99080126 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUB.uwE..E LHC I RICA I, n I'
BUILDING DIVISION APPLICATION/PERMIT LING P OJEC FIDENNIFIC SOOO I
IfUlLU1N0 PROJECT IDRM'IFICATION
BUILDINGADDRUS'. SANITARYN I. N'I'I.IC6DQN SUIIMI17AL DAII
D 04AShD2E Sa 721A - g_q
OWNEk:S li: ZPl{ONE C o TRACT R' N E: WQ LIC NO/: NIC CONIROLM
ARCI{ITECI'/ENGINEER: LIC NO: AD IrVI /LO ❑
ONTAC.' PHONE: BUILDING PIiRMIT INFO
!'�. l "'y),/ /'�Q ❑ Cnnsullanl Fccs Paid by Applicant(Initial) BLDG ELECT' PLUME MECH
7V( ,SCXJy J (�J�J ❑ ❑ � ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirthat I am licensed under provisions of Chapter 9 menstruating
JOB DESCRIPmenstruating
OalZ with Secllnn'700(yof Division Jofthe Businesxand professions Code.and myliceme is RESIDENTIAL:
won [ 1'IiRMH'ISSUANCE
FK,= in full force and effect. w ❑STOWL ❑KITCHEN REMODEL.
QUU Lrtenx Clu% Lip.If APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPF
F Z W Date Cl n,,S or
ARClll fliCl"$DECI.ARATI N PANELS ❑MUI.q'I-UNIT ❑S'1'RUCfURAI.
Z 0,m Z 1 understand my pluss shall be used as public moods CHIMN CATION
OZ-�'+C UP TO 200 AMPS ❑INTIiRIOR ❑C111MNLY RE PAIR
Licensed PmNyx' IMPROVEMLN'I SWIMMING POOLS
nmol OWNER-BUILDER DECLARATION 2111-IMMIAMI'S ❑
a �d'
p0.. thine that un:use n'hion the Contractor's License Law,for the (NL'R II0X1 AMT'S ❑I3A'fH RIiMODI?LlRlil'Alk UIiM01.1'I'ION
%O G U following rwson.(Seen....7031.5,Busine and Prnfcssiom Code:Any city or county SIGNS ELECTRICAL ❑ HIiR
W 3 0.y which recmur,a Permit hat cumauct,alter,improve,demolish,nr repair any demote
pro or 'I. 1 th appy II hp nits fl ''g ed.ume hent SPECIALCIRCIJIIIMISC.
Ny•]]
metric is licensedp tt th provoinesol he Controctor's Eareme Law(Chaiderg
Wap0 (commenting with Suction VO(XBof Divisin3 fN B .'nn dP f..'ons Code) 'f1:MP MIG ER OR IY)L.Ii INST.
COMMERCIAL:
L m c Wthat he is exempt ime, ar and the IN....for the alleged exemption.Any violation of ❑NEW BLDGIADDITION ❑DEMOLITION
RR"' Section 9UJ15byan,iv,dieant fee.peoutsubjects'Leapplicant to a civil Penalty of POWER DEVICES El TENANT ❑1OODSERVICE
n more than Eve hundred dollars($51X)). IMPROVE
=QQ1.as owner ofthe property or my employees with wages as their sole compensation, SWIMMING POOL.ELECT RIC
p. will do the%ii and the stmcmm is not intended southeast for sale(See.]OLt,Business ___9 N
OTHER
1';ce and Professions Code:The Contractor's License Law docs not apply to an owner of OUTLETS-SWITCHES-FIXTURES
Of
property who builds or improves thereon,and who Nes such work himself or through
his own employees,provided that such improvements am not intended or offered for NEW RIE SIDwITAL EIXCTR SQ FT.
sale.If,Incomers Ne building or improvement is sold within one year of completion,the S .FT.FLOOR ARr x 5/SQ.IT.
erhudder will have the burden of proving than M did amt build or improv,for par-
posc of sale.). TOTAL.:
❑L as owner of the property am exclusively convecting with licensed contractors to
common,Ne project(Sec,1844,Business and Professions Cole:)The Comex mr s to.
cerse Law noes not apply to an owner.&dro,sry who hurl&%or improves Merton.and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a ntumactor(sl licensed pursuant to the Convectors
License Ww. P17RMIT ISSUANCE,'
❑I am exempt under Sec. .B&P C for this mason
ALTER-DRAIN&VI?N'r-WATER(,A) VALUKI'[ON
Owner Date
WORKER'S COMPENSA'T'ION DECLARATION 13ACK PLOW PROTECT.DEVICE
I hereby affirm under pcnAly of perjury one of the following declarations:
I have and will 11,daueu Cen ificau of Consent to seff-insure for Workers Cmmpce- DRAINS-FLOOR.ROOF,AREA.GOND. STORIES 1'Y PIE CONST R UCIOI
as provided or by Section]9X)of the Labor Code,for the performance of the
work for which this permn is issned, FIXTURES-PERT RAI'
❑ 1 have malwill n ahouin Worker's Compensation lnsemneo,ax required by Section
AMlottbei, �Cu e,ILr the pn fur nl fNe workit,Each Nis permit is issued OAS-IIA.SYSTIIM-1 INC.401J'I'LETS (> C.GOUT' / A
�� ff 111I11
My Wopklya S'19pc'tiYti ani yII c r
Carica YZZ(OJ�4��rr pclicy No.: GAS-I?A SYS'I'1?M OVIiR 4 LEA)
CERTIPICAI'Ii OFI?XI?MI'fION FROM WORKERSGRI?ASIVINUUS'1'RI,WAS'Hi IN'16RC1?FfOR
COMPl3NSNI ION INSURANCE BUILDING DIVISION FEES
(jo,cannoweJnnt becnnoffices]if Nepemmim i,forcnchundreddelho,S100B GRRASHI RAI'
PLANCIIIiCK PEE
Ic,mi,th,,a in anyQmnaneso as to become
for which tt to pe mhlsee,Colshall S.WI?R-SANITARY-S'IY)RM EA.200 17.
not employ any person in any Innnncr se.as m become subject m Ne Wurkeri Compcn- F:NI?RGY ITE
z sanon Lxwsnf Cnllferam Date WATER I IBAI'ER WNENT/I?I.ECTR GRADING Illi
Z O Applicant t
NMICI?TO APPLICANT:If.afix,makingthis Certificate of Exemption,you should WATER SYS'fl?M?RI?ATINC, SOILS FI?E
become subject to the Workers Compensation provisions of the Labor Crate,you most
forthwith comply withsuch provisions or this permit shall W deemed revoked. WATER SERVICE
7z CONS'T'RUCTION LENDING AGENCY NIiW RI!SIUIiNT1Al.p1.Me. SQ.FT. PAID Date Rcceintp
U O that N
I hereby affirm thahem is a construction lending agency for e Performance of
the ends far which his permit is issued(Sec.3091.Civ.C.) TOTAL:
:
OU Lceder's Name TOTAL:
Lender's Address
0.m 1,edify that I have read this application and sum that the ab
above information is BUILDING PCI:
,r U
t: h correct.I agree m comply with all city and county ordinances and state laws mining it) QTY. MECHANICAL PERMIT FEE SEISMIC FEE
U Z building construction.and hereby a thu,c mpmnenmtives of this city to enter upon the
uIWvc mentioned pmpcny far impcction puHxncs PI?RMIT ISSUANCE FLECfRIC PGI:
(We)agree to save,indemnity and keep harmless the City of Cupertino against
liabilhies.judgmm�u.co. %trod expcnxex whtchmaym any way teems against said City AI.TER ORADDTOMI?C11. PLUMBING FEE
ofthegra ting, rhos lernmit.
All s, �T UI I)ERS'ANDS AND WILL COMPLY Willi ALL NON- DINT AIR HANDLING UNI'I'(ED 10.0X1 CFM) MECHANICAL FEE
S( JN U A[101 S.
� 7 AIR IIANDLINC,UNI'1'(OVER IILION)CPM) CONg'PIEUC'IION'I'AX
Sigmlurt I Appliaam :ontmAur am EXIIAUS'I'I IDOD(W/DUCE) IIOUSINGMI'L'IGAIIONIgiE
HAZARDOUS MAI'ERIAI S DISCLOSURF
Will,m u,I,.nl or Posers hml bu,occupam%tom nr landlc haemdous material I BATING UNIT('IT)ISLB(X)13'EU)
as defined by dm Cupen inn Manic' .J Code,Chapter 9.12,and rbc Health and Safe,, LEAPING HN
ONE (OVER I.MX113'I U)
Gita Section 25532W1'f
❑Yes s VFN I I I.ATION RAN(SING LE RESI D) PAID
Dom Nerei �
Will the applocam or future Wilding occupant use equipment or devices which BOLI.I:R-COME'(311P OR Iffo,,X113TU)
mit
Los eardom air contmnmands un defined by Nc Bay Area Aar Quality Management 'I UI
ixtricl4 A4,YJ/ pO1LER-COMP(OVER I(X).(XX)1f'N)
❑Yes
I have mad the hvard:as materials Chapter 695 of Ne Celt- AIR CONDITIONER ,o ISSUA DA'I i
d5,255mcnu under Cha v
fmmia IIeaIN @ety
Satins '5505,)SSJJ end 255}t.l uademaM abet tf the NEW RILSIDI?NTIAI.MECH. SQ.FT. ! vy
Wildingdsesmc tea .slut it is my responsibility t Lfyth,«Conant / U
o(Nc rtyvirtmtl.1 x ma��im's i.5uance oft Con ca j Ay.
Owner ur aulhocy VX„/ I( a¢Iy— TOTAL: ISSUED BY:
OFFICE