99080218 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY <qq Q O a /
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO,
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL
WILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTALDATE
/n SZ e5H n✓1 w C ✓Pe« no ,C4-
OW 'S NAME `^ P, E: - 52� F y'r�f. jI+ISIKA .^S 0 1 LfC Q:� NIC CONTROL#
RCHITEC'VENNGINEER: a , LIC NO: jWlrt-niirin Sr
l6, 4syilii P Sch ❑
CONTACT: PHONE: �r BUILDING PERMIT INFO
f-oi (0611 Wy CS��fs3559116 ❑ Coagullant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
QTY ELECTRIC PERIFEE
❑ ❑ X
I hereby affirmthat Into lcened under provisonoChapter 9(Commencing ❑
JOB DESCRIPTION
WOO withSminn]00 )af Divisinn3of he Business and Prafasio vC a ylicenseis RESIDENTIAL:
FSO in full fnrceandeRec ../{ PERMIT ISSUANCL•
GUI- himn,a Clu s Lic.p SFDWL ❑KITCHEN REMODEL
PZW Date Con[tator APPLIANCES—RESIDENTIAL []ADDITION [3 PLUMBING RE-PIPE
ARCHITECT'S DECLARATION ❑MUITI.UNIT L3 STRUCTURAL
Z O y ZJ 1 understand my plans shall be used as public records PANELS MODIFICATION
OZ-a UPT02WAMPS El INTERIOR EICHIMNEYREPAIR
zGFy.12 Licensed Profemional ION 2OI-IqO AMPS IMPROVEMENT SWIMMING PoOIs
a tY O Q 1 hereby of rte OWNER-BUILDER
on emmps to..the Contractors License Law for the OVER IOOOAMPS DBATH REMODEUREPAIR [I DEMOLITION
x O d U following reason.(Section 70.11.5,Business and Professinrs Code:Any city Or county SIGNS ELECTRICAL BOTHER iL
which requires a permit to Continual,alter,improve.demolish,or repair any samom W r r
pnermits issuance,al.so requires he applicant foreuch permitmBleasigned shmmem SPECIAL CIRCUITIMISC.
that In,is licensed pursmadauthe pmvisionsofthe COmrnctors License law lChafer9
(commencing with Section]01(gam Division 3 of the Rmineaand Professions Code)or TEMP.METER OR POLE.INST. COMMERCIAL•
a 4 e�' that he is exempt therefrom and he basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section]1131.5 byanyapplicant fora verent subjects the applicant u,a civil pemhy of POWER DEVICES
^rn ❑TENANT ❑FOOD SERVICE
n more wan five hundred dollars y ma,l.
= G ❑Lothe wcrOfhepestruco(myminacrltalo,brmed iasult,(sale compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
F- will Profework.andthe a muchmatori License
doss
apply(Sarto an
❑OTHER
6�'m and property
who b CNor iI bemp Contractor's Landow law docs not apply m if owner or OUTLETS—SWITCHES—FIXTUR
property who builds or improves thereon,and who aces re n work intended
or or through
his awn however,
provided hot such improvements thin not intended or offered for NEW RESIDENTIAL ELECfR
m1e.ILhoweventhe buildingmen(if posing
issoldhedid non build or ofcompletion, SQ.FT.FLOOR AREA 5/SQ,FT.
ettfsa leer will have the burden Of proving that M1c did not build or improve for pur-
pose of selene
❑h a owner eq the Set,70y,a exclusively contracting with licensed Contractors
to TOTAL:
constrvn the project(Sec.]OJJ,Ilusiness and Pmfessinns Code J'ITe Comtacmr's Li-
censeLawdoesnotapplymanowner of pot who builds or improves thereon,and QTY, PLUMBING PERMIT FEE
who contracts for such projects with u contraction(s)licensed oratan0o the Contractors
License Law, l PERMIT ISSUANCE
FlI am enemptnnder Sec. ,B&P C for his reaznn
ALTER—DRAIN&VENT—WATER(EA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hechy alarm male,penalty of perjury one of the fallmving declarations:
c]I have and will maintain a Cenificam of Commit to self-insure for Worker's Count DRAINS—FLOOR,ROOF,AREA,GOND.
taboo,as provided for by Section 37110 of he Labor Code,far he performance of the STORIES TYPE CONSTRUCTION
work far which this permit is issued. FIXTURES—PER TRAP
TtWr 1 have and will natural.Worker's Compenmtion Insurance,as required by Section
9]DB of the Labor Code,far he pc,fonnanmaf the work for which his Permit is issuM. GAS—EA.SYSTEM-I INC.J OUTLETS OCCGROUP G APN
My ierrF �pe s,W �e P"I CY N,xit y nu pre �' K�Y GAS—EA.SYSTEM-OVERJ(EA) ZS�3�O/-1
Carrier D FVtn a.2 ✓ IV
CER"fll'ICCOMPE SATIONIONFROM AN WORKERS' GREASEANDUSTRI.WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION RES
phis sermon need nm hecompleted if he pcmtit is far one huWrtddNlors($IIX) GREASC•TRAP
nrlws,) PLANCHF.CK RE
Loy any
any manner
stolokbrtwhich this pertainsissuComprt. SF.WF:R-SANITARY-STORM EA.2(NI FT.
not employ any person in any mnnn<r w as to hecomc subject the WorkerP Comport. ENERGY RE '
O z moon Lawn of California.Date WATER HEATER WNEW'ELECER
z Applicant GRADING FEE
N NOTIC'E'IT APPLICANT.If,after making this Cenificam of Exemption,you.should WATER SYSTEMITREATING
a ^ berme subject to the Workers Compensation provisions of the Labor Code,you must SOILS FEE.
kII G fonhwih comply with such provisions or his pmol shall he deemed revoked, WATER SERVICE.
0a
z CONSTRUCITON LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,ET. PAID
V0 Date Receipt
LIr Fhe work for which his permit is Issued(Sec.3097,Civ.C.)
Landers Name T
C.1 Lender's Address TOTAL:
F4 I certify that I have read this application and state that the above information is BUILDING FEE
N Cosmo.l agree to Comply with all city and county ordinances and state laws mlaing m QTY. MECHANICAL PERMIT FEE
C.1 � building consimetion,and hereby amherizc representatives of his city m enteropon he SEISMIC RE
abovememioned pmpeny far Inspection purposes. PlikMl'I'LtiSUANCE
(We)agree m save,indemnify and keep harmless he City of Caperton against ELECTRIC FEE
liabiliticajudgmcnn.ensu'andexpenses which may inany way accrve against mid City ALTERORADDMMECIL
in conse4uence of the granting Of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT AIR HANDLING UNIT(TO 10,100 CEM) MECIIANICALI'EE
SOURCE REGULATIONS
83 9 5 AIR HANDLING UNIT(OVER 10.000CFM) CONSTRUCTION TAX
Signature of ApplicanU(Controcmr IMme EXHAUST HOOD(WMUCT) HOUSING MI'I IGATION FEE
HA7,%RDOUS MATERIALS DISCLOSURE
Will he applicant or future building occupant store orhandle hazardous material HEATING UNIT CFO 100,000 BTU)
as defined by he Cupertino Municipal Code,Chapter 9.12,and he Health and Safety
Code,Section 25532(1)? HEATING UNIT(OVER 100,100 BTU)
[]Yes F1 NO VENT ELATION PANS INGLE RES ID) PAID
Will the applicant or future Wilding Occupant use equipment Or devices which Dare Receipt d
ii Locations air contaminants as defined by the Bay Area Air Quality Management BOILER—COMP(BHP OR 1(00.(00 BTU)
confer? TOTAL JJ
❑Yes F1 NO BOILFR—COM P(OV ER 100,0011 BTU)
I have feud he hazardous materials rryuiremems under Chapter 6.95 of he Cali AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Cade,Sections 2-5505,25533 and 25534.1 understand that nine NEW RBSIDEM'IAL MECH. SQ.FT.
building does not curmmly have a tenant,that it is my responsibility to notify the occupant
of he il�iHmeny 'ch must lR met priono issmnce of a Cemfiw ?Of�Oc��penSy.
Owns tbortzed ugcm 'r�)nk / TtYI'AL: ISSUED Y.
OFFICE