99100008 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERM
APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING DIVISION r BUILDING PRO.HTCT MENTIFICATION' 'I
SANITARY NO, APPLICATION SUBMITTAL DATE
BUILDING ADDRESS:
a a 5�`�� S-/
�N�k�ws ,moo C�
'S NAM- PHONE: C CIO 'S NAME: LIC IS NIC CONTROL N
IlAil
C? B w O 8
ARCHI'PIFI'/HNGINEEk'. LIC NO: ADDRESS' ❑
coN cc PHONE: r IBUILDING PE - INFO
�,/� /�//.�� ❑ Consultant Flow;Paid by Applicant(Initial) BLDG '.E PLUMB MECH
LICENSED CONTRACT OR'S DECLARATION Ty. ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby affirm Nal 1 vm licensed under provisions of Chapter 9(commend .,
0=2with Section 7001Di,iact 3ofthe Business and Moe,,mds Code,and my go, i PER 1'ISSUANCE NT
~w� in full force and ellen. � ❑SIV WL ❑KITCHEN REMODEL
�UU License Class Lie.N PLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
NZQ Oam Comu.cmr ❑MULTT-UNIT El STRUCTURAL
Q ARCHITECTS DECLARATION PA [IS MODIFICATION
F�Z lundersmnd y an' hallbeused as p0liereeordv U 102110 AMPS
❑INTE R ❑CHIMNEY REPAIR
OZ-0
I„yFR1 Lm0
emsed Proodati 20140AMPS 1 OVEMENT ❑SWIMMWG POOLS
CY ; OWNER BUILDER DECLARATION OVIER I(X10AMP5 ❑ ATH REMODEIIREPAIR DEMOLITION
C W Q I hereby affirm that I and exempl front the Cnmmmor's License Law fm the
ip5t t1 U following oa.,on.(Section 9(131.5,Business and Pndassions Gale:Any city nr county SIGNS ELECTRICAL
1+130.I" which requires a permit to construct,alter.Improve,demolish,or repair any s metdo
prior,.its issuance,also inquires the ap,fvaht for such pe.it 1.file.signed amemrn, SPECIAL CIRCUIT/MISC.
fly that he is licensed pursuant to the povi,ions of the Comradors License law(ChaprcC 9 COMMERCIAL'
Wa00 (commencing with Senion TXMB of Division Sof the Business and Professions Cade)or TEMP.METER OR MOLE INST.
a e y
in.,he is exempt I ca,fir.m ane the bud,for Ibc alleged exemption. NEW BLDG/ADD N
Any violation of ❑
I m Senion 9011.5 by any applicant faro permit mbinda the almiwnl to a civil penalty of POWER DEVICES ❑TENANT F SERVICE
not more than fee hundred dollars($510). IMPROVEMENT
=� 01,as owner of the properly,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC ❑OTHER
L will do the work,and theslruclum is not inlandedorafiered fonsale(SCcJ014,Business
63m and Liufeau.ns Code:The Cnlnrvcmrs License law does not apply to an owner of OOTLHTS-SWT1 CHU-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvmnents are not intended or olfcrc+l Ibr NEW RES IDP.NTIAI.ELECTR SQ
so,FT.
sale.If,however.the building or Improvement is sold I,add one year ofcompletion,the PLOD QEA L
owner-builder will have the burden of proving that he did not build or improve for put- f-S D
have of sale.). U
❑1,as owner of the properly,am exclusively contracting with licensed contractors m
on,8aclda,prtpact(See,7044,Business and Praressiuns Cale:)The Contmctors Li- � OCT 1 19( 9
cense Law doe,n.l apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT' .E
whocontracls forsuch projects with oconne,huh)I weread m,.am(.the Comructnr'x
License Law. PERMIT ISSUANCE
❑I am exempt under Sec. ,B&P C for this rcamn
AL'1'F:R-DRAIN&VIENT-WATER IEA)act VALUA'f10N
Dove
WORKER'S COMPENSATION DECLARATION 13ACK FLOW PNOTBCI'.DEVICE
hereby affirm
mai nada penally ofperjuryone of self following declarations:
Cr
❑ [have and will mainlainv Certificate of Cnnsemmself-inure lin Worker's Cnmpen- DRAINS-FLOOR.ROOF AREA,COND. STORIES TYPE.CONSTRUCTION
a mon,as provided for by Section 3100 of the Lather Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑ 1 have and will nu nmim Weake,'s Co apardelion Immediate,ns required by Section
31W of the labor Cede,I he performance militia work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP
My Worker,Compensation I nsurance cameranl Policy no nm her one:
Carrier: Policy No.: GAS-EA.SYS"CBM OVER4(EA)
Q 0 3
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSINSURANCECREASFIINDUSTRI.WASTE 1 RCIATOR
6UILDWGp FEES
or la,,.)pfiis section need not be completed ifthe Permit is for one hundred dollars IS 100) GREASETRAP
PIANCHECK FEE
I sonifythatinthe pe,mmmeeofihework lot which ,,the W irkem'edl,hn- SHWIHI-SANITA -STORM HA 200 FT.
kCE
pl ny pars min any mnanner so asmhecome suhjecunthc Workers'ComnPa^- ENERGY FEE
z W.of le.Dae WATERHEAT WIVENT/[LECfR GRADING FEF:
am a F/ � yy--��6yti
z h TO APPLICANT.B.a ter making Ihls Cemfieate.f F.xempuon,you should WATI!R STLM/fRE4l'ING SUITS FEE
(-m "I e subject 10 the Workers Compereadion provisions of the Labor Code.you muss
him.h,comply with such prnvismasor thio pennil shall bedttn¢d merged. WRSP,RVICE
CONST RUCTION LENDING AGENCY NEW RESIDENTIAL PI.M. SQ.FT PAID
ZDate Receip,p
l hereby am that fare is a constriction lending agency for the unficroodecof
!Uaffirm
work for which this pertnil is issued(Sec.3091,Civ.C) TOTAL:
0l-' Lenders Name
U Lender's Addre.vs TOTAL:
1 certify the,1 ove read @is appliedlin I and sane that Iho above Information 1, BUILDING PEE
h
it N correct.I agree to comply with all city and county ordinances and state laws relating m QTY, MECHANICAL PERMIT ' FEE SEISMIC FEE
U building construction,and hereby authorize represmediss of this city to enter upon the
.hove-mcndesed property far inspection purpose. F'ERMI'f ISSUANCE ELECTRIC ITE
(Wc)agree m save,indenmify and keep harmless the City.f Cupertino again.
habiliics,judgments,comsand expenses which may in my way uccnte against said Cay ALIERORADDTOMECH. PLUMBING FEE
in onscyuanre of the grmnin"of this pannit.
APPLICANT UNDE SAN 'ILh COMPLY WI HALL NON-POINT AIR HANDLING UNI'I'(TO 10,0000W) MECHANICAL FEF.
SOURCE RF '1 - ONS.
AIR HANDLING UNIT(OVER 140(10 I CONSTRUCTION TAX
m co pahae—Coullaaa Dole EX IIAUST EN)" IUUCT) HOUSING MITIGATION HE
HAZARDOUS MATERIALS .CLOSURI!
W Il the upDlicanl or foram building occupdm score.,handle moadou,mawnad III!KI'ING UNIT('C0 If101 eTU)
as defined M1y the CuDerinn Municipal Coda Chapter 9.12,and the Health and Safety HEATING UNIT(OV. 100,000 HTU)
Code,Section 25532fa)'!
❑Yes
ON. VIiND1.ATi0 AN(SINGLE RESID) PAID
Date Receipt p
Will the applicant or future building nccapam use cquipmcln or devices which Ig)IhEK OMP f3HPOR 1 W,, BTU)
emit hsza de s air c.ntaminalls as defined by the Huy Area Air Quality Management 'fD1A s
Dislncl+ B :R-COMP(OVER 100,000 BTU)
❑Yes 0N G�
Illnvereaddahma smamrials rcyuirements ander Chapter 6.95 of the Cali- ALR CONDITIONER SSUANCE DATE
food.I befit&Sal e,Serum 111.25533 and 25534. mulersrand lam if(he NEW RESIDENTIAL,MFAH. SQ.Ff.
buildingdnosnmtct mlyhuvcu ,t"Also ,poll"laymneffythces,,eam
oft re shichr'i yst oneutifiemeof0ec
r I onz age
oneTOTAL: ISSU[U BY:
OFFICE