99120129 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY - ��b I -3t
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMI NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL -
BUILDING PROJECT IDENTIFICATION
MD
BUILDINGADDRESS. - SANITARY NO. APPLICATION SUBMITTAL.DATE
�y OWNER'S NAME: P O E: CONT ORSN 1 LI BYO
` r -Y_ `Q ;p E$� , . (� /". •,^I.�L 4/(�\/\ N/C 9^/ CONTROL#
TE011pal [NEE AD µ a ' ❑ I /
CONTACT: l PHONE:
BUILDING PERMIT INFO
ZM97 6 ❑ Consultant Fees Paid by Applicant(Initial) BLD ELECT PLO B SUCH
LICENSED CONTRAC 'S DECLARATION QTY ELECTRIC PERMIT FEE
L hereby union that 1 am license ruder provisions of Chapter 9(commencing SOB DESCRIPTION
�'Zwllh Section]000)of Divislov3af the Business uvd Professions Cade,and myllcense is I T
F. in full force and effect PERMIT ISSUANCE
� AL-
Uz[P[,]] License Class Lic.# SFOWL [I KIT REMODEL
y6G Date Contractor APPLIANCES-RESIDENTIAL ADDITION ❑PLUMBING RE-PIPE
ARCHITECT'S DECLARATION El MULTI-UNIT ❑STRUCTURAL
r Z r Z 1 understand my plans shall he used as public records PANELS
:� MODIFICATION
UP T02OO AMPS
El CHIMNEY REPAIR
F C?,�t�c Lice ns.it Pmfivoiondl 201-1030AMPS IMPROVEMENT SWIMMING POOLS
` � OWNER-BUILDER mDECLARATION OVER IOW AMPS ❑BATHREMODEUREPAIRNEMOLITION
W CC44 G I hereby intimi on I am exempt from the Contractors o e:Any
Law for the Ell
THER
bd 3 Fs following reason(Sermon]on 5,Business and Professions Code:Any city or county SIGNS ELECTRICAL
a1=O y which requires a permit r1.e construct,alter,improve,demolish,or repair any mmaure
6 patliedmIo1licensed P.Eorequires,he the Imicisionunt for such Compactors iele sLawed statement SPECIALCIRCUIT/MISC.
5" that me cing with
pursuant loth)pm visions of the Contractors License Law(ChaptersComa) 9
94 (hot he is(commencing win Sectaciefon7W0)of basis
r doffices,.1 Business pl Pr.A., i Coma)or TEMP.METER OR POLE INST. COMMERCIAL:
that is is exempt therefrom add the hostas for the alleged exempnt to Any violation of ❑NEW BLDGIADDITION ❑DEMOLITION
Sutiuna than by any applicant for a permit subjects the applicant toacivil penalty of POWER DEVICES
Imo„y} notJnare than fit-
ve hundred dollars(8500). ❑TENANT [I FOOD SERVICE
5 p'[(I,asowneroflhe norm employees with wa esus their silecom tion, SWIMMING POOLE ECTRIC IMPROVEMENT
pipe y y amp y g pensa
[. do the work,and the stmcmre is not intended or offered for sale(Sec.]044.Business -1 OTHER
3 m
and Professions Code:The Connector's License Law it.,not apply to an owner of OUTLETS-SWITCHES- XTURES
property who builds or improves thereon,and who does such work himself or through ) —'
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTI LECTR SQ '-` /1\ I I
sale,If,however,the building or improvement is sold island one year ofcomplelion,the 1r SQ.FP.FLOOR AREA U .TT.
ter-builder will have the burden of proving that he did not build or improve for pur-
pose
❑71.asowne lieIA' DC4 �. ���
1,as owner of the properly,nm exclusively contracting with licensed contractors to TOTAL:
cousserve ctoLa the es not appl(Seey
toM4,Business and ry who onsbun ds or i proves pewter, Li-
came Low does not apply le an owner of progeny who bullas or improve Hereon,and QTY. PLUMBING PERM FEE j
who contracts for such projects with a contracmga)licensed pursuant to the Contractor's
License I. PERMIT ISSUANCE R
EJI am exempt under Sec ,B&P C fm this reason .V__,_ _
Owner Dam ALTER-DRAIN&VENT-WATEA) VALUATIO _—
ORKER'SCOM SATION DE kAT10N BACK. PROTECT.DEVICE �.1\ �� .c7�
I hereby affirm under penal ofperjuly oneo following declarations:
H ve and will maintains Cedificate of Consent to self-insure for Warker's Comped- DRAINS-FLOOR,ROOF,AREA,GOND. STORIES TYPE CONSTRUCTION
cation,de provided rm
for by Section 37M or the Labor Cada,for the perfoance of the -
work for which this permit is issued. FIXTURES-PER TRAP
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 ofthe Labor Came.for the performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4OWLETS - OCCGROUP APN
My Workers Compensation Insurance artier and Policy nominated,
Carrier: Policy No.: GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRL WASTEINTERCEPTOR BUILDING DIVISION FEES _
(This section n,dnolhecomplead Lfthe parent is for one hundred dollars SIM) GREASE'fRAP
m Its) PLANCHECK FEE
I certify that in the performance of the work for which this permh is issued,I shall SEWER-SANITARY-STORM EA.2W FT.
not employ my person in any mann,so as o becam th
me subject e Workers'Corrigan- ENERGY FEE
Zi satlon Laws of California Date
zWATER HEATER WNENT/ELECTR
z ICm I GRADING FEE
h NOTNOTICE TO APPLICANT:If,atom making this Certificate of Exemption,yoo should WATER SYSTEM/fRGTING
a beano)sv comply
y the Worker's Compensation provisions of the Lobar Code,you mit SOILS FEE
Lkl
forthwith comply with such provisions or This permit shall be deemed rcvokN. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMH. SQ.IT. PAID
Ll2 k fareh hich thi)hermit i issedgra..30 len Jing agency for the performance of Date Receipt#
o F 'he work for which this permit is issued(Sec.3o9],Civ.CJ
O Lender's Nanta TOTAL:
WLender's Address TOTAL:
a 1 cenify that I have read this appl'omion and state that the above infnrmmion is BUILDING FF.F.
rA correct.l agree to comply with all city and county on ivances and state laws relating to QTY MECHANICAL PERMIT FEE
V building construction,and hereby authorise representatives of this city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
Iiabiliticajudgments,costs it expense,which may in any way accrue against said City ALTER OR ADDTO MECH. PLUMBING FEE
in consequence of the Standing of this Permit.
APPLICANT UNDERSTAND ILL COMPLY WITH ALI,NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL FEE
SO .REGULATIONS
AIR HANDLING UNIT(OVER 10.001 CFM) CONSTRUCTION TAX
Si&Wture of AppllcanVControyylI !r' Dad/ EXHAUST HOLD(W/DUC10 HOUSING MITIGATION FEE
HAZARDOUS MATERIAL SCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Canadian Municipal Code,Chapter 9.12,and the Health and Safety
Cale,Section 25532(a)? HEATING UNIT(OVER I00,000 BTU)
3
❑Yes PAID
VENTILATION PAN(SINGLE RESID) Date Receipt#
Will the air eximsecant ia future building occupant use equipment or devices which, BOILER-COMP(3HP OR 1(1(1,0(10 BTU)
nil haeuNous air contaminants as defined by the Bay Aree Air Quality Management TO L:
islricl?
El Yes rLT'h10 BOILER-COMP(OVER 100,000 BTU)
(have reed the huardous mare' acagereme son der Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANC A
folia Health&Safety Cade,Secti s 25505.25533 a d 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have a nanWhatidismy pomibilmty o notify the dearleat
ol'th cots which must metinormis. ceofa Cerfificateof cy. I
O a t arizediggoA Date TOTAL: ISSUEDBY.
OFFICE