99110015 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO l.=IING-MECH MECHICALANICAL
li a ,O.
BUILDING DIVISION APPLICATION/I'ERM IT PING PROD-h1CCI MINI I.
BUILDING I'RUJECT IDEN'I'IFICATIUN
SANITARY NO. APPLICATION SUBMITTAL DAl
BUILDING ADDRESS:
ir. C D&fhv v� /� _2 ,.99
OWNER'S NAME: I+HONE: CONTRACTOR'S NAME: LICNO: ❑
I(Ep_ ,lc/ i-bzb -293' -N(4dN S14-N1 S b — NIC CON'I'ROI.k
v, •gµCHIT[CI'/C:NGINEER: LIC NO: ADDR1ESti:
CONTACT: PHONE: BUILDING PERMIT INFO
I� � P2rol r} l�n' l�� ❑ Consultant Fees Paid by Applicant(Initial) BLDG El.e PLO B MEC1
LICENSED CONI RACTORIS DECLARA'T'ION QTY ELECTRIC PERMIT FEE
I hereby affirm sant I ate licensed,nna provisions,r Chapter 9(e,nttnwemg J06 DESCRIPTION
I '00 with Serum70v(d cf Division 3oflhe litomeaand Professior,C .and my license is RESIDENTIAL:
M W PERMIT ISSl1ANCF.
��� In m,mostanaeffect G {�S -�gS6b
V License most
CliLie.p ❑ADI L O KITCHEN REMODEE
F Z4Uj Date f� Contrntlnr L -ry EtM\J 1 +`�.1 API'LInNCES-RESIDENTIAL L1 AUDI ❑YLUMHING RE-PIPE
I N<y ARCHITECTS DECLARATION PANELS OMUI:I'I-UNIT [_]STRUCTURAL
Z O h Z 1 understand my plans shall he used as public records MODII9CATION
OZ—a UP'10210 AMPS [IINTFRIOR OCHI.MNEY REPAIR
�L't:W Licensed Professional 201-1000AMPS IMPROVFMEN'I0 SWIMNIING POOLS
OWNER-BUILDER DECLARATION OVERTIXOAMPS ❑BATH REMODELIREPAIR ❑DEMOLITION
C C Q I hereby affimt that I am exempt from the C,mmcmrs License Law for the
K3LV following reason.(Section]0315.Business and Profession.Gale:Any city or county ^ SIGNS ELECTRICAL EOTHIiR
41 LL Na which require.a permit m construct,alter,Improve demolish,or repair any.sournoc
F'�OwJ prior to itsissuance.also requires the applicant for sash permit in file a signal smtentent SPECIAL CIRCU I'F/MISC.
that he is licensed pursuant to the provisions,l the Contractor's License Law(Chapter 9
(commervingwilh Section 7003.11be Imsincss and Pn+fcssionx Caldor 'TEMP.METER OR POLE.INST, I COMMERCIAL:
G.A.c C that he is exempt therefrom aml the basis for the alleged exemption.Any violation of 0 NEW BLDG/ADDITION ❑DEMOLITION
Section 70315 by anyapplicanl for a pv'rmil subjects the applicant,.a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
F. not more than five hundred dollars($500. IMPROVEMENT
SD OT,as owner of the property,or my employees with wages us their sole wmpensatinn, SW IMM ING POOL ELECIR
p. will do the work,mrd thucre
vormis nor intintendedcndnr,0'cmd forsalc(S:m.]IN111usinccr ❑OTHIiR
W� it Professions Calc:The ContraET
ctor's License law does not apply to an owner of OUTLS-SWITCHES-FIXTURES 6
a 3m property whn builds m Improves IM1cre,n,and who dors such work himsclror through
his own employees,provided that.such improvement,are not intended,r offered for NEW RESIDENTIAL r.LEC R S
sale.If.however the building or improvement is sold within one year ofe,mpletion.the / SQ.FT.FIAUN AREA $ISQ.14.
pavcr-bnildcr will have the bourder ,of pmvirg than he did not build or Improve finp.,
of sale.).
❑1,as owner o the property,am exclusively contracting with r Too d contractor ro 1i
onsc La the project(Sec.]UW,Business and property
who bei Coda pro Cnnrtamon. nd
no lawdscsr...1,apply man owner om,or owhn,,d ist prof improve,, ,,the thereon.and QTY PLUMBING PERMIT PEE
who convacte fnnucM1 pmjcros wilM1 a cnmmnngx)IiunveJ pursuant 1,the Cnnrrvaors
License law. PERMIT ISSUANCE
0 1 ant exempt under Sec. .B&P C for this reason
Owner Date
AL'I'17R-DRAIN&VENT-WATER(EA) VALUATION
ny
WDRKde,ICOM of perp110N DE Ce Following
BACK FLOW PROTECT.DEVICE 2 l D
1 hereby affirm under penally.f perjury one of @c rnlTmving Jxlaretions:
OThavesnit will maimainaCcnifcmc.f do,Labor Code.sure for Worker'ser ITh- DRAINS-FLO(IR.ROOFARIiA.COND. S'IYIRIIi. '1'YPIi CONS'IRIJC'TI('.
satin,,as hick this
for hy,Section 3]11(1 of 0c Labor Cndc,fnnhc per(nnnancc.I the
work for which this permit is issuW. FIXTURES-PER TRAP
❑ 1 have and will main win Worker's Compensation diiun work
for hi h requital ny Section
3]1X1,!the laMn Code.for the perrnrmanec of the work for which this pennilniawed. GAS-F:A.SYSTEM-I INC.y OUTLET (ICC.GROUP / APM,WA:
Cm'cr:rlfeis OCO�eryqujynJnYui+ncc eonlerpnlivy No PolicyBu)nbyyg�W7_0_0 GAS-EA.SYS'I EM-OVER t0 •'T JV•'
lSO CERRTIIFICfACTTE`OF EXEMPTION MOM WORKERS
EA �S
COMPENSATION INSURANCE OREASIHTNDUSI'RL WASTE INTERCEPTOR r
BUILDING DIVISION FEES
(This section need not he completed if lhcpermil is forma,hundred dnllam($Ilp) GREASETRAP
or Icxs.) I'hANCIILCK FEE
I maify bar mhe prliamanes.l'the work for hick fins,...iloixwed.hhall SEWER-SANITARY-STORM EA.2W FT.
not employ any person in any manner m as m became subject to the Workers Compcn- ENERGY FEE
Z .Z smarm Luws,l California.Dare WATER HEATER WNENT/ELEC R
Applicant (IRAUINO FEE
= NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/BEATING� SOILS FEE
,
be nubjcal to the Worker's Cmnpat,aiinn provsimrsol'the Labor Code you must
forthwith comply wib,oh provisions.,this permit shallh dcemedress+ked WA'I FR SERVICE
aQ
rte. Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMIf. SQ.F1'. LAID Date
Ll0Thereby affirm that then ix acunswcenn lending agency for the perfonnance,f
Inc work for which this permit Ir ismud ISa.3n9],Civ.CJ
fL U Ixnders Name TOT
L) Lenders Address TOTAL:
1 certify thol T hive read Ibis applicmion and aa.that Ihcahnve information is DIN(LEL'
.Fa (A correct.I agree to comply with all city and county ordinances and state laws relming to QTY. MECHANICAL PERMIT FEE
V z building cnnswdinn.and heresy uulhnrirc rcpremnmtivcs,I lhiscitymentermpnnthe 'I TIC FE
those mentioned property for inspection puT^yes' PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Eugenia.against CI
Iishilinc%.judgments,costs and expenses which may Murry way reeme agai,sl said City' ALTER OR ADDTO MECH.
in ,sequence of the granting of this permit. A101NG FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
SOURCE REGULATIONS, IM,
"C� ICS!Lodi
AIR HANDLING UNIT(OVER 1(1,0(1()CFM) C(I,STRUCH09'1'AX
Signature of ApplicarmComraer.r Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HA9ARDOUS MATERIALS DISCLOSURE
Will the applicant or film,building.cenpant sI corhandle har.mdons material HEATING UNIT('110 I OII,ky,BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safcry
Cod.,So,, 255321a11 HEATING UNIT(OVER 10H.IX()BTU)
O Yes JpNo VENTILATION FAN(SINGLE RESID) PAID
Will thea licmn.r(inure huildin•occu n use c I ur devices which Dov Receipt n
PP 6 e] Area
m BOILER-COMP(3HP OR)110,(1(0 BTU)
emit harardoua air contaminants as JcBncJ by the tally Arca sir Quality Management nQ
DimricR TOTAL: bJ�Q
[D Yes QNr+ BOILER-COMP(OVER 1[X)•fX11)RTU)
I have read the lmrardnusnonedslsrciremcn la under Chu1ser h95 of the Cul i- AIR CONDITIONER ISSUANCE DATE
yu
fania Health&Safety Code.Swion.s 25505.25533 and 255311 understand that if the NEW RESIDENTIAL MECH. SQ.FL e
building does not currently have a lenWL.that it is my respmsibiloym notify the.ecuponl / /— �j —1?
of the raluimnxmsw � t t rte I cert+Ocumr Oc u up y. 1/1/ l/ Y
u.
/1 1 Ie
Uwner or autharzcd agcm 0 Vale TOTAL ISSUED BY:
OFFICE