28999 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT No.PLUMBING-MECHANICAL O J 2 p 9 9 9
BUILDING DIVISION APPLICATION/PERMIT
BUILDING PROJECT IDENTIFICATION
SANITARY NO. APPLICATION SUBMITTAL DAT
BUILDING ADDRESS:
2. 1 `-1 1 Co N OON A-44 C--T-.
OWNER'S NAME: PHONE: CONTRACTOR'S NAME LIC NO: _CJ
"O/Z M A N L G P R VS i`Z- 0 T3��12 A p 2. 6 55 N/C CONTROL#
RCHITECT/ENGINEER: LIC NO: ADDRESS: 7 J ❑
CONTACT: PHONE: BUILDING PERMIT INFO
00r3 6�1^ / Z-j`L 3 r7 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB ME❑CH
Nt A �O/N'X Lr J�i�
LICEN ED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
C1 Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is NT AL:
W p PERMIT ISSUANCE
F W in full force and a tw 2 2 5-09 WL ❑KITCHEN REMODEL
U U License Class # t- APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
in Q GW+ Date Contractor _P ��. �^
ARCHITECT'S DECL _RATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z&n Z I understand my plans shall be used as public records UP TO 200 AMPS ODIFICATION
A ❑INTERIOR HIMNEY REPAIR
„V F-W Licensed Professional 201-1000 AMPS IMPROVEMENT
aM OWNER-BUILDER DECLARATION OVER]000 AMPS ❑BATH REMODEL/REP ❑DEMOLITION
10. I hereby affirm that I am exempt from the Contractor's License Law for the
p.,U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
OW E' which requires a permit to construct,alter,improve,demolish,or repair any structure
aprior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
V) that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
><*
(commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
py o 0 that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
>C en k Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
Fq Z� not more than five hundred dollars($500). IMPROVEMENT
L A ❑I,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business
CD ❑OTHER
W o0o and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS- TC S-FIXTURES
C4 property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RES ID LECTR SQ FT.
sale.If,however,the building or improvement is sold within one year of completion,the SQ.FT.FLOOR AREA $/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pur-
pose of sale.). TOTAL: U� d 6'
❑I,as owner of the property,am exclusively contracting with licensed contractors to ��
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li- 9
cense Law does not apply to an owner of property who builds or improves thereon,and QTY, PLU PiFfMIT FEE .
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law. PERMIT ISSUANCE
❑I am exempt under Sec. ,B&P C for this reason
ALTER-DRAIN&VENT-WATER(E VALUATION
Owner Dale
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE ` b O f>
I hereby affirm under penalty of perjury one of the following declarations:
t]I have and will maintain a Certificate of Consent to self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,GOND. S RIES TYPE CONSTRUCTIO.
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA,SYSTEM-I INC.4 OUTLETS OCC,GROUP APN
My Worker's Compensation Insurance carrier and Policy number are:
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE/INDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not be completed if the permit is for one hundred dollars($100) GREASE TRAP
or less.) PLANCHECK FEE
I certify that in the performance of the work for which this permit is issued,I shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as to become subject to the Workers'Compen- ENERGY FEE
Z salon Laws of California.Date WATER HEATER W/VENT/ELECTR
Z.C) Applicant GRADING FEE
i..� fj NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should WATER SYSTEM/TREATING
[~ ; become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
Wi,,,,i forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
p" Q CONSTRUCTION LENDING AGENCY NEW RESIDENTLAL PLMB SQ FT PAID
U O 1 I hereby affirm that there is a construction lending agency for the performance of Date Receipt#
w I the work for which this permit is issued(Sec.3097.Civ C.)
OV Lender's Name TOTAL'
U Lender's Address TOTAL
1 certify that I have read ttus application and state that the above information is BUILDING FEE
Lsorest I agree to comply with all cit)and count)ordinances and state laws relating to QTy. NIECHANICAL PERNIIT FEE
U Z i building construction.and herehv authoryiv
e representates of this coy to enter upon the SEISMIC FEE
w.r above-mentioned prupzrh-for inspection pur)ioszs
PERMIT ISSUANCE ELECTRIC FE
(We)agree to sare.mdemnif)and l ccp harmless the City of Cupertino against
liabilities.)udgments,costs and expenses which ma}in any way accrue against said Cuv ALTER OR ADD TO MECHMBING FEE
1 i
in consequence of the granting of this pernnt PLL
A PPL I(-AN I l'^LUER';T4'x US AN 11 is ILL i IN!PL) N 17H ALL NON-POI\T .AIR HANDLING UNIT(TO 10.000 CFM)
iO' C EREGi'1_+T10 MECHANICAL FEE
I
AIR HANDLING UNIT OVER 10.000 CFM) CONSTRUCTION TAN
11
Signature of Applicant/Contractor Date EXHAUST HOOD(\V/DUCT) HOUSING MITIGATION FEE
HAZARDOUS SIATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100.000 BTL')
as defined bN the Cupeihoo Nluni.,ipal Cude.Chaplet 9 12.and the Health and Safety
.55:7(al HEATINGHEATINGUNIT;OVER 10(1,000 BTU_
Code,Section
❑Yes ❑No PAID
VENTILATION FAN(SINGLE RESIDI Elate Receipt#
Will the applicant or fcture build:n,�__,ip^n.!use equipment or devices which
int hc_ardcus a;r contamm::ats a „- ,the Ba,, ^: Air Quahn A1a,aocmcnt � BO]LER-COiCiP i,HP OR 100 ODO BTL''i i T OTAL
- I
ilictnct° BOILER-COMP COVER 10^,(11)0 BTU'_
❑Sec ❑No
1 MR CONDITIONER
I hale read the haiarduus nratenals requirement..under Chapter b s'S tit Uig a i- ISSUANCE DATE
7
fomia Health&Sa1Ct)Code.Sections 2f5')'._=,5?3 and'_`534 1 understand that rf the NEW RESIDENT]AL MFCH SQ FT
huddmit does not correnth have a tenant ih,i(o-,,x re,pun hfl,x to noui)the occupant
01 the reauuc;nents�t hist,ma+t n:met ono;tri r,wan,:of Certil1catc sr 0.cap.:nr,. 1
TOTAL I)SSLED Bl.
OVier cy or aidho,« " La`s