII'(OVI?R 10,1180 CIM) CONSTRUCTION TAX
Slgwmreof Applica Cyactor Date I?XHAUST HOOD ONMUCD HOUSING MITIGATION FEE
HbCARDOUS MATERIALS DISCLOSURE
Will the applicant or furore building occupant store+r handle hazardous material HEATING UNIT G 0100,010 BTU)
;is defined by the CuMdinn Municipal Cade,Chapter 9.12,and the Health and Safcry
Cale.Section 2553210)1 HEATING UNIT(OVER 100.(10)BTU)
❑Yes El No VENTILATION FAN(SINGLE RESID) PAID Date Hmcipt
Will the applicant or Town Imadirtg occupant use equipment or devices which
Indushvardous air ammrrinants as defined by the Bay Arca Air QualityManagementROIL[R—COMI'03HP OR I(N),mX)HTU) Ld MOIL Y1
icR❑Yes ❑NmBOILER—COMP(OVER IW.000 BTU)
I have read the gar ads mals rrq yeents under Chapter 6.95 of the Cali- AIR L'ONUITIONI?ItISSUANCE DATE
t
- Ith&Safet 1 :N ni s 25 ,25533 and 25534.1 understand that if the NEW RISIDE:NDAL MECH. SQ.FT..
cot ew 't on is any resWnsibila,m ao'yme spam rte/
all epi o- anee of a C' nn -(M rnC/
aovlfurize gem TOTAL: ISSUED BY:
OFFICE