9090107 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY DIi GDIVIS'ION RUILB NG-ELECTRICAL PER
HmLDINr,DIVISION APPLICATION/PERMIT PLUMB MECHANICAL
FIC
-. BUILDING PRWELT.I135NTIFICATI0N4'. 1 .
BUILDINGADIN4It: ` SANITARY NO. APPLICATION SUBMITTAL DATE
2'2480 LI C-r . Cu PERTlNo CA °IS014 C� _ )
OWNER'S NAME: PHONFi: CONTRACTOR'S NAME: hICNO: //
V S 7A7 UR.AN) $-3,32-S& O NIC cnNTRol.a
CI It I'M/]:NGINIZIZR: LIC NO ADDRESS'. ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consullanl Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
mal
El ED 1?" ❑
ro, 1.
LICIthat I licensed
DECLARATION QTY ELECTRIC PERMIT FEE
L hereby antmlicensed ander previsions of chapter 9(commencing QTY DESCRIPTION
OWaZ with Seminn Tfkq fDr,kan 30flhc Business and Professions Cede,and., licensees
)e Y RESIDENTIAL:
�� in full force end dTett PERMIT ISSUANCE
m" �EFDWI. ❑KITCIfEN REMODEL
<—ULicense Class Lica
s Zw Dam Conuactor APPLIANC[S-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL.
PANELS
Z Or`Ojs� [understand my plans shall be used aspublic records MODIFICATION
OZ-+Q UP TO 200AMPS ❑INTERIOR El CHIMNEY REPAIR
f=..Y W Licensed professional 201 I(XM)AMPS IMPROVEMENT 0SWIMMING POOLS
C6 OWNER-BUILDER DECLARATION OVER 1000AMPS ❑BATH REMODEUREPAIR 0DEMOLITION
C Q 1 hereby aRnn that I em exempt fro^,the Contractor's Liceme Law for the
2:5,
lfollnwingroon(Section]031.5,Busbcss and Prom,,ions Cade:An ciYorcountY SIGNS ELECTRICAL ❑OTHER
3 aCOD which requires u permit m construct,alter,improve demolish,or repair any,wnare n
C)COD
primto its issuance,abu requires the applicant for such permit to rile a signed statement SPECIAL CIRCUF/MISC. Z�
2 pN..
that he is licensed pursuant to the provisions of the Contramor,License Law(Chapter 9
CaOC (commencing with Section 7")of Division 3 ofthe Business and Professions Code)or '1£MP.METER OR POLE INST COMMERCIAL:
a k ca LL that he is exempt mcnind and the basis lit the alleged exemption.Any vimation of El NEW BLDG/ADDITION ❑DEMOLITION
W„•y Section 9031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
not more than live hundred dollars Wad)
IMPROVEMENT
=O ❑I,aznwnentf me pmpeny.onny employees with wages es Oteirsole nnnpc^amlan, SWIMMINGI.0OLF.LF.CT'I11C
will do the work,and the woreare is not intended crafted for sale(Sec.7334,-stenos ❑OTHER
p�] se and Prof ono^s Code:'The Conlrunor's Ciccone Law Anes nm apply to an owner of OUTLE'f5=5WITCIINS-F RES —
6 property who builds or improves thereon,and who does such work himself or through
a,own empinyces, movidal but xrich improvement nre not intended m offered for NEW RESIDENTIAL ELF. 5
sale.ILhmvever,the building or improvement is sold within on-_of completion,the SO SFT FLOORu EA t $/SQ,FT.
zavn
er-bn'dder will have the burden of proving that he did not build or improve for par-
Iwf Ie.).
L4�.�wtmr of the property,am exclusively contracting with licensed conductors to inmSEP 16 1999 "
construct e project(Sec.]044,Buenas,and Premotor,Codu:)The G,mmnols I.i-
cerselawdoes not apply to an owner ofpropmy who bunds or improves mereo^.and QTY. PLUMBING PERMIT FEE
who contracts for such projects with n eomrector(s)licensed pursuant to the Contractor's
Lieewe Law. PERMIT ISSUANCE
❑ lam ex em Fsmdn Sea ,B&PC fo this match I_
Pner ._Due— ALTER-DRAIN&VENT-WATER GIA) VACUA'fION..a
,AvoREj7_R COMPENSATION DECLARATION BACK FLOW PROTFCT.DEVICE
I hreaffirm under penalty of perjury one of the following dcdamtiom: L. (!
❑ I have and will maintain a Certificate of Consent toself-insure for Worker's Compen- DRAINS-FLOOR.ROOF.AREA,COND' ST'Oft1E5 TVP CONSTRUCf[ON
sennet,as provided for by Section 37M of me Labor Code,for the performance of the
work for which this penitit is notion. FIXTURES-PER TRAP
El 1 have and will maintain Worker,Compensation Insurance,as required by Sulinn
39W of the labs CMB for the performance of the work lot whichmispcnnitis issued. GAS-BA.SYSTEM-IINC40UTLETS OCC.GROUP 'N
My Worker',Compcns tion Insurance carrier and Policy number are:
Carver: Policy No: GAS-HA.SYST17M OVER 4(HA) ti /
45
CERTIFICATE OF EXEMPTION FROM WORKERS' l/C
COMPENSATION INSURANCE GREASFANDUSTRI,WASTE INTERCEPTOR
('Ihinacnion acNnutbecomplercdifmepenan isforenehundmddolim,($100) q B., BUILDINGDIVI$IQN I•TiES
er less.) I GREASE TRAP PLANCHECK FEE
I certify that in the pzrformenceof the work for which this Permit is issued,l shall
not em In ;m SF.WF.R-SANITARY-STORM EA. Fri.
p y y pennn in any nnammr so its t0 become subject m me Walkers'Compen- ENERGY FEE
O Z trued Laws of California.Date WATER HEATER WNENT/ELECTR
Z Q Applicant GRADING PER
= NOTICE TO APPLICANT:IL attar making this Certificate of Exemption, no should WATER SYS TEM/I'RHAI ING
abecame subject to the Werkefs Compensation provisions of the Labor Codes you must SOILS FEE
G forthwith comply w an such provisions or this permit shall b:deemed revoked. WATER SERVICE
IIJ0
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FL PAID
UO 1herehyamrm flanhero I,a consltution leading agency for the perfmmance.1 Dnte etptM
4.a H the work for which this permit is issued(See.3097,Civ,C.)
C) Lender's Name TOTAL:
} W Leaders Address TOTAL:
I cent fy that l have read this applicsuon;rod state that the above intonation is BUILDING F17E
.'�. Z) toren.l agree tocomply with all city and county ordinances and slate lawsmlarngt0 QTY MECHANICAL:PERMIT FEE-
U Z building construction,and hereby authorize representatives of this city to enter upon the SEISMIC FEF.
above-^tentloncd property for inspection purposes. PERMIT ISSUANCE
(We)agree m are,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
lindolitict.judgro,rv,com,and expense,which nn ay in any way cane a,porm.aid city AL'1'lili UH ADO TO MFCIi.
in contaminative of the graming of this permit. PLUMBING FEE
AP NT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
URCE 'GULA MECHANICAL FEE
/9-9 Q AIR HANDLING UNIT(OVER 1(,008 CFM) CONS'IRUCf10N TAX
greater fr pplicanoComarcmr Cibm
EXHAUST HOOD GYMUCT) HOUSING MITIGATION PEG
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant nue or handle hazardnusmamal HEATING UNIT(TO 100,100 BT U)
ns defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
GAd.Section 25532E01 HINTING UNIT(OVER 100,000 OTU)
❑Yes ❑No VENTILATION FAN(SINGLE RHSID) PAID -
Date R eipt p
Will the applies.,or future building a .,.I use equipment cardesires whieh BOILER-COMP(JHP OR I W,(1p0 BTU)
nit humrdous air cmntationanl,as defined by the Bay Ama Air Quality Mnn.gemenl L:
Uistdct?
1 al JQJ
F7 Vex Fl No BOILER-COMP(OVER 100,000 BTU)
I have mad the hvN
aous materials"direments under Chapter 6.95 of the Cali- AIR CDNDITIDNIiR ISSUANCE DATE
la It &Salm Gale,Seallans 25505,25593 and 25534.1 understood that If the NEW RESIDENTIAL MECfI. SQ.FT. !-
nidingd not cu yhave.levant.that it is my responsibility to party the oeevpail
of pair cyw It must be met priorm issuance of a Cenif atcaf
11 6
aumoic ent TOTAL: ISSUED BY:
OFFICE