99110011APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING - ELECTRICAL.
BUILDING DIVISION APPWCATIONIPERMIT
PLUMBING -MECHANICAL
IIUII.DING PR(IJF.CI' IDF"FICNI ION
BUILDING ADDRESS:
SANITARY NO.
UHMIVIALDATE
OWNERS NAMIir:y� PHONE:
�•-L t'\r Q, n10 lorbsi LIDO -3AB
CONTRACT'OR'S NAME: LIC NO:
NIC
❑
COMBOL#
CHITECTMNGINEER: LIC NO:
ADDRESS:
CONTACT: PHONE:
BUILDING PERMIT INFO
'Ip,
'�ICre`7 oFi �f57•dJ'V
El Consultant Fees Paid by Applicant (Initial)
BLUG ELECT PLUMB MECII
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that T am licensed under provisions of Chapter 9 mostamencing
QTy ELECTRIC PERMIT
FEE
JOB DESCRIPTION
wr N Section ]fl(If) of Division 3 of the Business and Professions Code, and my license is
n full Teres snit tits f l
License Clues ,
Duro
RESIDENTIAL:
0SFInWL D KIJ'CDEN REMODEL
❑ADDITION DPLUMBINGRE-PIPE
El MULTI -UNIT El S1
MODIFICATION
PER M IT ISSUANCE
APPLIANCES -RESIDENTIAL.
TS DEtnrSY_
j ARCHITECT'S DECLARn ION
1 understandmy pleas shell he used as public records
PANUS
1
UP TO 200 AMPS
❑INTERIOR SWIMNEY MING EPAIR
IMPROVEMENT POOL
SWIMMING POOLS
D BATH RF.MODEUREPAIR ❑DEMOLITION
OTHER
1 Licensed Profasinnal -
o OWNER-BUILDERmDECLARATION
1 hereby . Sect that 1 am exempt from the Cnnluctm's License Law for the
fallowing renwa Ieadan 90315, Business and Professions ,de: Any city art county
j which requires a permit m construct, shag improve, demolish, m repair any swcwrc
201-Iqq AMPS
OVER Iand AMPS
SIGNS ELECTRICAL
1 prionaitnissuance,ulso mrdresthe applotim far such permit m file. signed sommem
SPECIALCIRCUIT/MISC.
that he is licensed pursuant o the provisions must, Contmcmrs license law (Chapter 9
TFMII MITER OR POLE INST.
COMMERCIAL
D NEW BLDG/ADDITION D DEMOLITION
[]TENANT ❑ FOOD SERVICE
IMPROVEMIEN'I'
❑OTHER
(commencing with Section 7") ofllivision 3 ofthe Business and Professions Cood or
not he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 9031.5 by any applicant for a permit subjects the applicant to a civil psnallyof
t more than rive hundred dollars ($100).
Lasonerof the property, or my employees with wages asrheir sole compensation,
Dw
will do the work, and the structure is not intended or offered for sale(Sec. 9044. Business
POWER DEVICES
SWIMMING POOL ELECT RIC
OfrG.ETfS—SWITCHES—PIX'I'URFS
i and Professions Codc: The Cmdrs rs License law docs not apply to an owner of
propeny who builds or improves thereon, and who dres such work himself or thisugM1
his own employees, provided that such improvements ate not intended or offered for
NEW RESIDENTIAL ELF:CTR SQ ET.
sale. If. however the building or improvement is sold within one year afcomplrtion,the
SQ. FT. FLUOR AREA
VSQ. PT.
owner -builder will have the burden of proving that he did not build or improve for pur-
pose of
'TOTAL:
D I, as owner of the property am exclusively contracting with licensed contractors at
construct the pri (Sec. 90M, Business and Professions CWc:) The Contractors Li-
,
cense Law does not apply to an owner of proper, who builds or improves memo,and
QTY, PLUMBING PERMIT
FEE
who contracts far such projects with a contmcmr(s) licensed pursuant to the Contractors
-
PERMIT ISSUANCE
License Law.
❑ I am exempt under Site , H & P C far this moron
ALL 17R — GRAIN & VENT— WAi ER (EA)
BACK FLOW PROTECT. DEVICE
Data
VALUATION
OO1
Par'
WORKER'S COMPENSATION DECLARATION
hereby affirm under penalty of perjury one of the following declarations:
DRAINS— FLOOR. ROOF, AREA, COND.
❑ I have and will maintain a Certificate of Consent toself-insure for Workers Cumpen-
station, as provided for by Section 37M of the labor Cafe, for the performance of the
STORIF
TYI'G CONSTRUCTION
work for which this permit is issued.
FIXTURES — PER TRAP
D 1 have anti will maintain Worker's Confirmation Insurance, its required by Section
3900(ifthe lahur Codc, forthe parkenoaccofthe work for whichtlisycmit is ed
My Workers Wnsu coria, and Policy nutrtbcr /
or
GAS—hA.SYSTEM-1 INCAOUTLITTS
OCC GROUP
APN
Cartier Policy No.: l.% lD
CERTIFICATE OF EXEMPTION FROM WO Bit/ [/
GAS— IiA. SYSTEM OVER 4 IG)
i
COMPENSATION INSURANCff:�r!!// T
(This section need not be completed ifthe pcmdt is tar one hundred dollars (S 100)
or less.)
GREASF/INDUSTRL WASTE INTERCEPTOR
HIIILUING DIVI SION EELS
GREASE '1'RAP
PfANCHECK FEE
SGWRR—SANITARY—S'I'f1RM IEA. 2(q FT.
. trinity that in th,permorencenffle workbaushich thinpermitisiss4ed, l shall
not employ any person In any manner se as to become subject to the Workers' Compen-
ENERGY FEB
WATER HEATER W/VENT/ELECfR
series Laws of CsIboar is. Date
Applicant I
GRADING FEE
NOTICE TO APPLICANT: If, same making this Certificate of Exemption, you should
become subject to the Worimes Compensation previsions of the Labor Cale, you must
WATER SYSTEMAREATING
SOR
forthwith comply with such previsions art this permit shall he deemed revoked.
WATER SERVICE
CONSTRUCTION LENDING AGENCY
I hemby affirm that there is a construction lending agency for the perfnm,amoofrc
NEW RESIDENTIAL PI.MB. SQ, PE
PAID
'Be, p
the work tar which this parmit a i,recd (Sec. ANI, Civ,CJ
lenders Name
I LY(TAL:
LendersAddress
TOTAL:
BUILDING FE F.
I certify that I have tend this application and state that the above information is
correct. I agree mcomply withal) city and county ordinances and state laws relating to
building consmmtion, and hereby uuthorlm mpresenmtives of rhls city to enter upon the
above-mentioned property for inspection purposes.
(We) agree m save, indemnify and keep hamtless the City of Cupertino against
QTY. MECHANICAL PERMIT
!9y
EB
PERMIT ISSUANCE
(ELECTRIC FEE
liabilities,judgments, costs and expenses which may in any way accrue against said City
in asequence of the granting of this panni.
ALTER OR ADD TO MECII.
PLUMBING FEE
AIR HANDLING UNIT GO 1Q(10(1 CFM)
MECHANICAL 1B71i
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
AIR HANDLING UNIT (OVER 10," CFM)
CONSTRUCTIONTAX
J 'I
Simat' nI Applicant/ m alar lam
MAT ®R AM DISCLOSURE
1{ ,Aant
III
EXIIAUS'1' HOOD(W/DUCT')
HOUSING MITIGATION FEF
HEATING UNIT Ob 100.000 (ITU)
futumb occupant store
tuna
the Clicertino Cg
the Cupertino Alunicipal C,de. Chapter 9.12, and the Health and Safety
Municipal 9.12, anthandle Heath ad Safety
C ftdefinedSes im
CaM. Section 8532(a)?
HEATING UNIT (OVER 100.000 HTO)
❑Yes ON.
Will be npplicom or finu,o budding by the B use .. Airri'mai'mu or devices which
,anitrict, dour air eonmminano us Acfnal by the Bay Arcu Air Quality Management
Di>trict?
❑Yes El No
PAID Data Receipt#
VENTILATION FAN (SINGIA RfSID)
BOIhL'It—COMP (nHP OR IIXI,IXXI BTU)
d'OTAL:
BOILIER— COMP (OVER 10X1,000 HTO)
AIR CONDITIONER
I have it the harmdousmatanal,do,amerem, under Chapter 6.95 ofthe Cali-
ISSUANCE DAPS '
NEW RESIDENTIAL MECH. SQ. ET.
fomia Heald & Safety Cade, Sections 25505, 8533 and 25534.1 understand that if rhe
huildingdas not curicatlyleave a tenant, that h po
is myersnviba
ility a, notify the cupant
.fill qusellire t•nt,whir ustbo not prlorto issuance ofu Cenifieate fOe cy.
1 ,
. / '1 �.
L
ISSUED BY:
Owns a solo ed o cm— aro
TOTAL:
OFFICE