99110007 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
•P [R IT NO. O�
CITY OF CUPERTINO ) PLUMBING -MECHANICAL
BUILDING DIVISION API LICATION/PERMIT S0001
96UM ATZT tW&J 6q'M) s27-Tgtf
LICENSED CONTRACTOR'S DECLARATION
I herehy alRrm that I um licensed under rrasiums of Chapter 9 foommencmg
�aZ with Start on](KKllnI'Division 3ofthe Business and Professions Care, and my license is
Fin full fore and effect.
d ��F]] License Class Lica
F+� IA Dale Contrmctor -
a,tARCHITECTS DECLARATION
Z FO v7i'NLL 1 unJersmnJ my Dlanx shall be used ns puhlic rends
ort�
g w j d Licensed Professional
OWNER -BUILDER
ur ffie RATION
6 1 hereby affirm on 1 am eBushm from the Conlms, Co license Lew for the
Ci�S 6 U following reason. (Notion fiomm Business andmp ve, de o demolish,
CMe: Any city or county
I++ O y whorl its issuance,
n permso to cermet, pplac improve, demolish, or rash any swcture
m� that hosts mrsece,alsor theres lbeaisions o for such Contractor's
ofile aicense Law (gned Chapter
} (co he isccen it rursnvm mlhe prmamnsnf the eBmidess License Law(Chnpar9
Qi
(commercial, Section IIglipdhasoofarN theeged cevndmn.An vi acro. or
d ax o N
hot he is exempr. any cep li and the hPer fur the alleges applicant
to Any vinlmion of
W z m her
](loan by any applicant Tia v Permit subjects the applicant to a civil Penalty of
FZ} not more shun Eve hundred dnllem ($50h).
SSC ❑ do the wernftcepe pace oris intended
with wages randei(Sec. 0ci4,B ,roess yy1yF-
ill do me work, anhllhemmeureisnnt Licens proffereds rsale(9ly to an,wner of
4 3 and Rolessinns CMB: The oyes d anon License law does nm apply m an owner of
propeny who soils, or improves thereon, and who rices such work himself or threugh
his own employeese builds ed mm isuchmprovement
mens is wild
ts ware not intended or oflcret for
take If, however, the building or en of proving
is sold within one year r improve
me
1�ws}neFr-huilJer will have she buNcn of proving mat he did not build m improve for put-
,fit,
ur-
r tf ct • prep 0,1 , B e i.a,,, ad enmrvumg with l«nsee conaaae, t.
Iron the es not
(Sec. o an Business and Istproperty
wh ions Cnor.) The Comnmmrs nd
anm law rices not apply je ta owner of property who builds or improves Boosted, and
who contracts for such projects with aeontrectoRs)licensed proceed othe Contractors
f2
License Law. ''Y
❑ I ren eumpt urNer Sec. B & I' C for this reason
MMM _ I Mi
_ o It IL -fl -T
❑ Consultant Fees Paid by Applicant (initial)
IOTY.I ELECTRIC PERMIT I FEE I
1 herehy aRrm hfider pen114q of perjury one of the following Jeclvratlore:
I have nnA will maintain a Cur ihcule of Consentto self -insure for Workers Compen-
nvtinn, as presided for by Section 37M of the LAW, Chile, for the performance of the
work for which this permit is Wood,
❑ 1 have mal will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the perfurmmnce of the work for which this pemit is issued.
My Workers Compcnsmian Insurance carrier and Policy number am:
Carrier: Policy No.:
CERMFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thissecllnn need not haeompletul ifthe permit is forone hundred dollars 151001
orlex )
1 certify that intheper andarcenftbework forwhich thispcmitisissued, I shall
not employ any person in any manner so es to become object t- the Workers Compen-
Z sauna Lnwsnf Califnnin. Date
O Applicant I
C. NOTICIi TO APPLICANV. If. after, making this CeniEenm of Exemption, you should
h LN' trona subject to the Worker's Compensation previsions of the labor CMe, you must
W� Lmhwith comply with,wch provisions or this remhiuhall he deemed revokes.
Q
CONSTRUCTION LENDING AGENCY
Z khereby
which thitbvuhere issued(Suc, 30 len ding agency for the performance of
U � Ilan work fur which mss pemml is issuaJ )Sea 309], Civ. C.)
Q U Lenders Nance
U L<ndee, Address
C I unity that I have mad this application and state that the above infomnrinn is
IA cnrean. I agree to comply with all city and county ordinances and stare laws relating to QTY.
building construction,and hereby authorize representatives of this city to enter upon the
sMa,cou ntionel property for inspection purpose.,.
(We) agree m suva indemnify and keep harmless the City of Cupertino against
liabilities,judgments. costs and expenses which may in any way accmc against said City
in consequence of me grunting of this permit.
APPLICAN'P UNDERSTANDS AND WILL COMPLY,W I'fH ALL NON -POINT
Will theap,IVtit nr furore building occupant score nr handle harmonic., material
as defined by the Cupertino Municipal Code, Chapter 9.12, and Ne Health and Safety
Code , Section 25532m)'I
❑Yea ❑No
Will the applicant or future Wilding occupant use cycipment or devices which
coif hnzaNuu, it amm ndents as defined by the Bay Arca Air Quality Management
rDEuicf!
❑Yea ❑No
1 have .it Ne commons tmamrials requirement under Cloister 6,95 of the Cali -
hard
iu u I & Sufety Cede, Sections 25505.25533 ons 25534. I urldmstM That if the
bu(I hgdn nomumntly hove atmmnt,lhailAy ro,quelhillly ljnMl'y the mecuWt
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UPTO 200AMPS
SIGNS EL17C'IRICAL
SPECIAL CIRCUIT/MISC.
'TEMP. Mli'PER OR POLE INST.
POWER DEVICES
OUTUTS-4 CHf:S-IBX'1'URP:S
NEWRES ✓iNT1ALELECI'R SQ FT.
ALTER - URA WATER IEA)
BACK FLOW PROTECT. D>"i�
DRAINS- FLOOR, ROOT, AREA, CO D
FIXTURES - PER TRAP
GAS - EA. SYSTEM -I INC.4 OUTLETS
GASB -EA. SYSTEM -OVER 41EA)
GRE ASUIN DUSTRI, WAS' 117 INTERCEPIDR
GREASETRAP
SEW ER - SAN TA BY- S'FORM HA. 200 FT'.
WATER HEATER WNENP/ELECfR
WATERSYSTT?M?REAI'INC
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ. Pr.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECIL
AIR HANDLING UNIT C 10,000 CFM)
AIR HANDLING UNIT (OVER I0,000 CPM)
EXHAUST HOLD (WMUCT)
HEATING UNIT OT) 100,000 ITU)
H17ATING UNI'((OVER 101,000 BTU)
VENTILATION PAN (SINGLE RESID)
BOILER -COMP QRP OR 100,000 BTU)
BOILER - COMP (OVER 100,000 BTU)
AIR CONDIT IONER
NEW RESIDENTIAL MSCI I. SQ. PE
FI?E
L�1
DING PERMIT INFO
LECT PLUMB MEC
❑ ❑ ❑
.JOB DESCRIPTION
RESIDENTIAL
0 SFDWI,
0 KITCHEN REMODEL
❑AUDITION
0 PLUMBING RE -PIPE
Cl MULTI -UNIT
❑STRUCTURAL
MODIFICATION
❑ INTERIOR
C1 CHIMNEY REPAIR
IMPROVEMENT
EW3SPOOLS
❑ BATH REMODEI/RIiPA1R
INDLMOLITION
❑ OTHER
COMMERCIAL
❑ NEW BLDG/ADDITION
❑ TENANT
IMPROVEMENT
❑ OTHER
❑ DEMOLITION
❑ FOOD SERVICE
SQ. Ff.4yti�AREAt,J �IJ \IIS/gQ. IT.
No/ly 91999 U
VALUATION
eco Q
C
BUILDINGDIVISIONFFES _
PIANCI IECK FEE
ENERGY PER
GRADING FEE
SOILS FEE
PAID
Dam Receipt p
TOTAL:
BUILDING PEE
FEE SEISMIC FEE
ELECTRIC FEB
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Date
/
ISSUANCE DATE
7, ,
IMAL:I ISSUED
OFFICE