99070067 APjrR'ICANITO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY (/
CITY OF CUPERTINO BUILDING-ELECTRICAL P
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
t BUILDING PROJECT IDENTIFICATION' I
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
V11� , 28
Its NAME: PHONE: 11 V�+�/p• C RACT R' MF.: LCNO.
I.Q� I T'1-^ NIC CONI j
ECT N IN IiR: LIC NO: p "S: ❑
COMI�-A�C. PHONE:: BUILDINGPERMITINFO
TR Ve I 0��� ❑ Consultant Fces Paid by Applicant(Initial) BLDG [ F.C9' PLUMB MF:Cii
u
LI'ENSED CONTRACTOR'S DECLARATION QTY ELECIRICPERMIT FEE
I hereby.firm mm 1.m Seamed tinder proviximm of Chapter 9(commencing JOB DESCRIPTION
RQa2 with Soul on 7000).fDivision 3 of he Business and Protaammcod- clay heenx°is l IDENTIAI,:
�00 wt PHRMI'I ISSUANCE
azinfellforceand afiem. 15_z ❑SFDWL ❑KITCHEN REMODEL
W License Class Lie. APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
ti<L Da¢ IZ Cnlnremor
ARCHITECI•SDECLARATION ^ ❑MULTI-UNIT CSTRUCI'URAL
F0w YV` PANELS
Z p I2 Z I'unJcmand my plans shall be raved ae public rccnrds MODIFICATION
OZ O UPTO200AMPS
Licensed Professional El INTERIOR CCHIMMINGP OL
201-IINNIAMPS IMPROVEMENT C]SWIMMING POOLS
lY W 6 I hereby affirm that N umexempt froUTLDPR m the Contractors License Law for the OVER IOW AMPS 0 BATH REMODEURF.PAIR El DEMOLITION
C7yy 06U following tracer, Section 70315,Business and Prnfeaninus Cale:Any city or county SIGNS ELECTRICAL. OOTHER
which requires o perndt et a ms iron aha'.improve•Amnm'wb,m repair any darner,
prior to its I.....cc,risen,quires the applicant lot malipifrod m file asignoJmutcmem SPIiC1 AL CISCO)17M ISC.
2 y that he is licensed pursuant[.the provision,of the Commemrs License Law(Chapmr9
WRIZ (commencing with Section 7000)of Division 3 or the Business and Professions Carlo)or TEMP.MITER OR POLE INST. COMMERCIAL:
Q.a p� that he is exempt therefrom and the basis for the alleged exemption.Any violation of ^0 N�E BLDG/ADDITION 0 DEMOLITION
^ Scetinn703156y any applicant for.pcmtil objects lheapplic.nfto n civil pvorthyof POWER DEVICES 1
m NANT El FOOD SERVICE
I-, mmme than five hundred dollars(SSW). IMPROVEMENT
�a 01.as owner of the property.or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
f 0 will do the work,and the structure is not intended orofferd lorxale(See 7044,Business ❑OTHER
W 3°.o and professions Cute:The Conuacmfs License law docs not apply m.n owner of OUTLETS-SWITCHES-FIXTURES
his o ny eche builds nr improves thereon,and who does such wnrk himself or red for
his own however,
the prnvidnd that such inmms sold w are not intervenor..off d for NEW It NSIpBNTIN,I?LECTR SQ I'll
mene-Ihnwesecll hhull he burden
of ovint issoldwiid none yldorimroveliorpar,ch.the SQ FT.FLOOR AREA LSQ.14.
owe,of as Wer will have the harden of proving that he did not buil)or improve for par,
pose oleic).
❑ 1,u owner of eche See 704,.m exclusively contracting with licensed contractors i. TOTAL.
construct the project(Sec.7044,Businux and Pmfc.vinns Ctrle)The Cnnuudots Li- - {
A cense Law does not apply ,,inowner of Is pet,who huildsor improves thereon,and QTY. PLUMBING PERMIT I PEE
who contracts for such projects with a nmtmctor(s)licensW pursuant o the Contractor's
License law. PERMIT ISSUANCE
0 I an,exempt under Sec. B&P C for this reason
)tuner Dem AL'PER-DRAIN&VENT-WATER BEA) VAALLUATION -
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE \ \ D O
I hereby affirm under penalty of perjury one of the following declarations: C.J
O l have and will maintain.Cenifcrteof CunsenituseLbinsurefor Workers Cumpem DRAINS-FLOOR,ROOF,AREA,CONE, STORI TYPE CONSTRICTION
..tion,as provided for by Sectio 370(1 of the Labor Code,for the performance of the
wnrk lin which this[x'nnil is issued. FIXTURES-PERTRAP
1 have and will meinmin Workers Compensation Immrmce.is required by Stoo len
37M ofthe labor Cale,for the perfomnumse ofthe work lin which,his permit is issued. GAS-EA.SYSTEIFI INC.4 OUTLETS OCIC.GROUPMyWAPN
Came.. sCompen style lCns ysce 'e.rptAt' nutppc[aF����tl� t GAS-PA.SYSTI:M�OVER 4(EA) yl� OZ
710INCATH OF F.XEMI'fION FROM WORKERS' 4V 6
COMPENSATION INSURANCE GRRANOINDUSTRI,WASTE POE14CEPTOR
BUILDING DIVISION RSh
('1 Lis section aced nm be compineJ if the pemsit is mr.rrh rdcdd.1Im,(SIW) ORBASE TRAP
or less.) PLANCHECK FEE
I cenifylhat inthep Kemanceofihe work(nr,shichlbrs isissued.lidell SEWER-SANITARY-STORM ItA.2W FT
not employ any person in any manner sots to 4(yne�ibjegtyn rkers'Compen- ENERGY FEE
0 z ..tion Laws nI Cglih'�i --jam/7 D WATER HEATER WIVE
.Z
z O ApplicLaw ''C u l GRADING FEE
y NOTICE'1 AP LICA :IL aft lOg this Cenifcam of Exemption,you should WATER SYSTEM/IERATING
F become subject m the Workers Compensation Provisions of the Labor Code,you nom SOILS FEE
forthwith comply with such prnvisiona nr his permit shill be Deemed revoked. WATER SERVICE
Q
CONS'TRUC'TION LENDING AGENCY NEW RH5IDENTIAL PLMIL SQ.FT. PATE
U0 (hereby affmn ahgtthen is a consiuction lending agency fenbe perfonnanceof Dare R;611
IL F-' thmi
e work for which this pert is imued(Sec.3097.Civ.C.)
C) U Lender's Name % N,:
Leader's Address TOTAL:
I certify that I have rcetl this applica ion and sure that the above information Ix r - _ - BUILDING FI t D
rV2 corm.l ugreem comply with all city and county oNinances and state l.wsrelnting to QTY MECHANICALPF.RMIT �1 FEF.
Z bung mnswdion,end hereby amhum<rcpresenmtives of this citymemer upon the SEISMIC PER
above mommod property for inspection purposes. PERMIT ISSUANCE
IWe).,me to save,indemnify and keep harmless the City of Caperton against ELECTRIC HE
liabilities,judgment.•cuss.and expenses whiehmaymwry way acerueagaimtsrid City AI,TI?It OR ADD TO MECII.
in consequence of the grunting of th's permit. PLUMBING F
APPLICANT UNDERSTANDS D VILL OMPLY WITH ALL NON-POINT AIR HANDLING UNIT(70I0,OU0 CFM) M[CHANICAL
SOURCERE I y�
T�7ip�L9 AIR HANDLING ON]'1'(OVER 10,0110 CFM) CONSTRUCTION TA
Signature o ApCenlmctor !! pate EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FTE
HAZARDOUS MAI'IiRIALS DISCLOSURE
W1lthaappli,am or future building cre.panlxmreor handle hmardous mare .) HEATING UNIT(TO I0yfIf10 BTU)
as confined by the Cupertino Municipal CtMe.Chapter 9.12,and the Health and Safety
Cale,Section 25532(.)7 HEATING UNIT(OVER 100,(10(1 PTU)
C Vc, No VINI ILAI'(ON FAN SINGLE RES11) PAID
Date Be ptk
Wid eche nppiic.m or future building t fli Bayur A a Air rainym or Mann eche li- Moil
BOIL ER-COMP(311P OR 100,000 BTU)
amu for? Yes air contaminan�5f s defined by the Buy Arcu Air Quality Management T 1
District! r,/' BOILBR-COMP(OVER 100,010 BTU)
❑Yes
'6[�}ry
I have head the hmrNous materials requirements under Chapter 6.95 of the Cali- AIRCONDITIONER ISSUANCE DA
forma Health&Safety Code.Sections 505.25533 125534.1 understand that if the NEW RESIDE.YTIAL MFCH. SQ.F1'.
buildingJas note n vee n I•atmitis .Pomihility m notify cote ni
of the my '
-.1
poor o. colo Ceni0 am of ecu. _ ��
Owneror .0f nxiat tent us Dam TOTAL: ISSUED BY:
OFFICE