99100113 (2) ..APPLIOANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL 1 E IT O.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL SOOOI -
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
/ 9 5) h
NER'S NA E: PHONE�TA
RACTORSNAME: LIC NO'.' RIC CONI'ROLg
ARCHITCCIIENGINEER: NOESS: ❑
ONTACT: PHONE: 6UILDING PERMIT INFO
rf .Z was sJ"11 3 ❑ Consultant Fees Paid by Applicant(initial,) BLDG ELECT PLUMB MCC"
V-r`f J �-- 6-35-7 z]/ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions Of chapter 9(enmmene'mg JOB DESCRIPTION
Q9z with Section70Ua)of Divixion3n'the Businessand Professions Code.and my license is RESIDENTIAL:
FSS in full f^ crump effect. PERMITISSUANCE ❑SFDWL ❑KITCHEN REMODEL
Out License Class Lie.# APPLIANCES-RESIDENTIAL. ❑ADDITION ❑PLUMBING RE-PIPE
F W Date Cl mmemr
ooa ❑MUITI-UNIT El STRUCTURAL
qDm ARCHITECTS DECLARATION PANEL$
Z O Vj Z 1 understand my elan,shall be rasedos public mord MODIFICATION
OZ—� UPT0200AMPS [I INTERIOR ❑CHIMNEY REPAIR
Fa N.kr� Licensed Professional 201-10MAMPS IMPROVEMENT E)SWIMMING POOLS
C Y�, OWNER-BUILDER DECLARATION OVER IDOAMPS OTHER
EJ REMODEIIREPALR ❑DEMOLITION
M
C 6 I hereby affirm that I am exempt from the Commctors License Law for the
?;O U following reason.(Section 703 L5,Business and Professions Cale:Any city initially uSIGNS ELECTRICAL
^uJ 3 t� which requires a permit to con.wel,alter,improve,demolish,or repair any structure
a, prior to its issuance,also requires the applicant l or such Permit o file a signed statement SPECIAL CHIC I I'IM1SC. �O
thatheislicensedPa....,OtheprodsionsoftacConlmnorsLicenseLow(Chvpter9 COMMERCIAL' r
Wp;p0 (commncingwith Section Vf100)uf Division3ofthe Business and Professions Cmde)or TEMR METER OR POLEWSt.
Q, o y that he is exempt therefrom and the basis for the alleged exemption,Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
t� Section 7031.5 by any.,Pat.,nor.permit subjects lbcapplicannon civil Perulty of POWER DEVICES EITENANT El 1700D SERVICE
F Z Y ^I m ire Lha^five hundred dollars($500). IMPROVEMENT
EC .owner ofthe property,or my employees with wages as their sole compensation, SWIMMINGPOOLELECf
yy� will do ework,and the structure is not intended numbered for sale(Sec.7044,Business ❑OTHER
and Pmfossions Code The Contractors License Law does not apply nm rut owner of OUTLETS,-SWITCHES-I'IXT L
d 3 property who build or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended me Rered for NEW RESIDENTIAL ELECTR SQ
sale.If.however,the building or improvement is sold within one year ofcompletion,ae SQ.FT.FLOOR AREA SISQ.FT.
enhuilder will have the burden of proving that he did not build or improve lin par-
, pose of Bala).
�,as owner of de Fropeit,am exclusively contracting with licensed convectors to TOTAL:
oostrun the project(Sec.7014.Business and Professions Codon The Cmamwmrs Li-
censeLowdoesmAupplytoanownerofpro,my who builds or improves thereon,and QTY. PLUMBINGPERMIT FEE
who contract for such projects with a contusions)licensed pursuant um the Contractor's
License law. PERMIT ISSUANCE
Elam exam
crSec. .B&PCfor this reamn
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Uma roc
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE 2 /O Jt o b
I hereby affirm under Penalty of perjury one of the following declarations: �J Cl
[have and will maintain a Certificate of Consent to scl-iname for Worker's Compcn- DRAINS-FLUOR,ROOF,AREA,COND. STORIES TYPE CONSI'RUCUON
tion,as Provided for by Section 37M of the Labor Code,for the performance of the
irk for which this pilon is ixmi FIXTURES-PER TRAP
1 have and will maintain Workers Compensation Imuance,as reAimed by Section
379)ofthe Labor Code,for the performance ofthe work for which this Permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP �(S APN23
My Worker's Compensation Insurance carrier and Policy number are:
Cartier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF SATIO INN FROM N WORKERS' 44
GREASEINDUSTRL WASTE INTERCEPTOR
COMPENSAt10N INSURANCE BUILDING DIVISR)NFEES _
(This section need not he completed i r the permit,,Immne hundred dollar,(S 100) GREASE IRA]'or less) i'LANCHECK FEE
I ceralf drat in the performance ofthe work(air which this permit is issued.ishan SEWIiR-SANITARY-STORM EA.2q)Fll
not employ any per ost in any moaner so as to become subjects.the Workers'Compen- ENERGY FEE
OZ sation Laws of California.Dote WATER HEATER WIVENTIELECR GRADING FEEZ 2 Applicant
fA
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTEMOREM INE
F
becomesubjectm the Workers Compensation provisions of the Labor Cade,you must SOILS ME
from,im comply with such provisions or this permit shall be deemed revoked WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMH. SQ.Ff. PAID Dam Receipt#
Q Iherehy.91cm thephere is a comuuction lending agency for the performance of
the work for which this permit is issued(See.3097,Civ.C)
L U Lender's Name 'TOTAL:
Lenders Address TOTAL: HULLOING FEE
1 cenify that I have read this application and state bathe above information is
as (�/1 corma.l agree to enmply with all city and co..lyordi^anecsandsmtelawstclmi^gm QTY, MECHANICAL PERMIT FEE
V Z building construction,and hereby nathortee representatives of this city to enter upon the SEISMIC FEE
above-mentioned property for inspection purlwus. PERMIT ISSUANCE
(We)as=to save,indemnify said keep hamless are City of Cupertino against I?LECTRIC FEE
liabilities,judgments,costs and expenses which may in any way eceme against said City ALTERORADDTOMECR
PLUMBING FEE
in consequence of the graming of this permit
APPLIC AT UNDERSTANDS AND WILL COMPLY WITII ALL NON-POINT AIR HANDLING UNIT(TO 111.000 CFM) MECHANICAL FEE
SOU iI
EGULATIONS.
AA 0— -- - �f'. / 119/2/( AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
l6ign ureof ppe U Contractor �Qii""ftlJ'g'!/! 7� Da�� EXHAUST HOOD ONMUCT) HOUSING MII"]CATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will Ne applicant or future building occupant store orleandle hloosims material HEATING UNIT(TO 100,000 BTU)
as dclined by the Cupeni^o Municipal Code,Chapter 9.12,and the Health and Safety
Cods.Section25532(x)^ HEATING UNIT(OVER 100.(W BI U)
EYes Po VENTILATION FAN(SINGLE RESID) PAID Uam Rtteiptp
Will Ne applicant or(mum building occupant use equipment or devices which BOILER-CUMP(3HPOR 110,0008N)
emit harmdous air comm�iinants as dclined by the Bay Area Air Quality Management
District? 'I(YI'AL: v
❑Yes �No BOILER IUO,(00 BTU)
I have reuJ the harudws mamrials requirements under Chupmr E95 of1hc Celi- AIRCONDI'NONER ISSUANCE DATE
(.ruin He W&Safety Code.Secdom 25505,2553]ud 25534.1 undersand amt if Ne NEW RESIDENTIAL MECH. SQ.1q.
bui senor cnrrendy lwveqq44 t,thvt it is my tesponsibiliry to notify the occupant �/y--C
n q mtmnrs wye�taynre res tpmr toiasmam raeeninem �9 c�
trot u u gens to TOTAL: ISSUED"BY:
OFFICE