99090013 (2) tNIR'�'S�N,ME
CANY;TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY Q 4 Q
nr GOPERTINO BUILDING-ELECTRICAL m1!NMLT�
,DING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL.
BUILDING PROJECT IDENTIFICATION
GADDRPSS: SANITARY NO. APPLICATION SUBMITTAL DATE
I
C)(D' OA�< l A-r- P
: PHONE: CONTRACTOR'S NAME: LICNO:�. /l _ O (-.... ( (; f •/rUINIC CONTROL.
ECT/ENGINEER:I• LIC NO. ADDRESS:Yl.�6 lC'T Y FIr-t._CI': PUONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(initial) BLDG laI PEf MECH
I,ICCNSEDCONTRAcroR'SOEChARATION QTY. ELECTRIC PERMIT FEE ❑ '�(l
1 hereby aubm that I am licensed under provisions orchaper e)(commencing JOB DESCRIPTION
Matz with Section 700o of Division3.Ohe Business and Professions Cade,and my license's PERMIT ISSUANCE R ID NTIA
C,,F ,n full force and etre o yh ❑SFDWL ❑KITCHEN REMODEL
QUU License Clas_T -2 Lic.p / APPLIANCES-RESIDENIHAL ❑ADDITION El PLUMBING RE-PIPE
QW Uam /n f�Contracmr
F>y ARCHITECTS DECLARAT N PANELS ❑MULTTUNIT ❑STRUCTURAL
Z O A Z 1 understand my plans shall Ie used as public records MODIFICATION
O2=-0 UPTO200AMPS [I INTERIOR ❑CHIMNEY REPAIR
Fnta: Liccnsel Free,...of 201-WIN)AMPS IMPROVEMENT E]SWIMMING POOLS
%Y.�; OWNER-BUILDER DECLARATION OVER IIXNIAMP$ El BATH RIMOD-(/REPAIR [I DEMOLITION
C C Q 1 hereby union that 1 am exempt from Inc Contractors License Law for the
ad c.U fulloom Section]031.5,yhomres and 1'ndcsoar,CIxE:An cit t ❑OTHER 4 0� t-
3 W b' b reason (:ec inn Y Y or county SIGNS I?LIiCfRICA1. �
m which reelinres a Iierndt To construct,ober,improve,demnrsn,or repair any Structure
F ai< priorto it,koam,e,also requires theappl leant fnrsnch.cnorn,(ilea signed statement SPECIAL CI RCUIT/MISC.
fhy2 mot he is l iccnsed pursuant w the provisions of the Contractor'S license Law(Chapter 9 4-1
W CQ0 (commencing with Section 7000)of Division 3 of the Business and Profe.ssmas Cafe)of TEM R MIST ER OR POLE INST COMMERCIAL'
as L e thus he is exempt therefrom and the basis for the alleged exemption.Any violmion of EW BLDG/ADDITION -❑DEMOLITION
XmW Section 7I31.5 by any applicant for a Permit Subjects the applicant to a civil penalty of POWER DEVICES ❑TE ANT 0FOOD SERVICE
not more man five hundred dollars($500). _
1-?Q I.as owner of theproperty,orm loees with woes m their sole con tion. SWIMMING POOL ELECTRIC I ROVEMCNT
❑ tYotnP Y B .ansa
F
will du the work.and the structure is notmmmlcd or offered for sale(Sec.]OW.Business THER
W �_ and Predessions Cods:The Comoretc lis License Law does not apply to an owner of ON LEI:$-SWITCHES-FlXTURES
a 3 pro,aMY who builds or improves thereon,and who does such work himself or through
his own employees,provided mat such improvements um not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.It.hasesxr,the building mierprovemem isudd willimoneyearofcompletion.the SQ.FT.FLOOR AREA VSQ.pT.
erlwilder will have the burden of proving that he did not haild or improve for pur-
,,,aofsnlc.).
❑ 1,as owner of the propeny,am exclusively contracting with licensed contractors m TOTAL:
names the pro act(Sec.9144,Business and Profess ,n C(xle:)The Contracmr's Li-
Sc Lewdoe,a...Plymnnoura,aI .,,arty wha buildsnr hn...iw,,hereon.and QTY. PLUMBING PERMIT FEE
who cortracts for such projects with a commetons)licensed puemanumtbe Commemr's
License Law, PERMIT ISSUANCE
❑1 an exempt under Sec. .Is&P C for this reason
Data ALTER-DRAIN&VENT-WATER(EA) VALUATION
her WORKER'S COMPENSATION N UfCIARATION BACK FLOW PROTECT.DEVICE
I hereby off pery.,lith under penalty of jury one of the following Workers
orker declarsomm:Campeau-
❑(have andwill main mi nation 37W ofConsam helaor Code.s„m forerformace ofthDRAINS-FLOOR.RODEAREA,CONU, BTORS TYPE CONSTRUCTION
salon,as provided for mi Section p00 of the Lobar Calc,for the performance of the
work Tot which this Permit is issued. FIXTURES-PCR TRAP
37 I have Latour
ode,f r Workers Compensation Insurance.h required by Section
i]IN)uf the laMn Ce,Jafur the Performance..f the work for which this Permit is GAS-PA.SYSTEM-I INC.40U'fLEI'S OCC.GROUP APN
My Worky('�s�j Wrnor� �tas.Incur cc cnrticrand Policy nyQib}ir,olr�/'/C ) GAS-BA.SYSTEM OVER4(EA)
Cartier: `sT l-IFM'WV1. J.N'Qd1A'HHnicylso, QVI& Y �2�,
t CERTIFICATE 01'EXI3MPIf`ON FROM WORKERS'
COMPF,NSAI]ON INSURANCE GREASI%INDUSTRI.WASTE INTERCEPTOR BUILDING DIVISION FEES
(I'I-oeotionneeJ not fro......tried it he permit is t'..n an,hundred dollars 0 RNP) GREASE IRAP
nr less) PLANCHECK FEE
I ecnify that in he N,f..e.,coflha work for whichthis pe.it is issued,I Shall SEWER-SANITARY-STORM EA.200 FT.
not employ any Person in any manner so as to baconm subject m the Workers'Camper- ENERGY FEE
Z2 APio.La sof California.Data WATI7R HEATER WNENT/ELECIR GRADING FF.0
=fK NOTICE TO APPLICANT:If,afar making this Cenificam of Exemption,you should NATER SYSTEMOREATING> become subject to the Workers Con,armlion previsions of the labor Code,you must SOILS FEE
fonhwith comply with such provisions ,,his permit sbnll tx deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.IT. PAID
Z Data Receipt a
UU St
0 Iht,,a affors thenhere is.adSer.Maxima lending agency forms perfamiance of
F•' 'he wo,for which this permit is issued(Sec.31M99,Civ.C.)
UIsndcr's Nanta TOTAL:
landcr's AAAress TOTAL:
>' a I.roily that I have read this m,pientim,i Islam thin the Move infmrma0nn is BUILDING FEB
correct.I agree It comply with an city and county m lace..Slid nmic laws mliam,to QTY. MECHANICAL PERMIT FEE
U Z building eonsb..Ins.and hereby ruLoommprescmtm,w,,a cols city tomer upon the SEISMIC FEE
bov-mmotit ned pm ny for inspection purpose, 1 T,RMHISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FHIi
habil it es. costs and expenses which may in any way creme against said City ALTER OR ADDTO MECH.
PLUMBING FEE
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.IX)(1 CFM)
MECHANICAL FEC
SOURCP.REGULATIONS.
AIR HANDLING UNIT(OVER I0.000 CFM) CONSTRUCTION TAX
Signature of ApPlicanJContracmr Data EXHAUST HOOD WMUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE,
Will the applicant or future building occupant Store(if handle boardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cu,mra Municipal Code.Chapter 912,end the Beach and Safety
Code Seen..n 25532(x)? HEATING UNIT(OVER 100,000 BTU)
ED Y, L]No PAID --
VI N'1'ILAHON FAN(SINGLE RI'SID) Date Ru i,4
Will the S,flicama,r Boom builder,teenP m use equipm.m Ut devie s which
e �
mit Momicus air metainant as deined by the Buy Ara,Air Quality Management BOIL1?R-COMP( ({p OR 100,M)BE TOTAL:
Uiarietl
0Yes 7N MOI000LER-COMPIOVER 100, BTU)
I have read the bavardous materials requirements under Chapter 6.95 of the Cali, AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Cade,Sections 3505,25533 and 255.11.1understated Nat if the NCW RES IUENT IAl.MECH. SQ.Il'.
building does nm curmnlly have a..rand.the it is my responsibility to notify the occupant
of the"trimroenu,which moa 1w con.nor m issuance of a Comficam of Occupancy.
TOTAL:
O anar of authorized agent Data ISSUED BY:
OFFICE