99120024 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES XSE BALL POINT PEN ONLY (' O10 Z
CITY OF CUPER"PINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
Ln BUILDING PROJECT IDENTIFICATION
UIDNGADISS: �(
SANITARY NO. APPLICATION SUBMITTAL DAZE
,f� S NAME: � HONE: I CONTRACTOR'S NAME: LI
2 NIC CONTROLx
F�IRIJEIEINITR IC NO: ADDRESS. ( ❑
CONMAACT: PHONE: BUILDING PERMIT INFO
1 I 5'lO ❑ Consultant Fees Paid by Applicant(Initial) BLE ELECT PI,u1He ME❑CH
LICENSED C RACr DECLARATION QTY. ELECTRIC PERMIT FEE /e��(
I heahy ufGrm thin 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
WOO with Sccuws"70 0 of Dniaoy�f Business license is RESIDENTIAL:
FO Q in full line,anJ y�/� I'CRM111T ISSUANCE
m— � r OSPDWh ❑KITCHEN REMODEL
ZLicense Cluvs N
N� NCIS—RfiSIUF.NTIAL []ADDITION ❑PLUMBING RE-PIPE
h 6 W U:nc Contac
ARCIII'I'ECT"S DECLARATION �MUI;TI-UNIT ❑STRUCTURAL
E..
o Z
Z 1 undcrsnn l ray prams shall be used as public accord, PANELS MODIFICATION
024E UP'1'02(N)AMPS ❑IMI'ERIOR El CHIMNEY REPAIR
F�.F'.W Licensed Prafcveio at 201-1000AMPS IMPROVEMENT (]SWIMMING r0OLS
�Y�; OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH 107M0 ELIR PAIR ❑ A10LITI01
6 1 hereby union that I:un exempt from the Contractor's License Law for the
3 LLFU-• iollowne,reason.(Section 7031.5.amines and Profession,Code:Any city or cam', SIGNS ELECTRICAL ER
y which requires a permit In construct,alter,improve,demolish or repair any structure
prior to its issuance.also requires the applicant for such permirlo lite aligned statement SPECI AL Cl RCUIT/MISC.
Ery that he is licensed pursuant the previsions of the Contractors License Law(Chapter 9
(commencing with lection 7000)of Di vision 3 of the Business and Professions Clark)or TEM P.METER OR POLE[NST COMMERCIAL:
Z.A.c C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
�
m Section]U315by any applicant lot upemil subject the applicant mucivil Penalty of POWER DEVICES ANT ❑FOOD SERVICE
n more on.five hundred dollars($500). IMPROVEMENT
❑ 1.a%owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
will do the work,and thestrunum is not intended oraReeed forsale(Sen.]DW.Business OTHER
=W m and Professions Calc The Commerce%License law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES
a3 property who builds or improves themon,and who does such work himttlf or through 51
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
,ale.If.however the building or improvement is sold within one year ofcompletion,the ESQ.FT.FLOOR AREA USQ.FT
caner-builder will have the booker of proving that he did or build or improve for pur-
r,e of I.J.la
1,as owner of the property,am exclusively contracting with licensed rmtowrre t. TOTAL:
pe
taped the project(Sec.7140,Rosiness and Prefeasiens Gds)The Canberra's La-
seLaw does not apply loair owner of property who builds or improves thereon.and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a conmacrgs)licensed pursuant o the Contractors
License Law. PERMIT ISSUANCE
I am exempt under See .B&PC for this reason
A1:1 HR—DRAIN&V ENE—WATER(EA) VAI,UATIO
mer Dee
WORKER nder COMPIiNSATION DECLARATION folio ON RACK PLOW PR(YT[CT.DEVICE,
1 hereby alit under penalty of(It'jury one of the following Worker v C
Ih.as and will lot by
ection icme of he Latte,Cod,for for Worker'sce risen- DRAINS—Iq,OOR,ROOF.AREA.COND. STORKS TYPE CONSTRUCTION
wino,as pooh this
Iia by Sectio 3700 0(the LmMn Code,for the performance of the
work for which Chia permit is issued. ITXI'URlil—PER TRAP
1 have and will maintain Worker's Compensation Ineumnce,as required by Section
37(0nfth 1�Mn Cale,forth,pc Etmmncc of the workf which tht nsissued, GAS—IiA.SYSTIvM-I INC.6OUTLETS OCC.GROUP APN
My Wor tri In: srvlMr enJ PolicY�u�lr
Comer (� PolicY Nal / GAS—EA.SYSTEM-OVER A(EA)
COMPENSATION
OMYINSATIO N INSURANCE
NSURANCE ORKERS' GRCASMNDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This section need not be completed a ds,permit is forsaw hundred dollars(SIM) GREASETRAP
lPLANCHECK FEEser re.)
I tttify that inthcpmfomarccm.hework for which this .it is lsmod.l shall SEWER—SANITARY—STORM EA.21X1 FT.
not employ any proton in any manner so as to become subject r rhe Workers'Compen- ENERGY htiE
O Z ration Laws or California.Date WATIIR HEATER WNENT/ELECTR GRADING FEE
Z Q Applicant
r%) NOTICE TO APPLICANT:If,after making This Certificate of Exemption,you should WATER SYSTEMaREArING SOILS FEE
f" become subject to the Workers Compenvation previsions of the labor Code.you must
forthwith comply with such provisions or this permit shat be deemed revoked. WATER SERVICE
Q
6D CONSTRUCT]ON LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,FT. PAID Dare Receipt
V I hereby nflirm that here is a compaction lending agency for performance of
F" the work Sir which do,permit n issued(Sec.3097,Ci,C.) TOTAL'.
QULender's Name
,r W Lenders Addacsv TOTAL:
5")
I cenily Ihm I hove reud this nppli,rio.and ser that the above infmmu
aon is BUILDING THE
�. UJ 111110.i n,me r,r uy with dl city and county nnimences and star laws relating to QTY, MECHANICAL PERMIT FEE
V Z building commuclent.and hereby mmhorrsc representatives ofthis city m enter upon the SEISMIC FEE
aMrvcmentioned property for inspection purpmes. PERMIT ISSUANCE
(We)agree ht save,indemnify and keep harmless the Cry of C,wr ino agubssl ELECTRIC FEE
L.biliries,judgmrnn,cmisand expenses whiehmay inany way.crow agaimisaid City AL'FI:R OR ADD TOMECIL
PLUMBING ME
in conxyucncc Ih do ing of this pennil.
APPLICA .RS NDS 1. Ct113QhY_WITH ALL NON-POINT AIR HANDLING UNIT ITO 10.00(1 CFM) MECHANICAL MIS
SO, 'G no
AIR HANDLINGUNTT(OVF,R LR0MCFM) CONSTRUCTION TAX
gmnm ofAp,1wmnU .wr Dat. EKHAUST HOOD(W/DUCT) HOUSING MIT[CATION FEE
IIA]ARDOUS MATERIALS DISCLOSURE
Will the applicant or future holding occupant store or handle hazardous material HEATING UNIT(TO L00.00 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
ode.Section 25532(a)? HEATING UNIT(OVER I(0A00 BTU)
❑t'cs N0 VENTRATION FAN(SINGLE RMID) PAID
Dare RecciplN
Will the air commmantra building ed accupant me BayAea Air Qualitnt or y
manages ement
ent BOILER—COMP DHP OR IW,WO BTU)
emit hazuNous air eomumiwms m delined by the Ray Area Air Qmliry Management TOTAL. 5 4_
Ditricfl
❑Yes �<Nn HOILIiR—GOMPIDVER I00,00 BTU)
AIR CONDI IONER
1 nave re: t.raw buss tnmd:d,reyaimmems render cnapmr x.95 of the coli. ISSUANCE DATE
fornix health nl'ct la. Rune.55 5533a 255 .1 understand that if the NEW RESIDT:N'CAL MECH. SQ.ET.
bu'JAIn do Be Yhuvdrnant lh '.'uvibil'nymrmtilythcxapant
of it 11 ns . ah ant a p' Ccmficmc'If(kcvpancy.
D anmorir col Doc TOTAL: ISS BY
OFFICE