99090052 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL P d
.BUILDViIG DIVISION APPLICATION/PERMITF7—' ,"
PLUMB NG-MECHANICAL.
t I,s".tt 1'BUILDING PROJECT IDENTIFICATION If 4A'O,;!III HUILDING ADDRESS: SANI'1'AItY N0. API'LICA ON SUBMITTAL UATF:
OWNER'S NAME: PHONE: AAII'
_ e I( N/C CONI ROL p
CHI'I'ECTIBNGI etc.: LICNO S ` .��'ll ❑
W
CONTACT: PHONE: THol I .
❑ Consultant Fees Pard by Applicant(Initial) BLDG ELECT Ilq Uu /tAE¢H
LICENSED CONTRACTORS DECLARATION r { ) I j , 'r - n r !t -' ' ^( 11 ��rJ}FLE tt'(, �/ L�4//
I hereby affirm that l licensed J provisionsf Chapter 9(commencing QTY .{ t LLECfRIC PERMIT lilts (til{
p g t E. r) t r n {,:'i' I. d re' }{ .z I-4 JOB DESCRIPTION
FwoZ th Sut nn]000pd D' 3 Ith H dPo fe::' ns C,Me and my licensers ' RESIDENTIAL:
O nn fail forceand eflecr PERMIT ISSUANCE
CWF• (� ❑SFUWL ITCHEN REMODEL
t4UyD Limn I'cx APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
<� Dale ury C r r �"`� `�
V ARCHITF.Cf'SDECLARATION QIN. BY ❑MULTI-UNIT ❑STRUCTURAL
F�N PANELS
Z p y K 1 understand my Plans shall he used as public records MODIFICATION
OZrr� Oil 10 AMPS ❑INTERIOR El CHIMNEY REPAIR
F,t3"LW Licensed Professional 201-1000AMPS IMPROVEMENT (]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER I000AMPS
1 hamhy ❑BATH REMODIiI./RIiPAIR ❑I31iMO1.'1'ION
C a alEna Had 1 sen cse.gn fm rotlm Contractor's License Law far the
XOWU ❑0'ITJ13R
W 3 kr which requires
renes..(Seen....]1131 5,Ilaamcee and vet demolish,
Cada:Any city or SIGNS HI.EC I'RICAL
m which reyuims a permit In anosl lb aper,improve,1 ,air
1,or repay any structure
print m,itsi'mn',nl..r...... a;he applicunt loo—1 permiuo Elna signed statement SP1?CIAI.CIIICUI'I'/MISC.
that he is licensed pureummo the provisions sf rhe Contractors Licase Law(Chapnr9
�Cy QQ (commencing with Section 7000)of Division 3 of the Business and Professimn,C.de).r 'II,MP.ME?'1'1?It0RPOL.E?INS'll COMMERCIAL,
Q.q e p• that he is exempt therclin;n nnJ Em basis fnr the alleged exemption.Any violmian of ❑NEW BLDG/ADDITION ❑DEMOLITION
WILL,, Section]1131.5 by any applicant for a from,snhjems the applicant o a civil penalty of P0WER DEVICES El TENANT ❑FOOD SERVICE
Z
n,more than five hundred dollars($500).N IMPROVEMENT
_< O 1.as ownersOhc prnpeny.nr my employees with wages as their sole compcnsmion, SWIMMING POOL ELf:CIRIC
B
%F. ,hr gmcmm is not hmemdedooffered far sale(Su.]014, usiness ❑OTHER
W m M will do dic,ok,anJand Professions Cade:The Contractors License Law does not epPIY to an owner of D OfTTL[iTS-SW'I'TCf{F.S-FlXTURES
a3- property who builds or improves thereon.and who does such work himself or through
his own employees,provided that such improvements are not intended or offered fnr NEW RESIDEMIAL ELECTR S
sal,If,however,the building or improvement is sold within one year of completion.the SQ.Ery.F1,00R AREA ESQ.FI.
wner-buiWer will have the burden of proving that he did no,build m improve far pur-
pose f I )
❑ 1 z. ner ftp pr pent me clue IY tmc(nB wiNl sed t t rsm TOTAL /
consumer th project(Sc 7019 business and Ponfiev,sions Cooth,)TIN Contractors len
, �•ts I !'[-JIM' Pt FRM1I)I":' t ,- t ) t tlFEB' zcense Law class tapply t fprpcny hbildsa 'mprocrh and +u17771: t 'who contracts fir such projects with a conmnoRsllcensed pursuant to the Contractors t
,
License law. ' PERMIT ISSUANCE,
Ellam exempt rarer Sec. ,B&P C for Has recon
Owner Dole
AL'I BR-DRAIN&VENT'-WATER(EA) VALUATIONft O`
WORKER COMI'IiNSA'I'ION DECLARATION BACK PLOW I'HOTEC'I'.D O''/�, � o t.9 J
I hereby affirm under penalty of perjury one of the following deelam,ions:
I have and wit l maiman a Certilicum ofCossent sen self-insure for Worker's Camper- DRAINS-FLOG OF,AREA,GOND. STORIES '1'YI'P.CONSTRUCTION
saran,as provided for by Sector,37110 of the Lnbnr Code,for the Performance of the �
work for which this pernat is i isned. FIXTURE: 1'1?H'1'ItAP I Crue t
❑ 1 have and will mesion, Worker's Congetmaimn Innnarea,as required by SectionJ
3700(of 1hoI.mbotCn1,bar olImport'nnnam'c.f Nc am k for which this Permi,i,,rad. CAS ❑A.SYS'IUM-1 INC.4OUTLE9' OCC.GROUP APN
My wmwrar�nn,�nen,;t_I`;=.a-_n-.8mder amt rr,lier q nT -
CnriAT_ftEXC �- L1 Policy No.M AS-I?A.SY - li IEA) e C-',105-4
CIiRTI14CAT1?OP LXI?MPTION FROM WORKERS' ` _ P�
COMPHNSAIION INSURANCE GREASI%IN .TRL W CYT
(Thisseciien need not be complared if the pero
mit is for ne hundred dollars($1IX) ,II111.DIN0DI VISION FEESor less) - GREASE'III to ALANCHEGK PI?I?
I ccnifythat inthe performance of the work for which Nix permit is issued,(shall _
nst employ Imy penton in any nnanner so es to hecome object to Ne Workers'Compen- ] _ NERGY FEE
Z sonansl-aws.f Caldarem Dam
ZApplicant E I r GRADING FEE
to NOTICE TO APPLICANT.IL,her making this Carica,,of Exemption,you shoutA'1'ER SYSJT 'A'
become subject m the K'oder's Compensation provisions of the labor Code,you mm SOILS FEE
forthwith comply with such provisions or this Permit shall be deemed revoked. 'ER, ' s
0. 0
off. Z CONSTNUCI'ION LENDING AGENCY SM �� Dam M
V 0 Thereby affirm that is a construction lending agency for the perfnrtnancen
the work for which this permit is issued(See.3097,Civ.CJ
U Lend s Name - OTAL:
O L) Lend AMl AL 1 19991 can f dr t I tr ve read tM<a car on and sw¢that,he above infornat `UILUINGII;IJir pp 1r,." '
(A comet 1 g t ply with all city and county ordinances and state laws mlat g t Q I 1 MECHANICAL PERMIT +� 7 + r . } E�tsl 7
IJ Z building construction,and hereby authorize representatives of this city to enter upon the ..0 n ll' '. „t. , I. . 1 ante,'' 4
SEISMIC FEB
ahwe-mendonel property lin,inspection purposes. MIT ISSUANCP.
(We)agree tosaves indemnify and keep hvmdass the City of Cupemno ngninst ELECTRIC FEE
liabilities.judgment,costs and expenses which may in any way starve against said City N:TEiR 11'11 OfCH.
in consequence of the grunting A this permit. PLUM
APPLICANT UNDERSTANDS AND WILL C V WITH ALL NON-POINT AIR HANDLING ON["I'(TO 10.000 CFM)
50 .E REGULATIONS. MECHANICAL.Plili
0. AIR HANDLING UNI'I'(OVER 10,000 CFM) CONSTRUCTION TAX
.Ignatma of AppllamNLoataator ate EXHA1,1l100DWOLUCPI HOUSINGNIHICNOONIIT
HAZARDOUS MATERIALS DISCL0 RE
Will thenpplimnlin fuuuc huiWing n¢upam stare orhanJle hnrarJous mvtenel HBA'IINC IJNI'I'('T0IU0,111108'TG)
as deOnud by the Capertine Municipal Core,Chapter 9.12,and the Health end Safety
C,xle,Section 25512[u)p IIHA'DN0 UNIT LOVER IINLOW B'TU1
❑ye, 0 No
VI3N'I'ILA9'(ON PAN(SINGhIi RESID) PAID
Umc Receipt p
Will the applicant or future
ov building occupant use equipment or devices which BOIL FR-COMP QHP OR 1(X),(101 BTU)
,if haralloux uir nmwminams ns refined by,hc Bay Area Air Quality Management TOTAL:
isuict] ROILER-COMP(OVER 11111.0011 BTU)
E]y" ❑Nn
I have read the hrandetx rwmrials remrannems under Chapter 6.95 of,ha Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety C de,Sections 25515,25533 and 25534.1 understand that if the NEW RESIDENTIAL,MECH. SQ.FT.
Im ing does mot caltly have a tenant.th; smy res nsibtltty m art Be occupant
thereyuircnunnr t met prior Ceardf a ofA
raindami,ed ages e 1 TOTAL-: ISSUF.D9 l
OFFICE