99110075 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT WENI'IFICATION
NUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL GATT..
fV_4o Ri/ttRost WA (
OWN LL�F. PHONE: CON'BACfpR'S NAMB� r LIC NO',
(/ [/.v,� NIC CONTROL
.qW CHITECI'/LNGINEER: LIC NO: ADDRESS ❑
CONTACT, PHONE; BUILllING PERMIT INFO
❑ Con ethant Fees Paid by Applicant(Initial) BLDG ELLCI' PLUM MECH
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERM I FEF.
I hereby affirm Thal 1 am lRenscd made,provision:of chapter 9 fnnmmenning JOB DESCRIPTION
WOO with Section 7")Of Division J of the Business and Professions Code.and my license is RESIDENTIAL:
FW. in full force and effect. PERMIT ISSUANCE ❑SFDWL ❑KITCHEN REMODEL
XU~ License Class hies#
6y L 107 A tj ❑ADDITION ❑PLUMBING RE-PIPE
y d C D:nc Ci for
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
z OyZ l understand my plans shall be used as public records PANELS L MODIFICATION
OZ�Ls UPTO200AMPS o 0IMfER10R ❑CHIMNEYREPAIR
F�Q!ZW Licensed Professional 201-1000AMPS IMPROVEMENT OSWIMMINGPOOIJS
C Q 1 hereby off nn hsVi I am BcxelmUCGnDECLARATION
the Conva tar's Liccnu law for the OVER IOW AMPS ❑BATH REMODEL/REPAIR DEMOLITION
X 3=F following Orion,(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL. ❑OTHER
whi,h regmre,a pcnml m conaroct,alter,improve,demolish,or n air any saactum _
E"-W+� prior to ROmshpermit to life a signed statement SPECIALCIRCIIIT/MISC.
Ihmheislieenwdpucvua.Itomeprovisimm'nt the Conuaanr'a License Law(CM1epter9
WEE p0 (u)mmencingwiih Section70 )of Divisionlofthe Businessund Pm, r - R OR POLE INST. CdMMERCIAL
ase W that he is exempt therefrom and the basis for the alleged exempuun, o f ❑NEW BLDG/ADDITION ❑DEMOLITION
��y Sation 7UJLS by anY applicant for apenmir subjecn the applicant to 'il nl f [� ..r OTT-NANT ❑FOODSERVICE
norm th five hundred dollars WOB, 11 a a OTHER IMPROVEMENT
F zy< O 1 f theproperty, Y employees with g. .theirc pen:f n. IM '(I�IiGLCCfRJQ Qto
F�
will do thek and the structure t intendedofferedf (See9(W s OTHER
w
and Probes C dc: DO,C t l ,License Law does not apply to a or,o \PTICHPS FIKT(RU:
propcny h h 'IJ—, on,nove,,leocuri.and shoduc,: h work himself throu, ID[N iI LELECTR �,Q PT.
hi,u,ir employees.pn d d In.,. M1 im,rovernins t intended r
sale.If.however.the budding or improvement s sold within oaeyev completion.the �..-. SQ.IT.FLOOR AREA VSQ.FT.
ow
ser-builder will have the burden of proving that he did not build
Elf sale.).
me.). ot the pnrcenY,am exduvively enthroning with li< Z IT=
nxtmet the p...gat(Sr,7014-Busines and Pnrtessimm Ctde:)' Cu c n
nel,aw Jacx ani upplymnn mwnendpmpcny wno build,nr inpmves tbercmn.and QTY Ph N FEE
who mnvactx fiusuch pmjcce with v mn(met or(s)liccnsad pmarm l tothe Conwcror's
Lireme Law. PERMIT ISSUANCE
❑1 am exempt under .B k P C for this reason
ALTER-DRAIN At VENT-WATER III) VALUATION
arc TV Pa
OR
KERS CObtl ' SATION DE RA'T'ION BACK FLOW PR(TITiCf.DEVICE. C/t
T hereby off nn
under penalty
one at
to arBowingdeclerationx:
(]IM1avc unJ wlll nwinmin nCertifcum of Cnnxcnn0 self-imurc lin Wnrkeix Compen- DRAINS-FLOOR.ROOF.AREA,CONIX SIORIES TYPE CONS]SUCTION
retina,as provided lot ni Ss issu 37W of the labor Code,for the performance of the
wed for which ills permit is issued. FlXTURGS-PER'1'RAP
37 1 have and will maintain Worker's e ofhCompensation Insurance,which his pentr by Section
My ofthr's Co Cde.fonhsurance carrier and Polic !nubram:
permit is issued. GAS-EA,SYSTEM-I INC.d OUTLETS OCC.GROUP .� 6 APIN
/ &
MyN'orkeh Compensation Insurance artier and Policy number ore: SI•.Jf
Camee Policy No.: GAS-EA.SYSSUM-OVER4(PAT D O
CIiRUrICATE OF EXEMPTION FROM WORKERS'
GB.ASPJINIlt15UI WASTE IN IRCEfTOR
COMPENSATION INSURANCE ilUI1..U1NG DIVISION PEES
(TM1is vection necdnm M1ecmmpEted it the permit is!Drano hinlraldnllars($1M) GREASE'fRA1'
or IcssJ PLANCIIECK FEIi
I cenifytha in the Tied o..earofthe work for which lhis pennit is i...ad.I shall SEWER-SANITARY-STORM FA.2W FT.
not employ any penin in any manner u)as to Meome subject to the Workeri Compen- ENERGY FEE
z station Laws of C.Iifomiu Dam WATER HEATER W/VENT/F:LECB GRADING FEE
z O Applicant
NOTICE TO APPLICANT:It,aver milking This Certificate Of Exemption, no should WATER SYSTEM/BEATING SOILS FEE
F % become subjcvv u.Thu Worker's Cumpeosmina pmviviuns at the Labor Cads,you meq
Cil
forthwith amid,with such pruvlsionx Or lh,ran ,shall he deemed rcvnkal. WATER SERVICE
a �
7z. CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.ET. All Dams licipra
U 01 bemby alfithi the Here is ruction lending agency fur the performance'If
I"r the work fur whish this perms is arced sued((Sec.3097,Civ.C.) ` T
Q W header's Name
Lenders Address TOTAL: 5 1999
F0. 1 crow,that 1 base read mis.ppllcmion and state that In.above aformminn o B L N 'j,
In masa.1 ogrcc n.emnpfy with all city and county ord'mance and state lows relating bi QTY. MECHANICAL PERMIT FEB
U z building construction,and hereby imhorizc representatives of lhls city to enter upon the SEISMIC ItiE
.(rove-mentioned property for inspection purryrses' PERMIT ISSUANCE 'B'1_p_0fg(Cn:r.
(We)agree,.save,indemnify and keep harmless the City of Catania.against
Iiabilitieajidgntem,cops andexpcnsss which may in any wayaccmcagmmt said City ALTER OR ADD TO MECH.
PLUMBING FEE
in PLICA Ofthegrantingof thioperm((.
i APPLICANTT CFM) MECHANICAL N :HSTANDS A 1 WILL COMPLY WITH ALL NON-MINT AIR HANDLING UNIT(TO TO." PEE.
SOURCE RF� A NS.
AIR HANDLING UNIT(OVER I0.00N1 CPM) CONSTRUCTION TAX
Signature of ApplicantlCnnml o Dam EXHAUST HOOD IW/DUCT) HOUSINGNITIGATION FEE
HAZARbBbS MATERIALS DISCLOSURE
Will the applicant or future Wilding occupant store of handle hazadous material HEATING UNIT(TO IW.000 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cade.Section 25592(x)' HEATING UNIT(OVER UN."BTU)
Yes ON.
VENTILATION PAN(SINGLE,RES ID) PAID Il:nu Rccciplp
Will the applicant or future hmifding OcnITned use equipment or devlees which
mit hvudoms air conumnintnt,an refined by the Bay Area Air Quality Management BOILER-COMP(3HP OR I000)(0 It IU)
I' 'AL'
Dn.0°m7
❑Yes No
BOILER-COMP(OVER 100,000 BTU) a
❑
w
I have mast the hazardous materials reyuiremenn under Chapter 6,95 of the Cali- AIR CONDITIONER / ISSUANCE1)) TE
Rrmin Health A IY Code,Sections 25505,25533 and 25534.1 understand that if the NEW RF.SBBiMrlAL MECH. SQ.EP. / 7J _Q�
building doe.' - n1,y have.leer Inn it is my a"au"ibikly mnotily the rocapard
of qu' tc a iP1hau'I he t/priorb ixnunn Cmrtlficyt�rtpauc4
Owner or readmitted agent / r Date r TOTAL: ISSUED BY:
OFFICE