99070083 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT Q
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING.PROJECT IDENTIFICATION
BUILDING ADDRESS SANITARY NO. APPLICATION SUBMITTAL-DATE
/op s 4 � /, er
OWNER'S NAME: PHONE: CONTRACTOR'S NAME LIC NO: " �,
'?
? J— /1 NIC CONTROLY
/1 y
_IIIGUCT'/LEN NEER: LIC NO: ADDRESS: ❑
CONI'AC'I': PxoNE: BUILDING PERMIT INTO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ 3" ❑ 0�
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEEI hmeby iflirm mat I am licensed under provlslons ocom
f chapter 9(commencing QTY
DESCRIPTION
OMZ with Section 7000)of Division 3 nflhe Business and Professions Code.and my license is
00 PERMIT ISSUANCE RESIDENTIAL
F ly F in full force and c_4 A ❑SFDWL ❑KITCHEN REMODEL.
�UV Liatc 7 C Liap -r APPLIANCES []ADDITION❑ADDITION ❑PLUMBING RE-PIPE
yGLDatc Contactor �f�.a.<r
A CHI'1'ECT'S DIECLARATION 0MULTI-UNIT ❑STRUCTURAL.
F y PANELS
z O on�, I understand my plans shall be used as,ldw records MODIFICATION
OZ�Q UPT02MAMPS ❑INTERIOR C3 CHIMNEY REPAIR
E+ {Y Licensed Professional 201-1000AMPS IMPROVEMENT 0SWIMMING POOLS
thatOWNER-BUILDERmond DECLARATION OVER EXREAMP$ O BATH REMODEUREPAIR O DEMOLITION
1 hereby a(firm that I um exempt from the Cnsions C s License Low for the
{?�SOaU which inquiresa Permit
n]BM.S. t,alter.
Smpr Professions Code:or Any city or county SIGNS ELECTRICAL 00Tf1ER
which 11,i as a permit r.construct,alien improve,h ,.it
t or mpeir any structure
Jct Chit he itsrstiouli,also requares meinitoram(.r.mchperminoicensele Dr.J matemem SPECIAL CIRCUITIMISC.
�}
thatheincing with
pursmmnothe ofDwions.f the Contractor'snd ProlisiconConine,Code)or
_
ly�C�� Iromnocncing with Section]aa))nfDivision 3o the Business and Professions Code)or TEMI`.MITIER OR POLE INST. '
4 iaC M C mnlp
at he is exel therefrom add the basis for the ullegee exemption.Any violation of El NEW BLDG/ADDITION 0 DEMOLITION
,, Section 7031.5 hyanyupplicam for a permit subjects the applies.[,.a civil penally of POWER DEVICES
t ro than five hundnedd.11ors($500). OTENANT [I FOOD SERVICE
y0 ❑Inoas.svner of the propeny,nrmy empinyas with wages es their sole compensation, SWIMMING POOL(ELECTRIC IMPROVEMENT
will do the work.and the structure is not imendedoraffered lot sale(Sec.7044,Business ❑OTHER
W3 and Professions Code The Contractor's License law doss nor apply m an .her of OUTLIETS-SWI'PCHES-FIXTURES
progeny who builds or improves Ihcr on,and who does such work himself or through
his own employees,provided that such impmverients oro not amended nt mffercd for NEW RESIDENTIAL ELECTR
adce If,howevem the building or improvement is sold within one year of completion,the Q. iT1 RARE 11 $/SQ.IT.
r-builder will have the burden of proving that he did not build or improve for put- -
y se of side.).
❑L as sine,of the progeny,am exclusively commaio,with licensed contractors to 'I OTAL: n O IFIC19 I ��
construct the posject(Sec.7044,Business and Professions Cde:)The Contmeto's Li-
Wse Law Jxs nm apply to an owner ufpmpeny who builds or improves merwn,and QTY, PLUMBINO PERMIT FF,PJUL.
ho contracts for such projects with a conuacmr(s)licensed purNam to me Contractors
License taw, PERMIT ISSUANCE
0 1 am exempt underSm. .B&P C fm this mason
ALTER-DRAIN&VENT-WATER(BA) N
Owner Uate
WORKER'S COMPENSATION DECLARATION RACK FLOW PROTECT.DEVICE OQO 'gapI hereby M.under penalty of perjury one of the following declamations:I have and wit l maintain a Certificate of Consent l.sell-insure for Worker's Comped- DRAINS-FLOOR,ROOK AREA,GOND. STORIES TY PE CONSTRUCTION
tylion,as prnvided for by Station 371X1 of the Lahor Code,for the performance of me
�9 for whichoris permit is issued. rIXTURES-PER'I'RAP
�j 1 have and will maintain Worker's Compensation Insurance,se requited by Section
4]1M)oftkkJhhc�Low,Code,In,the pent rmunceaf the work for�wwhicchh-this Knoll is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.CROUP AP
My
slid Policy he
Camer:rWC.(CERTIFLCATE OF E2711haripar IncfcurtiPfION FROM WO 2I RBRS'Fp GAS-EA.SYSTEM-OV17R4(EA)
COMPENSATION INSURANCE GREASFANDUSI'RL WASTE INTERCEPTOR
Mak section need not he completed it d cpermit is fo...chundred dollars($1(10) BUILDINO DIVISION FEES
or less.) GREASE TRAP PLANCHECK FEE
Imnify that in the Performance ofthe work forwhich this Permit is issued,l shall SEWER-SANI'T'ARY-STORM F- .200FT.
not employ any person in any manner so as m become subject to me Workers'Comped- ENERGY FEE
O z so inn laws of California.Dole WATER HEATER WNEMUELECTR
z Applicant GRADING FEE
.Na NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTENVI'REM ING
> Nwome subject to the Worker's Compensation provisions of the labor Code,you must SOILS PER
P.I ..� hmhwith comply with such provisionsor this permit shall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDINGAGENCY NEW RESIDT:NIIAt.PLMB. SQ.FT. PAID
Ihereby a0imi ,.itiis...d( eb.3olendmg agency for peRormance of D¢ ReceiplM
F the work forwhich this permit is issued(Sec.Jfn].Civ.C)
O Iendels Name 'TOTAL:
LJ Lender's Addrtzs TOTAL:
Fy 1 certify Nm 1 have mad this application and slate mm he above marmarmiod is BUILDIN
In comers.1 nares n,comply wins all city and county oNmances and state laws rderins m QTY. MECHANICAL PERMIT FEE
L) Z huildins commuction,nd herebyou0usriz.ercpresenmtivcs of this city m enter upon the SEISMIC FF.
sbovementioned property for inspection purposes PERMIT ISSUANCE(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
hahilitics.judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH,
in .sequence of the grant ins of this permit. YLUM8ING FF.E
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IOp00 CFM)
SOURCE REGULATIONS. {/ MECHANICAL FEE
�� AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
re of Applicanl/Cnmmc r eT EXHAUST 11001)(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will lhert,licant or future building occvpentorre or handle hrombus material HEATING UNIT(TO 1011,000 BTU)
aldefined by the Cupeninn Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 255920)? HEAPING UNIT(OVER 1010,000 BTU)
❑Yes ❑No VENTILA'I'[ON VAN(SINGLE RESID) PAID --
W d the nit ei itm or fulua building by do,B are equipment or Devices which
Dam Receipt M
tit
District?
s air conmminanu un defined by Oro Ray Area Air Quality Management BOILER-COMP(3HP OR I W,fNlO BTU)
DisvinP TOTAL:
❑Yes ON. BOILIER-COMP(OVER I[g1,Ef111BTU)
I have read the hazardous materials muiremensc under Chapter 6,95 of the Cali- AIR CONDITIONER
4 p ISSUANCE DATE
hunts Health&Safety Code,Sections 25505,355])and 2.55]4.I u.dcrsd that if the wmNEW RESIDENTIAL MI CH. SQ.FT. ,��
building Jaa not cnrendy have a tenant,mm it is my responsibility to notify the cecupam
.fda'.yyullctrtenlswpyh mus dorso Issuance of.CediTl DC�pja�nCy.
z�' cd agent ) a TOTAL: ISSUED BY.
OFFICE