99090153 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY Q
CITY OF CUPERTINO BUILDING-ELECTRICAL P
BU ILDINGIDIVISIO,N APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILIIING PROJECT IDIEXI IF'ICATION
OW
' HUIh)ING ADDREESS'. ^eV F 11
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SANITARY NO. APPLICATION SUBMITTAL.DATE
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I CONTRACTORS NAME: LIfC NG9F
4 "';53-L04? U
NIC CONTROL#
IITECf?NGINEEH: LIC NO: ADDRESS: 1 ❑
CONTACT: PHONE1LDING PERMIT INFO
Q� ❑ Consultant Fees Paid by Applicant(Initial) HLDG ELECTPLUMB PATCH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby aRrm that 1 am himmsc l under provisions of Chapter 9(rommcncitig JOB DESCRIPTION
WOOazz with Section 7")of Division 3 of the Business and Professions Code,and my license is RESIDENTIAL:
WOO O PERMIT ISSUANCE
Fm• Licene fail Class
effect. ❑SFDWI. ❑KITCHEN REMODEL
Q,UU
License Class Lie'# APPLIANCES-RESIDENTIAL ❑ADDITION 4;116&MBINGRE.PIPE
Fn C sal Dnm Counde, r
C
ARCHITECTS DECLARATION ❑MULTLUNIT []STRUCTURAL PANELS MODIFICATION
ZOonZ 1 understand my plimshall be usedaspublic records
OZ L- UPT0200AMPS El INTERIOR ❑CHIMNEY REPAIR
T-•'_+F 41 Licensed Professional 201-100OAMPS IMPROVEMENT SWIMMING POOLS
y�5 Q I hereby off rtn tlhayi 1 an
OWNER-BUILDER
mmLthc DECLARATION
License Law for the OVER III00 AMPS El BATH RFM00EL/REPAIR DEMOLITION
x O L O following reason.(Section 9031.5.Ba,mu,anJ Prom....a,Code',Any city or county SIGNS ELECTRICAL ❑OTHER
w a w i"' which q p nth I I .h ter p demolish. p any swearer
l i:Cw, pr ort t La q 'Ib appllc If suchpe nil fl '6 dd.1mornl SPECIAL CIRCU I'I/MISC.
M'� Ihat h licensed pursuant the p un thefC wemrsL Law(Chapar9
ai�OtO (commencing with Seatron?0o0)ofDivision3 of the Business and Professions Codc)or TEMP.METER OR POLE INST.
COMMERCIAL,
Of.d cC that he is exempt therefrom and the basis for the alleged exemption.Any violation of DEMOLITION
�MSection?031.5 by any applicantfor a Permit%objects the applicant to a civil penalty of POWER DF.VICF_5 FOOD SERVICfinot more than Eve hundred dollars(55IIBL t QLas owneroflbe pmpcnyoras}'empinyceswith wages as their solecompensation, SWIMMING POOL ELECTRIC
will do the work.hand the structure is not intended or offered far rule t See.9(004,Business
L i oa and Pm[asin I,Code, 11,c Contractor's Lu,cnec law docs soh apply m an—act of OUTLETS-SWITCHES-FIXTURES
pro,wrty who builds at improves thereon,and who does such work himself or through
his own employees,provided That such impmncinems arc not intended or offered for NEW RESIDIIN'1'[A].ELECTS SOFT
sale.ILhowever,the building or improvement i,sold within oneycerofcompletion,the SQ,IT.FLOOR AREA SISQ.IT,
ter-builder will have due burden of proving that he did not Wild or immune for par-
low of salol.
1,as owner of the patent am exclusively contracting with Iicenmd contractors to TOTAL`
,
tawnier he projen(See 7014,Bmin.vc.,,it Professions Code:)Tor Contramm's Li-
scLac,doeun apply to an owner tar property who builds or ngmnves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a contractor(s)licensed pumuumuo Inc Contmmor's
License Law. PERMIT ISSUANCE
1 am exempt under Scc. .B&P C for this rezmn
ALTER-DRAIN R VENT-WATER(FA3 VALUATION
der Dae
WORKER'S natty COMPENSATION DF.CLAHlowing BACK FLOW PROTECT.DEVICE
1 Hereby nflirm under penalty of pc jury one of the(allowing declarations:
❑ Inma and will I...I,neCion 3700Athe Lator Code.
thrt Worker's Cnmpem DRAINS-I LOON.ROOF.AREA,COND' STORIES TYPE CONS'1'Rl1C'1']ON
saint,as Provided hi f r by Section 39IX1 of the Loom Gde,far the performance of the
work for which this Inrmn is issued. FIXTURES-I'lik'1 HAP
Fl 1 have and will maintain Workers Compensation Insurance,m required by Section
37Wofthe labor Colic.for the performance orthe work for
rwhich
�(this permit is issued. GAS-EA.SYSTEM.I INC.4 OUTLETS OCC.GROUP APN
'race, pnsayo grace ear{Crand Poli,Po cy No� ^ �11:9542SH GAS-G.SYSTEM-OVER I(FA) 1 -3
Cameo +•sh.L1
CERrEfCATE OF EXEMPTION MOM WORKERS' GRF.ASFJINIIDS'1'RI.WASTE INTERCEPTOR
BUILDING DIVISION FEES
(Ihieseaionnccdma be mntplemd,flM,semann banns,hundred Jollarx(3100) GREASETRAP
nr los) PLANCIIECK IEE
I cenifythal inthe Nodurcrarceoflhewnrkror whichthis permit nissued.lshall SEWER-SANITARY-STORM EA.200 Ft,
not employ any Person in any manner m as to become subject to the Workers Cooper- ENERGY FEE
Z satin.law,of California.Dare WATER HEATER WIVENT/ELECIR
Z O Applicant GRADING TLE
NOTICE TO APPLICANT:If,after making this Ccalrmam of Exemption,you should WATER SVS'1'EM/fHEAT1NG
h SOILS EEH
F buorao subject m the Worker
pn Compcmaii% provisions o e dr Labor Code,you muxt
fnhwith comply with such provisions or anis permit shall he Aecnmd revoked WATER SERVICE
WP. PAID---���
UZ CONSTRUCTION LENDING AGENCY NEW RESIUIiNT1AL PLMB. SQ.FL 1� Dred.\\ ReceiptN
U O IhcrebY affirm that there isaronewnion lending agency for the perfowarme of 1
V. the work for which this permit is issued(Sec.}091,Civ.C.) (1i'1I U—V LTOTAL: 'II
pU Lender's Name U.
N Lenders Address TOTAL:
1 ccnity that 1 have read his ap,dweliur and ,are that the above infmtnmion is BUILDING F`En 9 7 iffiIII
F's Z) orevel.l agreem comply with an city and ,,,any ordinances and mom lew,erindng m QTY. MECHANICAL PERMIT FEEL/'I
U Z buildingcomhm
.etction. d hereby..thoris.m,emseemovee of Ibis Illy to enmrupom the SEISMIC PEE r
douse-mentioned property far impcaion purphrsec PERMIT ISSUANCE
(We)agree to mve.indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
hithilitic,.jud,wo...nnuamd expertise,which may in any way.ccrneagaimtaaid City ALTER OH AUU TO MECH. PLUMBING,pRO _�
in consequence til the gnn' S"In"permit.
APPLICANT TINDER S AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.00x)CFM) MECHANICAL FEE
SOURCE RFF ULA
AIR HANDLING UNI'I(OVER 10,Ug)CFM) CONS'I'RUC'I'ION TAX
Siyrlh re of pp hcenUCommaor I Date EXHAUST HOOD(WIDUCp HOUSING MITIGATION FEE
HA%ARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant.wore or handle hadanfous material HEATING UNIT(TO 100.000 BTU)
as defined by the C.pLimo Municipal Code.Chapter 9.12.and the Health and Safety
Codc,Section 25532(a)'I HEATING UNIT(OVER 100.000 BTU)
❑Yes E]Nn PAID
VENTILATION FAN(SINGLE RESIDI pont Receipt
Willthc applicant ,,far."holdn"'acupma use equipment nr device„ which VENTILTIBOILER- OMP(3 (SINLEHP OR 1,EMD)U)
snit hasardous air contaminants as JefineJ by the Bay Arca Air Quality Management 'OTV MITI
District? BOILER-COMP(OVER 100.000 BTU)
[I yes (:J No
1 have read the hmardous mattiuI r mems under Chapmr 6.95 of the Cali AIR CONDITIONER ISSUANCE DATE //�� non
tihmia Heal@&Safety Code,Seo. s 25 !(255}3 and 25534.1 unJersmnd Lha if the NEW RES[DFN1IAL MECH. SQ,FT. CJ Y
huilJ ng dtcv not rah yy hu trona �Jl l” !six sibilitylouutdythcrctvpml / T
of h requhrnnu s !c flus tri ace of a Certif-ter or Occupancy. ! Z
17 s9 `r D
0.tTmeal agent Dam TOTAL ISSUED BY:
OFFICE