99120059 (2)APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY qq 1: V 0s `I
OFFICE
CITY OF CUPERTINO BUILDING - ELECTRICAL
PERMIT
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAI.
BUILDING PROJECT IDENTIFICATION
_
BUILDINGADDRESS'.
.ANITARYNO.
APPLICATION SUBMITTAL DATE
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•RRACTOR'S NAME: _ LIC NO:
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❑
CONTROL #
RCHITE /ENGINEER: LI O'.
ADDRESS: N
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CONTACT: PHONE:
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BUILDING PERMIT INFO
❑ Consultant Fees Pair) by Applicant (Initial)
BLDG ELECT PLUMB MECH
1:1 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I heachy am. that I am licensed under provisions of Chapter 9 (cote C
with Section]000) of Division 3 afore Business and Professi tde, andin
fall lose and e1F
is a
^�i /
ELECTRIC PERMIT FEE
❑0z
y❑O
nd _ F
JOB DESCRIPTION
RESIDENTIAL:
❑ SFUWL [I KITCHEN REMODEL
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
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Q.
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License Class _I_o—Lie.#
Date Contmemr
2 - Z 121% ITECTS DECLA TION
I understand my plans shall be .,wins public records
❑ADDITION ❑PLUMBING RF, -PIPE
❑MULTI -UNIT ❑ STRUCTURAL
MODIFICATION
PANELS
❑
t3jej
{{
� �
CW)L�following
UP TO 200 AMPS
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT ❑ SWIMMING POOLS
❑ DEMOLITION BATH REMODEVkEPAIR (] DEMOLITION
[I
Licensed Professional
OWNER -BUILDER DE CLARATION
I hereby affair that 1 am exempt form the Contractor's License Law far the
reason. (Section 7031.5, Beulness and Professions Code: Any city or county
Any
201-1000AMPS
OVER IOW AMPS
SIGNS ELECTRICAL
Ii y
G
which reyuire.s v permit to common, al¢q improve, demolish, m repair any dammum
prior to its issuance, also requires me applicant for such permit to rile a signed statement
that he is licensed pursuant to the provisimeofficComamorsLicense Law (Chapter 9
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
COMMERCIAL:
�p
(commencing with Section 7003) of Division 3 ofthe Business and Professions Care)or
o y
mat he is exempt therefrom and the basis for me alleged exemption Any violation of
❑ NEW BLDG/ADDITION ❑ DEMOLITION
POWER DEVICES
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mw
SQ❑Lothe
F
0.3
Section 7031,5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500)
employees
as work, the the sant army emplended with wages far sale 044,Bumien,
toHnLimens Law does or apply to a., Business
will dothewons Codec he Conneum isctor's owner of
and Professions Code: The Conuaeeo License Law does not apply
TENANT ❑ FOOD SERVICE
PR MENT
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES -FIXTURES
property who builds or improves thereon, and who does such work himself or through
s if
his own employees, provided that such improvements tar intended or offered for
NEW RESIDENTIAL ELECTR SQ FT.
SQ. FT. FLOOR AREA
$/SQ. Ff.
M1ower e is sold ware
is the
m an
within n one yeaor
-
owner -builder w l l haveh of proving
coill have the burden of proving chat he did not build or improve for Aur -
he improve
Firm
farlder
pose of aowne
I 'f0'I'AL:
I, as owner of the pmperty, am exclusively contracting with licensed contractors to
conalmed the pmjut(Sea](W4, Business and Prof sions Cedep The
cense Law docs not apply to an owner of property who builds orimpr t d
B FEE
Im
who contracts armch pmjocts with. con.omm(s) licensedpursuvnu aCilfat 'sESS
License Law. , `fr
❑ 1 am exempt under Bea , B & P C for this reason
I A
V
coact Date
VALUATION
WORKER'S COMPENSATION DECLARATION
ffirm under penalty of perjury one of the following declam
I hereby aNAM
❑ I have and will maintain a Cenificate of Consemm self -insure for Worker's Camper-
anion, as provided for by Section 3900 of the Labor Code, for the
DRAINS -FLOOR, ROOEA A,COND.
STORIES
TYPE CONSTRUCT' ION
work for which this permit is issued.
I have and will maintain Workers Compensation Insurance
L
3]W of thppe��Lw�bor Code, f1.onM1e performareauuayynppce �o�f the worklfapr^w�'hich th e
CvnlerrrkUk]I nP(pOnsu [$ShBzdolicarund
y NafYlnl `nT�Ol
NC
GAS -EA. SYSTEM -OVER 4(EA)
DEC. GROUP
�APN A
.r[�
CERTIFICATE OF EXEMPTION FROM WORKERS'
zz
Q
COMPENSATION INSURANCE
(Thisecenon need nm beee. pie ad iftIN pamm. is for one hundred dollars ($IIXp
or less) /
Icenifyth n open tenceo hework ferwhlch this permit is lssocd.l shell
totem to an ant en
employ y o q e o a subject to the Workers Compen-
in
sation Laws of
GREASE/INDUSTRL WASTE INTERCEPTOR
BUILDING UI VISION PEES
GREASETRAP
PLANCHECK FEE
SEWER -SANITARY -STORM F.A.2IX1 FT.
ENERGY HE
WATER HEATER WNENT/ELECTR
Applicant
GRADING FEE
NOTICE TOA ICAMf: IL after making this Cenifate of Exemption, you should
become subject m the Worker's Compensation provisions of the LVM+Code, you mua
comply with such provisions or this Permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I far. hurt, nn that there Issue ges.30 [ending agency forma perfannvnec of
me Werk for whleh this pcnnII Is issued (Sec. 309], Cil CJ
Lender's Name
Lenders Address
information is
I certify that 1 have read nilsty
that the shove cos
WATER SYSy'F.M/TREATING
WATER SERVICE
z ti
In
Wforthwith
❑
V O
W H
OU
L1a
�r
SOILS FEE
_
PIp'ID �^
II DNe\\ Ror�cipt#
NEW RESIDENTIAL PLMB. SQ. FT.
' U 'TO'fp
I III
TOTAL:
.[]
U1LD14Y EC 1999 11
U rA
:A
U z
and coup y ordinances mating
agree teer,rad camply hareby my andc apntymdiwnces andstme culartfam the
correbuilding tuliva of this citymenler upon the
audio,,, and harim
QTY. MECHANICAI. PERMIT FEE
k,
p' ISMIC PEE
PERMIT ISSUANCE
611_ RIC FEP.
above-mentioned property foadmentotinn purposes
dame -mach ationurposes
(We)ngry ave, indemnify and k• armless @e City of Cupertino against
ALTER OR ADD TO MECH.
�1.TR�7HING'
'
liabilities,jud cots costs and roses icM1 mvy many way nccrve against saiJCity
'n consequ reof egrumin fmi ermit.
AIR HANDLING UNIT (TO 10,1010 CFM)
MECHANICAL FEE
APPLIC T U ERST NO WILT. COMPLY WITH ALL NON -POINT
SOURC 'G Lr 10 ..
AIR HANDLING UNIT (OVER 10,1000CFM)
CONSIRUCIONTAX
�!
Signal of AppheramCmunigor Date
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCf)
HOUSING MITIGATION FEE
HEATING UNIT (TO 100,000 BTU)
Will the applicant or future building occupant smrc or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
HEATING UNIT(OVER IFL000 BTU)
Code. Searle. 25532(a)7 -
❑Yes F7 No
PAID
Date Receipt If
VENTILA'T'ION PAN (SINGLE RESIDI
Will the applicant or future building occupant use equipment or devices which
it havardous air contaminants as defined by the Bay Area Air Quality Munagentent
Dlsrtictl
❑Vas ❑ No
BOILER -COMP CHIP OR 100k000 BTU)
TOTAL: 2
BOILER - COMP (OVER I W,)W BTU)
AIR CONDITIONER
I have read���//�zardnus mat Is real ants under Chapter fi.95 of the Cali-
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. ET
fnmio Halm & SI Code, Surf 25 , 25533 and 25534. I mmustand mm if me
build does t 9A 0p W.
thata is my restmaibild, m notify de ecapam
me reqs' r6raw iEh met lannatiera cola .ilia f(xcupanry.
ISSUED BY.
TOTAL:
Ownermiaothorizedagem Data
OFFICE