99080143 I APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 0 ,z OI
I' CITY OF CUPERTINO BUILDING-F.LF.CTRICAL -
II BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING AUURISS: SANITARY NO. APPLIC^ B DATE
90L.L.(N Gs9 Rab 7
OWNER'S NAME: PHONE: CONTRACT'OR'S ACR'S NAME: LIC NO:
PG K <1Gond ST 7qqS_515_ NIC COMROL p
A C ITpp-CENGINEERS�. LIC NO: ADI
I FSS:
/3- 0 =C) Zo Leri �qNe CVP Ch
CONTACT: PHONE: BUILDING PERMIT INF
❑ Consultant Fm Paid by Applicant(Initial) BLDG EL^LL� ^
ECTPLUMB MECH
TR
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE EW IsG/
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�p with Section 7(XX)).f Division 3oflhe Buslness.nd Prole,voo—nseCCod,molmy license is PERMIT ISSUANCE. RESIDENTIAL:
CLL F in full force anJ e� J D ❑SFDWL ❑KITCHEN REMODEL
QUU DatenseC s Lica APPLIANCES—RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
N<L Date Contra<m
CHITECTS DE ❑MULTI-DNR ❑STRUCRIRAL
z p n� 1 understand my plans shall be used as public ands PANES MODIFICATION
OZ— UPTO200AMFS INTERIOR [I CHIMNEY REPAIR
;: Licensed Professional 201-I0BAMPS IMPROVEMENT (]SWIMMING POOLS
Y
OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODEVREPAIR (]DEMOLITION
5 Q I hereby alarm m shat I eexempt from the Contractor's License Law for he
k O 6 V following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
u7 3 LL which requires a permit to construct,altar,improve,demolish,or repair any swcture
,F]�O primandsissuance..1m equirestheapplicant for such permiuo flea signedstatemeatONEWRESIDENTIALELECTR
CUHUMISC.
d� thatheishernsedpurveanuothepro,monsoflheCombactorsLiwmcl.uw(Chupler9
LL CO bco mmuingwoh Section 700u)nf Dlv,num3.flhe Boarcasand Prol'esxions Code)nrR OR POLE INST.
that he is exempt therefrom and the basis for the alleged exemption.Any vinl.It.n of NEW BLDGIADDITION ❑DEMOLITION
Section]031.5 by any applicant fora permit subjects the applicant to a civil penally ofICES
H TENANT ❑FOOD SERVICE
ZGnot more then five huMretl tlnitmx(t500). IMPROVEMENT
❑1,as owner of the property,or my employees with wages as Neirml,compensation, POOL ELECTRIC
will code work,and the stmcture Is not intended m ofmed far sal,(Sec.]044,Business OTHER
and Profess...,Cale:The Cmaranore License I,aw dons not apply to un owner ofWITCHES-FIXTURES
progeny who builds or improves themon,and who does such work himself or through
his own employees,provided that such improvemems are not intended or offered forENTIAL ELEC R SQ FT.
sale.IL however,the building or improvement is sold within one year of completion,me SQ.IT FLOOR AREA ESQ.FT.
owner-builder will have the banded of proving that he did not build or improve for pur-
of
pose
e as ale.). f the property,um exclusively contracting with licensed contractors to TOTAL:
construct the po,,1 Be,7044.Business and Rnfe,mm Code:)The Contractor's Li-
cense Law docs not apply to on owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a commicmr(s)licensed pursuanuo the Con.acmrs
License Low. PERMIT ISSUANCE
1]IamexemptunderSec. ,B&PCfmIhianason
Owner Date
ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE � O
1 hereby affirm under penalty of perjury one of the following declarations: "oo D
❑I haveand will maintain aCertificamofConsenno self-inure,for Workers Comped- DRAINS-FLOOR.ROOF,AREA,COND. STORIES TYPE CON UCf10N
1 .firm,as provided for by Section 37W of the Labor Code,for Ne performance of the
work for which this permit is issued. FlKTURES-PER TRAP
❑I have and will maintain Workers Compensation Insurance,as required by Section
37(X1 ofthe Labor Code,for the Performance ofthe work for which this permit is issued. GAS-EA.SYSTEM.I INCA OUTLETS
My Worker's Compensation lnsumrrc carrier and policy number are: OCC.GR UP APN
Currier: Policy No.: GAS-EA.SYSTEM OVER 4(EA) Y
CERTIFICATE OF EXEMPTION FROM WORKERS' O
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
(This section need not be completed Han,permit is for one hundred dollars(S 100) BUILDING DIVISION FEES
or less.) GREASE.TRA j—\ �f 11 PLANCHECK FEE
I coal fy that in the performance of the work for which this Permit is issued,I shall SEWER—SA STQRM'EA 200 FT l
99
not employ any moon in any manner so as to bacon subject to the Workers'Comped- ENERGY FEE
0 ,Z cation Laws of Cal linin.Date MWAnRMENTMLECTRzApplicant I GRADING FEE
NOTICE TO APPLICANT.If,a0er making this Certificate of Exemption,you should FA 1become subject to the Worers Compensation provisions of Ne Labor Code,you must SOILS FEE
forthwith comply with such pmvioons or this Permit shall be deemed revoked.UOCONSTeis.ciONCENDINGAGENCY MB. _�Q£L PAID Recei tNI hereby etfrm that there is a cnnswetinn lending agency for the per0rrtnance of Pthe work for which this pgygedISec.309],Civ.CJ TOTAL:
Lenders mA /..L.U Lenders AJdres= TOTAL:
1 certify that I have orad this application and state that the above information is BUILDING FE.TA correct.I agree In comply with all city and county ordinances and state laws redoing to . HANICAL PERMIT FEE
building construction,and hereby amhorim representatives ofthiscity mcnmr uponde SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabditics,judgments.costs and expenses which may in any way seem,against said City ALTER OR ADD TO MECH.
in coequence of the granting of this permit. PLUMBING FEE
ns
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT ITO 10,11M CFM)
MECHANICAL HE
'OURCF CATIONS.
AIR HANDLING UNIT(OVER Iq(NIO CFM) CONSTRUCTION TAX
Signawr o- ppli 0Contmnor em EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant.,future building.ccupammmi handle harurdous material HEATING UNIT OD 100,1100 BTU)
as defined by the Cupenin.Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 255321d)9 HEATING UNIT(OVER 100,0011 BTU)
❑Yes ANo VENTILATION PAN(SINGLE RESID) PAID -
Dam Receipts
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(lHP OR 100,000 BTU)
emit tornadoes air contaminants as defined by she Bay Area Air Quality Management TOTAL:
DIsMCR
❑Yes VN. BOILER-COMP(OVER 100,000 BTU)
AIR CONDITIONER
1 have read the h ode. us materials 5.2553 cnta under Chapter 6.95 of the Cali- ISSUANCE DATE q
f.mia Health&Safety Code.e a tena 25505.25533 and 25534.1 undersand that if the NEW RESIDENTIAL MECH. SQ.FT. �/ C(� 4/
buildingdeez no currently have a tenant.that it is my responsibility on notify Ne cecupant
f the requirermnts wNch,�tust beret Pdormissuance.fa Cenifsem Oc pancy.
O rte nr. agent
Date TOTAL- ISSUED BY:
OFFICE