99110037 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICALS_
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IIIENTIFICATION
BUILDING��,. N � �J ar SANITARY NO. APPLICATION SUBMITTAL DATE
OWN MB PHONE: CO R CfOR'SAME: LIC NO O
S U v S.L1. / N/C CONTROL N
'H1T'EC'VENGINEER: CJ`/ LIC NO: Ap R SS: ❑
A JF
Co
L �s PHONE: (,, ' BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT P I) MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby aRlnn Nm I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
O0Z wish Smion]000)of DivisinnJof Ne Business and Professions Code,andm license is
uIOO y PERMIT ISSUANCE.
F in full force and eRro9 2 O " WL ❑KITCHEN REMODEL
aUV License loss ✓✓ LiaN APPLIANCES-RPSIDENTI AL [I ADDITION [I PLUMBING RE-PIPE
yL Dam Co.
ARCHITECTS DECLA ATIO /.(,' El MULTI-UNIT []STRUCTURAL
z p n z I understand my plans shall be used as public recons PANELS MODIFICATION
OZ—Q UPTO200AMPS El INTERIOR [I CHIMNEY REPAIR
;:4tw Licensed Professional 201-IOWAMPS IMPROVEMENT (]SWIMMING POOLS
< X` OWNER-BUILDER DECLARATION
P4g"' OVER 1000 AMPS ❑BATH REMODEUREPAIR [I DEMOLITION
I
hereby affirm ohm I um exempt from the Contrndor's Licens sew fm the
�o5O6 U following reason,(Seat..]031.5,Business unit Professions Code: city or county SIGNS ELECTRICAL R
t++3 u,y which m uims a .it to construct,ager,improve.demolish repair any structure
y� prior to its issuance,also rtquimsthe applicant for such pe to Eleasigned statement SPECIAL CIRCUR/MISC.
} shat he is licensed pursuemmthe provisions of the Co cors license law(Chapmr9
GC (commencing with Section](Xlfq.f Division J.ft maressand Professions CodOor TEMP.MET ER OR POLE IN COMMERCIAL:
that he is exempt therefrom trod 1M1e basis for alleged exemption.Any violminn ar [1 NEW BLDGIADDITION DEMqWTtK
Ii+CI WN Section]031 S by any opplinmt fora perm' .ubjects Ne applicant to a civil Penalty of LOWER DEVICES []TENANT OD SERVICE
t more than five hundred dollars(S5 IMPROVEMENT
=6 ❑Las owner of the pmpeny.mmy ployarwiN wagesssoheirsole compensation. SWIMMING . 'LECTRIC
0 wJl do the work.and Ne smuchim i otimcndcd aroBemlfnr ole(Sec.]014,Business []OTHER
1 and Professions Cale:The C. toes License Law docs not apply to an owner of OUTLETS- ITCHES-FIXTURESoe
propcny who builds m imps es shererm,unit who dres such work himself or through
his own employees,pmv' d that such in
are not Intended or offered for NEW IDENTIAL ELECTR SQ FT
ZIf. or improve for pur-
le.1.
rwnethe propcny,am exclusively contracting with licensed contractors to TOTAL:
th roject(Sec.7(J .Business and Professions Liam)The Cotractors Li-
decsnotapplylounowner.fpr.peny who builds nr Improves thcrcnn,and QTY. PLUMBING PERMIT FEE
zactsfor such projects with a contraemr(s)licensed pursuantto the Contmcmrs
aw. PERMIT ISSUANCE
exempt under Sec. .B&P C for this reason
ALTER-DRAIN&VENT-WATER IEA) VALpATION
Date Zr�
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICEf1f
40 1 1 hereby anion under Penalty of perjury,one of the fullnwing detlaratimi '
❑I have and will maintain a Certificate of Consent to self-insure for Workers Compcn- DRAINS-FLOOR.ROOF,AREA.COND. STORIES TYPE CONSTRUCTION
sation.as provided for by Section 3700 of the Lahor Code,for the perfortmmce of the
2war for which this permit is issued. FIXTURES-PER TRAP
have and will maintain Workers Compensation Insurance,m required by Section
] .life Lubar Cale,for the peromarace of the work for which this permit is issued. GAS-EA.SYSTI?M-d INC.40UTLETS OCC.GROUP APN
MyWCamerrker m .nn U�PWr1P Pal cy NoY nulnb����i!_" /-
oro pensa Jalorance ISS 5,< GAS-EA.SYSTIiM-OVER6(GA) 55
_01704,7
j�CEERRTIIF�IC/ATTE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE ORGSFIINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(This section need not be completed i f the Permit is for one hundred dollars IS l lift GREASETRAP
m Icss.l PLANCHCCK PEE
I certify that in the performance ofthe work for which this Permit is issued,l shall SEWER-SANITARY-STORM EA.200 Fe.
not employ any person in any manner so as to become subject m the Workeri Compero ENERGY FEE
Qz smion Laws of California.Data WATER HEATER WNV, IF.LECTR / GRADING FEE
Z 2 Applicant
N NOTICE TO APPLICANT:If,after making this Campania of Exemption,you should WATER SYSTEM/TREATING SOILS FEE
ai become subject t.the Worker's Compensation provisions of the Labor Code,you must
fnnovint comply wild bprovisions or Nis permit shall be decreed revoked. WATER SERVICE.
Uj
Q
7 z. CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,IT PAID Data ReceiptN ,
Ll I hereby affirm that there is a construction lending agency for the performance of
Hthe work for which this permit is issued(Sec.3097.Civ.CJ
Lender's Name TOTAL:
0 U Lenders AJdress TOTAL: BUILDING FEE
certify that 1 have read Nis application and state that the above information is
V) correct.I agree m comply wish all city and county ordinances and some laws relating m QTY. MECHANICAL PERMIT FEE
V Z building conswetion,andherebyauNnrize mpresentabvesof Nis city toenrerupon the SEISMIC FEE
► above-mentioned propcny for inspection purposes. PERMIT ISSUANCE
(We)agree to sive,admin fy and keep harmless the City of Cupertino against E IC FEB „j
Iiobilitics,judgmenu,costs and expenses which may in any way accme against said City ALTER OR ADD TO MECH. P o NG FEE
in uquena.rthe granting of this permit.
APPLICA UNDERSTDSA WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'f(TO10,tX111CFM) M I{AN E g 199
SOU/R)C.R iGULATION R7Z- ii
�1 $1 AIR HANDLING UNIT(OVER 10,000 CFM) C TRUCTION TAX
Sir.amm idApp� L�i et/ mitmemr We EXHAUST HOOD(W/DUCT) H SING MITIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding occupant store or handle haurdous material HEATING UNIT(TO 100,1300 BTU) . .. ...._.
as defined by the Cupertino Municipal Calc,Chapter 9.12,and the Health and Safety
Cade,Section 255J2(a74 `�/^, HEATING UNIT(OVER 100, TU)
p Yes / VENTILATION PAN(SIP.RESUH PAID --
Data ReceiptN
Will the applicam or future building occupant use cquipmeno or devices which BOILER-COMP(3 OR 100,000 BTU)
mit haramous air contaminants as defined by the Bay Area Air Quality Management TOTAL:
District' XRHIDEWIALMECH.
(OVER 100,000 BTU)
ZI YesX.
I have read Ne hazardous materials requirements under Chapter6.95 ofthe Cul,- IRER ISSUANCE DATE
form ulsh&Safer Cede,Sections 25505.23573 and 25517.1 undersmnJ Nat if Ne SQ.P.
but in d«snmau ily aestenanLNmitismyrrs nsibilitymnodfyshe«upant
of nt a 12ust be met prior m iesuame of a Cen,Benof
/u
m
tTOTAL: ISSUED 13 Y.
OFFICE