99080061APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY 9 o S o d b
CITY OF CUPERTINO BUILDING -ELECTRICAL
PE MIT NO.
BUILDING: DIVISION APPLICATIONIPERMIT PLUMBwc-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING Apf)RCSS. j O
SANITARY NO.
APPLICATION SUBMITTAL. DATE
O AMC: WIO
CO 'S AM
N/C
❑
CONTROL N
t//YlS/as
NCHI'IECPEN GINEE LICNO:
aNTACT: PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
BLDG EV7 PLU B ME
❑ le�\j
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
QTY ELECTRIC PERMIT FEF,
JOB DESCRIPTION
withscrom 700(1 of Drvtsion 3 of the Businessand t' 'es ionsC e,a drtiy bec',,cis
in or11 farce an /Y�/•
License CP s LiaN
Date Conwc
RESIDENTIAL;
❑SFDWL ❑ KITCHEN REMODEL
❑pDDIT10N F1 PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
PERMIT ISSUANCE. -
gPPLIANCGS-RESIDENTIAL
AR i1TECT5 DEC A'1'
I understand .,arms shall M1e used as pu ham" d,
PANELS
up TO 200 AMPS
❑INTERIOR El CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOLS
❑ BATH REMODEL/REPAIR (]DEMOLITION
Licensed Pmfessinnal
OWNER -BUILDER DECLARATION
1 hereby apron that 1 am exempt from the Contractor's License Law for the
following reason. (Section 703 L.S. HOstiness:md Professions Cade: Any city or county
which manner a Permit to construct, alter, improve, demolish, or repair any structure
201-1000AMPS
OVER 1001) AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUITIMISC.
prior to its issuance, also requires the applicant for such Permit o file a signed statement
that he is licensed pursuanuo the provisions of the Contractors License law (Chapter J
TEMP METER OR POLE MIST.
(commencing with Section 9000) of Division 3 of are Business and Professions Cole) Or
that he is exempt merchant and the basis for the alleged exemption. Any violation of
❑NEW BLDG/ADDITION ❑ DEMOLITION
POWER DEVICES
Section 7031.5 by any applicant for a pcmrit mhjms the applicant to a civil penalty of
not mom than five hundred dollars ($510).
❑1, as tatter of the property, or my employees with wages as their sole compensation.
will dome work. and the structure is nm intended omlTered for sole (Sec. ]614, Business
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
SWI MMI NO POOL HLECI'RIC
and profresjam Cade:'Ihe Car tmcmL. Licence Law does not apply ,, an owner of
OUTLETS -SW I'TCIIF.S-FIX'
NEW RESIDENTIAL F.LE'CTR
m
pPe ty who builds or improves thereon, and who does such work himself or through
his own employers, provided that such lntpovements are not intended or offered for
FT AREA SQ. FF
sele.If, hvoincomeballdit,umurprovement is sold withinoneyearo(completion, theSQ.
ownerbuilder will have the burden of proving that he did not build or improve for par-
pose of Sale.).
D
TOTAL:
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 9144. Business and Professions Cale:) The Contractors Li-
AUG 10 1999
D
cann, law does not apply to an owner of prnpeny who builds or improves thereon, and
who contracts for such prnjects with a contractors) licensed pursuant to the Contractors
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
License law.
❑ 1 sum exempt under Sec. , B & P C far this mason
ALTER- DRAIN & VENT- WATER (EA)
water Datc
WORKER'S COMPENSATION DECLARATION
BACK FLOW PROTECT. DEVICE
I hereby affirm mndnrpenaky of perjury one of the 0dlowing dealaratiore.
✓(� ��
DRAINS -FLOOR. ROOF.A
I have and willmainein a Cemficim of Conant mlGinsure for Workers Com Pen-
workas provided for by Section 3900 of the labor Cede, for the performance of me
for which this permit is issued.
STORIES
/
TYPE CONSTRUCTION
FIXTURES - PER TRAP
1 have and will maintain Worker's Compensation hormone. to, required by Section
3 (the labor ode, for mulafOmwna of the work far which this pormit isissaed.
My N'r' Ca t o mmmor comerend POlicy 44VVNN t0
Cams{,% Policy N:.:w v
GAS -EA. SYSTEM- INC. 4 OUTLETS
OCC. GROUP
APN
3
GAS - EA. SYSTEMOVER4(EA)
CERTIFICATE OP LXI?MFOON FROM WORKERS'
1-7
COMPENSATION INSURANCE
('Ibis sutinn need not be crnnplemd if the permit is (name hundreJ dollars S 1001
or less.)
GREASEANDUSTRL WASTE INTERCEPTOR
BUILDING DI VISION FEBS
GREASE TRAP
PLANCHECK FEE
SEWER -SANITARY -STORM EA. 2(KI FT.
Loy mythininthe Pey manner
nrso stolhe orkfor ma-ichthia perthe W rkent'Compn-ssued. [shot
not employ any pelpm in any manner so as m become..ubjea m the WorAers' Compen-
ENERGY FEE
WATER HEATER W/VFNT ELECTR
sation Laws Of California. Date
Applicant
GRADING FEE
NONCE I'O APPLICANT: IL aper making this Cenificme of Exemption.. You should
barren suhject on the Workers Compcnouion provisions of the Labor Code, you mast
WATI7R SYSTEIT TREATING
SOILS FEE
foMwhh comply with such pravisiom or this Permit shall W deemed revoked.
WATER SERVICE
CONSTRUCTION LIiNDING AGENCY
I hereby affirm thin there is a construction lending agency for the performance of
PAID
Dale Receiptq
NEW RESIDENTIAL PLMB. SQ, FL
the work for which all permit is issued (Sea 3097. Civ. C.)
TOTAL:
Lenders Name
Lender's AJdress
TOTAL:
1 certify that I have rail this application and slate that die above m(ormation is
BUILDING FEE
correct l agree to comply with all city and county ordini and state laws rclatingto
building consuraum. and hereby mulumile oncewamoves of thin city to enter upon the
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE
above mentioned property for intpcction empous.
(We) agree to save, indemnify and keep harmless the City of Common, against
PERMIT ISSUANCE
ELECTRIC FEE
liabihtiest,judgmenu. roots and expenses which may imany way.,rom agaimt.end City
in consequence of the granting of this permit.
ALTERORADDTOMECH.
PLUMPING FEE
APPLICANT U DERSTANDS AND WILL COMPLY WID ALL NON -POINT
so RCEREC 1140 / /O/ ^�
/',I A (�J( (/A•
AIR HANDLING UNIT (TO 10,000 CFM)
MECHANICAL FEE
AIR HANDLING UNIT (OVER IB,a(XICFM)
CONSTRUCTION TAX
Si t pI mdA7ontmctor Date
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION FEE
HEATING ON I'I'(TO I Wins) BTU)
Will the applicant or future hwildmg accupnnt store or handle humorous material
as defined by the Cupenimo Municipal Cole. Chapter 9.12, and the Health and Safety
Code, Section 25532(n)?
HIIATING UNIT' (OVER 100.000 BTU)
❑Yes
PAID
VCN'I ILAI'[ON FAN (SINGLE RLSIU)
Data Receiptq
Will the applicant or Tum building occupant use equipment Qu nr dMana which
tin hmardnus air contaminants u defined by the Bay Area Air Quality Management
vier?
❑Yes
BOILER -COMP GHP OR 100,000 BTU)
TOTAL
BOILER -COMP (OVER 100,000 ETU)
AIR CONDITIONER
1 have real the hazardous materials randmincnts under Chapter fi95 of the Call-
ISSUANCE D TE
NEW RESIDENT IAI, MECH, SQ. Fr.
famia HeoOh & Safety Cade, Sections 25505, 25533 and 25534. I unit mad IMI if the
huilAing oat ally 6ovculenant,thatitlsmyresMnsibilinym tiIf,M cupwt
s�
of th a 1st hich must he mel prior . issuance of a Ce Ore
V 41
ISSUED Y.
tun/ whoritt agun )am
TOTAL:
OFFICE