99100161 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY — -41--Qq 1 —
CITY OF CUPF.RTINO BUILDING-ELECTRICAL PERA T
IRMI
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MF:CBANICAL SOOOI
BUILDING
PROJRCI'IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPIJCAUON SUBMITTAL DATE
IU
OW 7iR'$N MF.: PHONE: C NI'kAC/I'OR'S NAMIi: /� LIC NO
-5 l —1 V x% 33 I WC CONTROL«
ARCHITECTIENGINEER: LIC NO. ADDRESS: ' I/ 1 ( ❑
CONI'ACU PHONE: :2-'2,- J BUILDING PERMITINFO
o� 9�2 730 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PIAMR MECCH
LICENSED CONTRACTOR'S DECLARATION QTY, ELECTRIC PERMIT FEE
1 hereby alern mm I am rcca.ad mader prwldors of chapter 9<cummeodmg JOB DESCRIPTION
CCz,
with Prol'aasiorx Cdc,amdmy license is E
W O0 w I'IikMIT ISSUANCE WL I]KITCHEN REMODEL
F nfuillom,mideffccl. GG``j�
<UU License s G`3 Lic.p �n^'-�� APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
y 6 Dam Comm
F.71a ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
z OyZ lundeeaand my plans shut]he used aspuhlic records MODIFICATION
�O UP'102W AMPS ❑INTERIOR ❑CHIMN17Y REPAIR
P Lntw Licensed Professional 201-INM AMPS IMPROVEMENT E]SWIMMING POOLS
G E-4 OWNER-BUILDER DECLARATION
Ck � OV ER IOOOAMPS ❑BATHRF DELREP R O EMOLMON
at C< 1 hereby aRnn that 1 am exempt from the Commerce's Licenx law for the
iWyi5S I,U following reason.(Section 7031.5,Business and Professions Cat,:Any city or county SIGNS ELECTRICAL ❑OTHER
I++a a.y which mqufres a permit to construct,alter improve,dcmollsh,or repair nay stm ism
0C. poor u)iL ismance,al.so requires the applicant for such Permit to file asigned statement SPECIAL CIRCUI'
in.,he is]teemed pu throo m the paskions of the Contractors License Low(Chapter 9
�j 6�'p0 (commencing with Section]1X10)of Oivision3ofthe Nusiness and Pndessions C�de)or TEMP.METER OR POLE COMMERCIAL:
6q75 e y that he is exempt therefrom and the Insists for the alleged exemption.Any violation of ❑NEW BLDGIADDITION ❑DEMOLITION
W^h
Section 7031.5 by any applicanlfor a Permilmklpets thovpplicamnn u civil penahy ol" POWER DEVICES El TENANT ❑FOOD SERVICE
not more Than five hundred dollars($51X1).
Z} OTHERr 6C IMPROVEMENT
_< 0Lusmwork,the pmpeny,or myemployces withwagesmlhei(Sm.compensation, SWIMMING POOL ELECTRIC
W Fq.,� will do thework,and the he ctingCont is norintended oroificiread wdoes not apply to
owneBusr of ❑OTHER
L5� and Professions Crate:The Contractor's License Low Vas not apply m an Ron
owner of OUTLETS-SWITCHES-FIXTURES
properly who builds or improves Thereon,and who Jews such work himself or Through
his employers.provided that h' p cm tintended r BercJ Ior NIiW RF.SIDEN'1'IAL ELECTR SQ fT.
ole If however.thebuilding improvement IJ Iti y f n D SQ. RARG 95Q.FT.
txllJ ll have theWhich f poising that I did t Iw IJ
f: la flh P pertY am x I IYcontracting wit 1'en: OCT 2 1999
suuu Lha pr jar(yes 7M4,Business cad Profession,C de.)11 e L hour,m a L
cense Luw Jas our apply loan owner of property who builds m improves th J TMIRM T FEE
whacontmctsfnrsuchpmicrs withucomonatOO liccmaptersuaa ))I
0nlha Co rah
License Law. I�
0 1 am exempt under Sec. .B&P C for Ih By
N1IER-DRAINde B TF.
Owner Date
WORKER'S COMPENSATION DECLARATION Bq W //-yelp
I hereby entero under penally of e perjury,one of the following Je /
�(]Ihave and will maintainbyerimr.17Ne of theLaor Coe,fortfor Ws rw S R. .AH STORIES TYPE CONSTRUCTIOF
xminn,as provided fpr by Senior 7]W of the Lehn Code,for the perfinmonm nl the
work for which this permit is issued, Irl%'TURF.$-1'IiR TRAP
1 have and will ode,fi maintain Workers Compensation rkfor hi m required by S mad.
37W of the Labour Code,fonhe performance of Ne work for. chis pemdt hammed. CAS-EA.SYSTEM-1 INCA OUTLETS OCC GROUP AI'N
My Workers Cpmpeneation Insurance carrier and Policy number arc:
Cartier: Policy No.: GAS-EA SYSTEM-OVER4 MA) ` L7
CERTIFICATE Of EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUS'IRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
('Deis section need not becompleted if Ne permit is forone hundred dollam($I00)
m less.) GR BASE TRAP P1,ANCHECK FEE
I certify that in the pertomethreofma work far which this panni]is issued,l shall SEWER-SANITARY-STORM EA.2W FF
nm nuPloyl y pc rape many mar"',e,,asrobecpamsubjer,to the Workers'Conlpen- ENERGY FEE
0z s0ion lawsoNGlifnmiaD WATER HEATER WINENTRLECTR
z � ApplicanlT .e./ 5 GRADING PER
.N. NOTICE TO APPLICANT:If,after asking this Certificate of Exemption,you should WATER SYSTEM/fRBAD NO SOILS FEE
f Gxome subct m jethe Workers Compvnmtiaa provisions of Ne Labor Code,you most
forthwith comply wah.mehpmvisionsor this permit shall Im deancJ revoked, ( WATER SERVICE
:Dz CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID Dec Rm<iprp
V 0 l hereby a0hm that is o consnmction lending agency for perfommnce of
H the work for which this permit is issued(Sec.3097,Civ.C.)
04. Lenders Name TOTAL:
1 Lender's re
Address TOTAL: BUILDING FEE
I certify that 1 have ad this application and swat Nal the above information is
h correct.l agree to comply with all city and county ordinances and state laws relating m QTY. MECHANICAL PERMIT FEE
V z buildingcanswction,and hereby uwhorin representatives ofthis city to enter upon the SEISMIC FEE
arrive mentioned property for inspection purposes. PERMIT ISSUANCE
(We)aa.lo,;mc,and, thy mW hanks,keep hmless the City rf Cupertino vguinst ELECT RIC FEE
ti Iiabilities,judgmenls,coswand expemms which may in anywayaceme against said City ALTER OR ADD TO MECH.
in mm ssf cnce of the granting of This permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
MECHANICAL
gOUkC(gREGULATION�.SY�/ / FEE
/O AIR HANDLING UNIT(OVER 10.0)(10 CFM) CONSTRUC"1'ION'AX
Signature dApplicanUCono em ! I Oare I EXHAUST HOOD OMMUCT) HOUSING MITIGATION PER
HAZARDOUS MATERIALS DISCLOSURE
Will the applicnnlorfuture building rccupansmre or handle hazuNoesmmmial HEATING UNIT(TO 100.0110 BTU)
C...
Joined by the Cnperino Municlp:J Cnde,CNlpmr 9.12,and the Health and SlRcty
ndc,Section 25531[u)'! Ig�N/,� hIIiA'1'ING UNIT'TONER IIXI,IIIXI BTU)
❑ 10 r a
Yes i" VENTILATION FAN(SINGLE RPSID) PAID
Utak Receipt p
Will the applicant or future building occupant use equipment or devices which BOILER-
-mit W.Afma air contaminants us dafmcdb the Bu Area Air Quality Management COM P(3 HP OR I NLOW BTU)
Y Y Y 6 TOTAL.:
District 1 BOILER-COMP(OVER I00,0N)BTU)
❑Yes X.
I have randrhe hrrardom materials requimm
m �ts make Chapter 6.95 of dm Cali- AIR CONDITIONER ISSUANCE DATE
fomia I{ealth @Safety CWe,Senium 25505,25533 and 25534.1 understmd that if the NEW RESIOENTIALMECH. SQ.FT.
building docs not currently hove a tenant,that it is my resprmeibility Ip notify the osteoma
of I1��ryrremf nu wh'�l��nyyln be mm prier m issuance ads Ccrtilicme f Occu
Owner or amthorz agent
.are TOTAL: ISSUED BY:
OFFICE