S 1099 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
,CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
♦ ' BUILDING DIVISION APPLICATIONIPERMIT PI-UMBING-MECHANICAL. S O
BUILDING PROJECT IDENTIFICATION
99
BUILDI&ADDRESS� L SANITARY NO. APPLICATION SUBMITTAL DATE
O ERPHONE: ONTRACTORSNAME LIC NON/C CONTROL#
AR I LIC NO
DORESSy /) ❑
CONTACT: PHONE: !`• FLIM, BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) LOU ELECT OMRMECH
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE ❑ ❑
1 hereby affirm that I an licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
aO zO with Section 20mlmf Division 3 mlhe Business and Pndessions Code,and my license is PERMIT ISSUANCE RESIDENTIAL:
in full fame and eIT
UV LicenseC Lic.# ❑SFDWL ❑KITCHEN REMODEL
yZW Date Comracmr APPLIANCES-kESIDEN'fIAL ❑ADDITION ❑PLUMBING kE-PIPE
I.224 ARCHITECTS DECLARATION PANELS El MULTI-UNIT ❑STRUCTURAL
zpX, understand Imy plans shall be used as public records � MODIFICATION
Oz-, UP TO BIT)AMPS El INTERIOR ❑CHIMNEY REPAIR
F� Licensed Professional OWNER-BUILDER DECLARATION DEMOLITION 201-Ifl(It1AMPS IMPROVEMENT
]SWIMMING POOLS
G
1 hereby affirm that 1 am exempt from the Contractor's License Law for the OVER I(XIf1AMP5 ❑BATH REMODELIREPAIR (]DEMOLITION
3 a V following reason.(Section 2031.5.Business end Professions Any airy or county SIGNS ELECTRICAL 2.L Ll OTHER
y which requires a permit to construct.alma improve,demoliots or repair any structure -
prior to its issuance,also mquiresthe applicant lot such permit to rile a signed statement h SPECIAL CIRCUIT/MISC.
y, that he
menccensut Sectio rtothe of Division
of the ContraceBusiner's License Law(C ode) 9 COMMERCIAL:
l CO (cat he is exempt therefrom
and of basisor3of theexemption
Professionslationof TEMP.METE OR POLE INS I.
6 y e p� that io is exempt therefrom and the heels for the inducers
thalleged exemption,Any violation of [_1 NEW BLDG/ADDITION ❑DEMOLITION
Section LSby hundrery dollars($50dfor a nit subjects the applicant toacivil penalty of POWER CE El TENANT ❑FOODSERVICE
p. cot meewne fvehundredty,or dollars($50d.
❑I,as owner of the property,or my employees with wages as their sole compensation, SWIMMIN ELECT I IMPROVEMENT
I. will Bothe work.and the structure is not intended.,.ffefed fim,me(Sec.2f144,Business ❑OTHER
6C and Professinno Code:The Coriander's License Law does not apply to an owner of OUTLETS- II' liI UR '
.. property who mild,or improves thereon,and who dues such work himself ar th v.
his own employees,provided that such improvements are not intended or offered for NEW RESIDE 1l-ELECTR SQ FT
sale.If.however,the building or improvement is sold within one year ofdomplenon,the SQ.FT.FLOOR ARG $/SQ.Er.
owner-builder will base the burden of proving that he did not build or improve for put- -
pose of
cele.).
❑ Las owner of the property,.B exclusively contractingironed,with licensed contractors i- TOTAL
conmruct Nep jeer(See.2(144,Business and ProfessionsCodegThe Contractors.I-
demLaw does not apply toanowner ofproperty who builds orimproves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a coutractor(s)licensed pursuant to the Contractors
License Law. PERMIT ISSUANCE
]Imnexemptunder Sec. ,B&PCfimthisrcasan
Owner Dam ALTER-DRAIN&VENT-WATER(EA) - VALUATION
WORKER'S COMPENSATION raw
DECLARATION PACK PLOW PROTECT.DEVICE
IM1ereby affirm under penalty ofp juryury ere of the followin6 Jeclurntions: '
❑I have and will maintain a Cenificate of Consenuo self-insure for Workers Compen- DRAINS-FLOOR,ROOF,AREA,CONE. STORIES I'YPE CONSTRUCTION
.dation,as provided for by Section 32m of the Labor Gyle,for the performance of the
work for which this permit is issred. FIXTURES-PER TRAP
I]I have and will maintain Worker's Compensation Insurance,as required by Section
3200 of the Labor Code,for the permanence fthe work for whichthis permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS DEC.GROUP APN
My Worker' C ��pe s Imams amimmid Polity um
tS Carrier: C a Policy Nm.: GAS-EA.SYSTEM-OVER 4(EA)
CERTI MPPTION FROM WORKFRS'
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE IN EPTOR BUILDING DIVISION FEES
(Tee
Has section amid not be completed if the permit is for one hundred dmllars($1BE GREASETRAP
or less) - NC E
1N.Y.,df,that In the any..a.,so
ofine work
ci for which this permit is issue.)shall
n emoy my person in any mannermvs mbearme suhjecuothe Workere'Compen- SF.WF.R-SANITARY- RM EA.2011 FT.
tiplicam AL oo Laws of Culifomiv.Date �si���
Q t - WATER HEATER/ tNT/ELECTR - aVt�n��NtW
pNXW
ICE TO APPLICANT:If,after making this Cenificme of Exemption,you should WATER SYSTF /TREATING
a he eros subject to the Workers Compensation provisions of the Labor Code,you must - SOILS FEE
forthwith comply with such provisions or this permit shall be deemed revoked. D
WATERS ICE
ThbCONSTRUCTION LENDING AGENCY NEW 'SIDENI'IAL PCMB. SQ.FT. PAID
Wz' hereby affirm that there isucooswnioo lording agency[oohs Per foararceof - vte Receipt#
the work lar which this permit is issued(Sec.3092,Civ.C.)
O Lender's Name TOTAL'
{Ui.I Lenders Address - 'TOTAL:
I certify that 1 have read this application and some that the above information is BUILDING FEE
ttZl correct.I agree to comply with all city and county ordinances and state laws relalng to QTY. MECHANICAL PERMIT FEE 774-0
V building construction,and hereby authorize representatives of this city to enter upon the SEISMIC FEE
above-mentioned property for inspection purryxses. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way accrue against said City' ALTER OR ADDTO MECH.
in consequence oft ranting of this permit. PLUMBING FEE
APPLICANT ERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,081)CFM)
SOURC GULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER FLOW CFM) CONSTRUCTION TAX
Signature of Applicant/Comencem Date EXHAUST HOOD//DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theappliemot or future building mecupamomeor handle hvzaalots material HEATING UNIT(TO 100.000 RTU)
as def nd by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Crude,Scamm 25532(v)2 HEATING UNIT(OVER 1110,( BTU)
❑Yes ON. PA
VENTILATION PAN ISI LE RESID) late - keceipt#
Will the applicant or futsa building occupant use equipment or devices which BOILER-COMP( OR IIXI,(NXI BTU)
111 emit hazatdoue air contaminants as defined by the Ray Area Air Quality Management TOTAL:
District) 1
71 yea ON. BOILER (OVER100.1100 BTU)
1 have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CO ITTONERitUANCE D
heads Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the RESIDENTIAL MECH. SQ.FT.
building does ntcumm tlyhave tenant Naini yresponofability to notify the ncupant
To rents wh' me prior t ssuanve a Cenlfleate of Occupancy.
meq
ate � 02
- —D j 2 I - TOTAL: ISSUED BY: •
OFFICE