99120057 (2)APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL.
BUILDING DIVISION APPLICATIONIPERMIT Inn PLUMBING - MECIIANICAI
nNC beat 4YT uIFs 1'IFIC
,;,, AXV/rn V6
CONT'ACL ' ^"^'-
1 hereby a1Bmt that I am licensed under Provisions of Chapter 9(commcnciny
WOZ with Section 901X) of Division 3 ofthc Business d Professions Codrid mylittnx is
�,2 in fun forte and effect 6 111306
U I.iccn ar Clea L Lie. g
NzW Du¢ Cotnrac
LL ARCIII'I EC'S DECLARATION
f -H Z 1 onJersend my plan, shall M uncd to Public carried,
9z°^o
W LiccmoJ l'nncssional
OWNER -BUILDER the
tW�] 1 hereby o(Sect that I am exempt main athe Cnntfae Co ❑erns, Law for the
xGx 6. f- followingmasona Permit
t 9onstr Business and improve,
de oli Coda Any city or county
W 3 c sIf which requires a permit m construct, cher, improve, demolish, or repair anY ,wooer
�a Prune it, issuance. also tequires the applicant for such permit to file a signed statement
that he is licensed pursoanuothe provisions of the Contractors Liceaselaw(Chzpsnr9
Iccambetaing with Section 700()arIivnion 3ofthe Business and Professions Cedelsa
IL Xc y that he is exempt therefrom and the hasis fill the alleged exemption. Any violation of
W N lection 7031.5 by any applicant for a permit subjects the applicant to a civil penally of
at more than five hundred dollars (85(gB.
SD 0I,as tracer Of the proeedY, or my employees with wages as their sale compensation.
F• will Jomework. and theswemm n not intended or oBcleJ for sale (Sec.9044. Bm'ires
ce mW Prom„ a Codc: Hato Contractor's Lacus, Law docs not apply to a w: of
oat
property who build, or improves thereon, ,r who docs such work d d (or or IM1rongh
his nam o ver c he provided that milt meat k l,ld av arc ton intended (or nRcruJ the
sale. r-uilder ithebuildingtor rint Of
isathwithinoneyearofcompletion, 0c
crbuilJcr will have the burden n( Proving that he did not build or improve for par
qac of sale.).
0 1, as carrier Of the property, am exclusively convening with licensed contractor, us
unstrvet the project (Sec. 7144, Business and Professions Code:) The Conuacrors Li-
canse Law Jres not apply to an owner of property who builds or improves thereon, and QTY
who con mm s for such prejecu with a contractuds) licensed pursuant m the Commences
License I.,
0 1 am exempt under Sec. . B & P C for this mason
Owner Date
WORKER'S CUM PENS A'1'ION DECLARATION
1 herchy of hent under penult, of perjury one of tire fellow to, dechrtmium,
ave and will maintain a Ccnilicam of Coosennn,d Fiame, for WOrkcr's Con ien-
:aliou, as provided for by Section 391X) (if the Labor Coca. for I perf<annmce of the
w rk for which this permit i, issued.
1 have and will maintain Workers Compensation Insurance, as mquircJ by Section
37X0 of the Labor Code, for the performance Of the work for which this permit is issued.
Ca W,Acrs mgcnsation lmur rimer toil Policy numb,
Carver: ��y�levnie.aAe[1,rmrrva:n/fn4ti5-SS/I
CERTIFlCCAmOTEhOPFFGlINTIONINSURANCE NSURANCE
(Thsaction nmdnM1ecompleted
ORKERS'
if the pemtit is for onehundred J011an 181(X0
I,, less)
I certify that in the perfnnnance of the work lar which This permit is issued I shall
not employ any persan in any mammrsu as tohecumc cab I to the Worms Colnpcm
OzxuHnn Luwx of Culi( ja. L _
O nppl P
NCI ICE 1O API' TCANT: II', u11cr making his Certificate of Exemption, you should
F•'
bee vme,object m the Worker's Co, Formadl n prnvixines of the Labor Code. you must
a'7 fnnoi0h comply with. each praskionsnrlhis pence, shall be deemedrevoked.
aQ
,UZ CONS0NLENDING AGENCY
U Thereby affirm that
em is aros
nmetiun lending agency for are performance of
—the work far which this .it is issued (Sec. 3097. Civ. C.)
er
17 Lend's Name
U
Ixnder's Address -
O. 1 candy that I have read this application and same that the dole infowatina is
(A correct. I agree to comply with all city and county nNlnunees and state laws relining to
CI%. building ,retroaction, and heroby ameniee reprexmrtives of this city m emcrupun the
:moor-mcntloned property far insleainn purpnsu,.
(We);,Tato m save, indetnnil'y and keen females, the City of Cupenlno against
liabilities, judgments, costs and expenses which may in any way same figures sold City
in nsequcare of the graming of this permit.
APPLICANT UNDERSTANDS AND WILL COMI-LY WITH ALL NON -POINT'
SOURCE REGULATIONS. I n -
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle Immoralists material
as defined by the Cupenina Municipal Crile. Chapter 9.12, and the Health and Safety
Coda, Section 25532m)9
[3 Yr, Nx<o
Witt the applicant or funs, hui loins occupant use equipment or devices which
mit hnxurdnus air courcenems its deinwl by the any Arca Air Quality Manoganenl
Ui.arict90
Yet,nu
I hme it the hadous mamrials ra i iremcer, under Chapter 6.95 Of the Cali
forma health & Safety Cure. Sections 2550. 25533 coral 25534.1 mrdemmld that if the
building does nor currently have a mnank that it i, my re,ponsllahly to notify the vacation
,of mmiremenu I hichanust he mer ethic 10 issuance of a Cenifcam of Occupancy.
/��/O /Y/TVX. �. .7Y�v
Consultant res Paid by Applicant (initial)
ELECTRIC PERMIT FFE
PERMIT ISSUANCE
APPLIANCES - RESIDENT'IM.
PANELS
UP TD 200 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING P001. ELECTRIC
OUTLETS - S W TrCHUs - FIX I ORES
SQ ET
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN & VENT- WAT ER (EA)
HACK RAW PRO] ECT DEVICE
DRAINS -FLOOR, ROOF, AREA, COED.
ITS FURES - PER TRAP
GAS - EA. SYSTEM-] INC.4 OUfLI7S
GAS - EA. SYSTIiMAVER 4 (EA)
GREASUINDUSTRL. WASTE INTERCEPTOR
GREASETRAP
SEWER - SANI'T'ARY - STORM EA. 200 FT
WATER HEATER WIVENTIELECFR
WATER SYSTEMT[ REAPING
WATER SERV ICC
NEW RESIDENTIAL I'Lhfll. SQ. IT.
TOTAL
QTY. MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MF:ClL
AIR HANDLING UNIT IN Arad CFM)
AIR HANDLING UNI F (OVER 10.00 CFM)
EXHAUST HOOD OVIDUCT)
HEATING UNIT (TO 170.000 8'1'U0
HEATING UNIT (OVER 110.100 BTU)
VENTILATION PAN (SINGLE REST U)
BOILER -COMP (311 [1 OR I0JS0 II'1'U)
BUTLER - COME' (OVER 100,000 13 1 U)
AIR CONDITIONER
NEW RESIDENTIAL MECIL SQ. pT
OFFICE
I
DING PERMITINFO
LIICT I'LIlh1It MEC
❑ ❑ ❑
JOB DESCRIPTION
RESIDENTIAL:
O SFDWL
O KITCHEN REMODEL
[]ADDITION
[I PLUMBING RE -PIPE
O MULTI -UNIT
El STRUCTURAL
MODIFICATION
D IN'I'PRIOR
OCHIMNEY REPAIR
IMPliOVEMF.N'I'
E] SWIMMING POOLS
0 RATH REMODEUREPAIR
0 DEMULI'IION
00111 ER
9M
OMPR IA :
V� 'L
O NEW BLDG/ADDITION
ODI!MOLIT N
❑TENANT
01'OOD SERVICE.
IMPROVEMENT
O OTHER
SQ. FE FLOOR;RHA I SISQ. FT
/3,�`a
] STORIES 'I'YPI!CUNS'pillC'I'10
BUILDING DIVISION FEES
PLANCHECK FEE
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
Date Ralsoll#
TOTAL:
BERIC
FEE S
E
PLUMBING FEE
MECHANICAL I7HE
CONSTRUCTION TAX
HOUSING MITIGATION FF.E
FAR)
Data Rcccipl p
ISSUANCE DATE
12--g-99