99110023 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '-1 I pU
CITY OF CUPERTINO BUILDING-ELECTRICAL P
PI
BUILDING DIVISION APPLICATION/PERMIT MECHANICAL
BUILDINNGG PPROJEROJECT IDENTIFICATION
BUILDING ADDRRSF: SANITARY NO. APPLICATI N SUBMITTAL DATE
101x10 ?_91
�2 �9j� /M�/�� CONTROL
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r/ NIC CONTROL#
C I' T/F.Ns BF.R: LIC NO, gUDRE55' ❑
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CONTACT: PHONE: BUILDING PERMIT INFO
-reg ' /AA0� 2.,5s 661( ❑ Consultant Fees Paid by Applicant(Initial) BLDG/ ELEcr PLu❑MB MECH
LICENSED CONTRACTOR'S DECLARATION QTY, ELECTRIC PERMIT FEE �/
1 hereby affirm That 1 an licensed under provisions of Chapter 9(commencing _ JOB DESCRIPTION
F1_�aZ with Section 7")ofDiAman 3nflhe Business drills rnfeseions Code,.ad my license is RESIDENTIAL,
in full force and effect. PERMIT ISSUANCE
W -- ❑SEGAL ITCHENREMODEL
Q,UU License Class Lia# APPLIANCES-RESIDENTIAL 2A'6DITION C1 PLUMBING RE-PIPE
yG uu Dam Contend.,
ARC)11'LEE'PS DECLARATION
[IMULTI-UNIT [I STRUCTURAL
p cn Z 1 undersdtanmy plans shall be used as public records PANELS
Z MODIFICATION
O Z.N UP T0200AMP5 ❑INTERIOR El CHIMNEY REPAIR
Ir h„I"'Q Licensed Professional 2nLlf DAMPS IMPROVEMENT SWIMMING POOLS
,</ •.1 OWNER-BUILDER DECLARATION OVER IDWAMPS L&idsp REMODEUREPAIR (]DEMOLITION
yRy PS W 1 hereby union that I am exempt from the Commnor's License law for The
p(O 6 U following reason.(Station 91131$,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
W 0 m which reuniter a permit to sm,aucl,rhes,improve,demolish,or repair any emsemre -
��yy�' prior To its issuance,also requires The applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
fit}
,be,he is licensed pursuant to the provisionnnf the Courtiers License Law(Chapter 9
(commencing with Section 9f1007 of Division3of the BTuiness and Professions Code)or TEMP.METER OR POLE INST
a d c a That he is exempt therefrom a d the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION [I DEMOLITION
nySection 9031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
f1-Z} am more Non five hundred dollars(8500). IMPROVEMENT
SQQ ❑I,as ownerof Ne property,nr my employees with wages as dhcirsole compensation, SWIMMING POOL ELECTRIC
py
will lathework,andmourname is ndindmiciloroBored for sale(Site 7044,Business ❑OTHER
3 and Professions Code:The Contractor's License Law does not apply to an owner n OUTLETS-SWITCHES-FIXTURES
property who builds or improver thereon,and who does such work himself or Through
his own employees,provided that such Improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT
sale.If,however,the building or improvement is sold within one yourefa,mplefmn,the SQ.FT FLOOR AREA S/SQ.FT,
ITeobuilder will have the burden ofpm,mg that he did not build or improve for pur-
c,I ala). 2
❑L io owner of the pruperty,are exclusively contracting with licensed commcNrs m Intl ) 1 19
construct the project(See.TATE Business and Professions Cods:)no Connector's Li- --
consc Law does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE
who contracts for such projects with a contmcmr(s)licensed pursuant to the Correctors
License Law, 'RMI I NC
❑I am exempt under Sea ,B&P C for this reason
R E (E VALUATION
vt Cate WORKER'S COMPENSATION DECLARATION p W ylFr= 7-5; o O O
1 hereby affirm under penalty of perjury one of the fallowing Aedtions:
nm
E] I have and will maintain a Cenifientcof Conscat to self-insure for Workus` Compea- STORIES TYPE CONSTRUCTION
saaen,as provided for by Section 3900 of the Labor Code,for the performance of Tho
work for which this permit in issued. FIXTURES-PER'TRAP
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Cale,for the performance of The work for which this permit is issued GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP AP
My Werkey5,��py� tipd Policy,�fi 7
Carrier �IA1 Fsa y)L,,aiye carne Policy Na: 7' + GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/ INTERCEPTOR WASTEIMERCEPTOR
BUILDING DIVISIONFEES
(This unction need not be completed i[Nepemdd is for one hundred collas($IBB) GREASB'fRAP
or loss.) PLANCHECR PEE
I certify that in theperfmmanmofthe werkforwhich thispermit is issued,i shell SEWER-SANITARY-STORM EA.200 Ff.
not employ,any perean in any manner sn as to become subject m The Workers'Cheaper- ENERGY FEE
ZZ cation Laws of California.Date WATER HEATER W/VENT/ELECTR
O Applicant GRADING PE
ti fA NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTEM)TREATING
a ; become subject to the Worker's Compensation provisions of the Labor Code,you most SOILS FEE
LS7 forthwith complY with such Pnwisiorn or this Permit shall be deemed revoked. WATER SERVICE
r Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
x'
C.7 Iherehy affirm that rnw
here is lending agency for the performance of Date Receipt#
the work for which thys p��l is isyt;A(Sw.309'1.Civ.CJ
{Ir H Lender's Name dd-1l G TOTAL:
Cl Lender's Address TOTAL;
i certify That 1 have read this application and state that The above information is BUILDING FEE
.Eat vI correct.l agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICALP MST FEP.�^"�
L Z building construction,and hereby authorise representatives of this city to enter upon the SEISMI FEE
above-mentioned property for inspection purposes. Lr t1 U
(We)agree to save,indemnify and keep harmless the City of Cuperner,.,am,, PERMIT ISSUANCE E LEIT[fic FEE
liubilities,judgmemr,costs unJ expenses whichm.ym aywayawmeagahvl s.id City ,of ALTER OR ADD'TO MECH. A Ann
consequencein of the granting of this permit. P M INC FEB
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT('1'O 10. CPM) NE AL FEE
SOU LAEGULATIONS
/ AIR HANDLING UNIT(OVER 0,000 CPM) CONS RUCTION TAX
Signal ofApplic VCovo-I eY Did. EXHAUST HOOD(W/BCCI') HOUS CMITICATION NF,E
IAZARD01 ATERIALS DISCLOSURE
ill the app corfuture building occupant store or handle hazardous material HEATING ON IT(TO 100,000 BTU)
as defused by The Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Coda Section 25532(.)? ,�N HEATING UNIT(OVER 100,00(1 BTU)
El Yes ; a VENTILATION FAN(SINGLE RESID) PAID
Date Receipt#
f Will the applintator inantse definedding by the rat Byse Area
Air
mlity or Mees whichgcosat BOILER-COME QHP OR IW,"BTU)
-emit hazardous air contaminants as Defined by the Bay Area Air Quality Management
UiarictY
TICR
❑Yes VNa BOILER-COMP(OVER 100,000 BTU)
I have real the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
cache Health&Safety Corp.Stations 25505,25,133 red 25534,1 understand that if Ne NEW RESIDENTIAL MECH. SQ.FT. ��
buildia does act currently atenanl.thath is my responsibility to notify the compact / Y
of,, emed'.1i I s h p Ior�lsoeyl5 nceof.Czni&atel D cy.
pw author agent V 6 um /_ TOTAL: ISSUED BY:
OFFICE