99080048 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL P
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT]DEN'TIFICATIQN
BUILDING IDDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
• 141197 Z)P-- Y, 4
OWNER'Sb ' PHONE: CO ACTOR'SNAM LICNO:
rti �1 d -353 'A L Sea 7L 3 s' "'c coN RQ a
RCHITECT/ENGINEER: LIC NO, ADDRESS ❑
.9.631C-J va t"tril /Lae- San la rias
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ . e ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRICPERMI'F FEE
1 hereby of irm that I am licensed under provisions of Chapter 9(toatmendag _ JOB DESCRIPTION
QWZ with Seran7000)afnmislon 3ofine Buxineatind Prde"xm.x CoxL,aodmy license is
w o 0 t PERMIT ISSUANCI? RESIDENTIAL:
E+Wp ;it force trade s. J.i ❑SFDWL ❑KITCHEN REMODEL
�UV License LIC.k APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
.<n. Docontmcmr
ARCHITECT'S DECLARAT [I MULTI-UNIT ❑STRUCTURAL
Z O m Z I understand my plans shall be used kv public records PA" MODIFICATION
OZ=`Q UPT02MAMPS F1 INTERIOR [I CHIMNEY REPAIR
QNFeoi Licensed l'rofeashmal 201-1000AMPS IMPROVEMENT (]SWIMMING PDOLS
Cyd , OWNER-BUILDER DECLARATION OVER IOXIAMPS D BATH REMODEUREPAIR ❑DEMOLITION
Q 1 hereby affirm that I.m exempt from the Comrecmr's License Law for the
K 3 L U following reason(Section 7031.5,Business and Professions Cade:Any city of county SIGNS ELECTRICAL ❑OTHER
ul a which requires a permit to consisted,offer,improve.demolish,or repair any structure M !r Lt- /N l�e.t
FLL� prior to its issuance,also requires the applicant for such pemsina file a signed statement SPECIAL CIRCUIT/MI
that he is I rimed pursuant to the pnrvisiomnf the Contracmts License Law(Chapter 9
WCC (commencing with Section 7000)of Division of the Business and Professions Calif)or 'TEMP.METRO OLEINST. COMMERCIAL:
11 e C that he is exempt therefrom and the basis for the alleged cxemption,Any stridden of ❑NEW BLDG/ADDITION ❑DEMOLITION
(L Section 7031.5 hyanlicant far.permit subjects the.,ticna civil penalty of POWER DF FS
^rte y appannI of []TENANT ❑FOOD SERVICE
5Gnot more than live hundred dollars ycropl.
❑ I,o"ownerk,the property. rmyemntendes oiNferedustheirm.annpensminn, SWIM GPOOL ELECTRIC IMPROVEMENT
(.. will(to the work,nntl the structure is not Intended or offered tarsale(Sw.70f4,Iluxinexa ❑OTHER
Wa m and PndcW is Conle:'fhe Camramor'x License Law does not apply ,,an owner:, O ).HTS-SWITCHES-FIXTURES
proper,who builds or ininravea therc+m,and who does such work himself at 1r al.
his own employees,provided that such improvements are not intondcd or ancient for NEW RESIDENTIAL ELEC9'R ,SQ F1'.
sale.IL however,the building or improvement is sold within one year of compleina,the SQ.FT.BOOR AREA $ISQ.FT.
erhudler will have the burden of proving that he did not build or improve lin par
po a ol'm1e.).
❑ Les owner of the py,operam exolusively contracting with licensed,damomnts to TOTA
mmtmn the ponce,(Sec.70,14,Business end Fish..as Cn1e:)'Me Contractors Li-
cense Law does not apply toanowner of property who builds or improves thereon and QTY PLUMBING PERMIT FE
who contracts for such projects with a contractions)licensed pursuant m ContractorstheContractors
License Law. PERMIT ISSUANCE
lam exempt under Sec. ,B&P C fruits reason
Owner Dom ALTER-DRAIN&VENT-WATIiN(EA) VALUATION
go WORKER'S COMPENSATION DECLARATION BACK FLOW PROTEGE DEVICE
1 hereby affirm under penaltyof perjury one of the following dalamtiom:
❑I have and will maintain a Certificate of Consentto self-insure for Worker's Conipen- DRAINS-FLOOR,ROOK AREA,COND,
"lion,ax resided fur b Section 37M of the Labor Cade,for the STORIES TYPE CONSTRUCTION
y. perfammnce o(thc
I'll, which This permit is issued, FIXTURES-P[R TRAP
1 have anti will maintain Worker's Compensation Insurance,m required by Section
37M a fine Lubar Cade,for the performance afthe work for whichmis permitis issued GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Wfmker CaC rIYTIFICAT P.OF IiXF.MI+TaloION FROM WORKERS
GAS-F.A.SYSTEM-OVER4ICA)
COMPHNSATIONINSURANCE GREASEANDUSTRI.WASTE INTERCEPTOR
BUILDING DIVISION FEES
Cfhix section aced not be completed ifthc permit i"far one hundred dnllnm($IlX)1 GRP,ASE TkAP
in,less) PLANCHF.CK ME
I certify mut in the performance of the work for which this permit is issued,1.shall SEWER-SANITARY-STORM EA.21X)TT.
not employ any person in any manner so as to become subject to the Workers'Compen- ENERGY FEE
O Z Notion Laws of California.Date WATER HEATER WNEMI'/ELECTIR /I
Z Applicant V GRADING FEE
.N. NOTICE TO APPIACANI':It,after making this Certificate of Exemption,you should WATER SYSTEM/TREATING
a ' become subject at the Workers Compensation prosisions of the Labor Gale.you must SOILS FEE
forthwith comply withmch provisions ar it permit shall he deemed revoked. WATER SERVICE
UZ CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
affirm 0 Iherehy unn thanhereis acons[mdirn lending agency for the performance of Dam Receipt«
ur F the work for which this permit is issued(Sec.3097,Civ,C.)
0Ulender',Name TOTAL:
Ulender's Address _ TOTAL:
1 certify that 1 have read this application and state that the above information is BUILDING FEF.
EYE correct.l agree to comply with all city and county ordinances and state laws refuting h+ QTY, MECHANICAL PERMIT FEE
holdingcnnstmninn,and hereby ordalUe represeatntivea ofthix city Ili enter upon the SEISMIC FEF.
alwve-memilaed pntptoy to,inspection p rtfo., PERMIT ISSUANCE
(We)agree In save,indemnify and keep harmless the City of Gtpari s)against ELECTRIC FEE
habilisieajudgments,.,(,.ad expenses which may in any way taros,agninstsaid City ALTER OR ADD TO MECH.
in nxayucncc of the grunting of this permit. PLUMBING FIlE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TO 10,000 CEM)
MECHANICAL.
SOIL E WULATIONg�,/
k J'/, _ C. g/U/-s� AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCfION'AX
Signature MAPPHerl VCnmmmaf C/e/r—`fu. EXHAUST HOOD(W/DUCT) HOUSING MITI TION FEE
HAZARDOUS MATERIALS DISCLOSURE
Wllthers,dicam or(omre building occupant store or handle haurdommatend HEATING UNIT TO 11X),00(1 BTU)
as defined by the Cupenim Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532(a)( HEATING UNIT(OVER 1080X9 BTU)
E]Yes El No VENTILATION FAN(SINGLE!RESIDE PAID
Date Receipts
Will the an, Nam or future building occupby
rt Bay Are.
AirQuilicid lit Management
BOILER-COMPDHPOR 100,11MBTU)
it hazardous air conmminam as Defined by the Bay Arta Air Quality Management TOTAL
Dwtnet7
C]W, No
BOILER-COMP(OVER IOgWORTU)
❑
I have reed the locations materials res memeats under Chapter 6.95 at Cali AIR CONDITIONER ISSUANCE DATE
fond.Health&Safe[,Cnda,$ccdnns 155D5,25533 and 2.5534.1 understand that if the NEW RESIDENTIAL.MECH, SQ.FT.
huildlagdocs not enrrearly heveannant,motif is ntyrespandbiliy to nosily lheoccupont
of she requiremenn watch must he met prior to issuance of t Certificate of Occupancy.
Owner or mohoriled agent Date TOTAL: ISSUED BY:
OFFICE