99080197APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY 9 "10 'kin-1 cl
_ �/ r OFFICE
CITY OF CUPF.RTINO BUILDING - ELECI RICA],
PERMIT NO
-
WILDING DIVISION APPLICATIONIPF.RMIT PLUMBING - MECHANICAL
pl- x;;xa] "%" BUILDING PROJFCI 'IDENTIFICATION(r1;•t_Sid':f
allow
BUILDING ADDRESS:
SANITARY NO.
AP LICA'1 ION SUBMITTAL DATE
OWNER'S NAME: PHONE:
C( IRpC'FORS NAME. NO:
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CONTROLso
C EC'PHISGINEER: I.IC NO',
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ADDRESS.
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mTAM: PHONE:
'x' /+Ai':- 1i1,'BD7LDINChI'ERMIT INFO -, •xl,'1 ,; ;: ;'
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Consultant Fees Pa by Applicant (Initial)
BLDG ELECT PLUMB MECI I
❑ � ❑ ❑
LICENSED CON IRACPOkS DECLARATON
1 hereby arum that 1 licensed d p - f Chapter 9 mTomme s
with Section 71000) of Division 3ofthe lux d rf" Cul•md mylw
/, ^
in flllforce and cff,,u ;7 U' �
License�I.ic.k
Dam anmanx, _v
Q TY
;l ' rELECTRICxPCRMIT ,// 1 1f 1
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1`. FEEL Up'
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JOB DESCRIPTION
RF. IIAx'
❑SFDWL ❑ KITCHEN REMODEL.
❑ADDITION El PLUMBING RE PIPE
❑MUCD -UNIT [_1 STRUCTURAL
MODIFICATION
[I INTERIOR E3 CHIMNEY REPAIR
IMPROVEMENT E] SWIMMING POOLS
F1 BATH REMODFUREPAIR ❑ DEMOLITION
❑ OTHER
PERMfr ISSUANCE:
APPLIANCES- RISIUF.NTIAL
RCHrrECI'S DECLARATION
1 nJemm�J my plans shall6c u.ad ax public records ��C
Licensed Prufc..innil
OWNER - BUILDER DECLARATION
hereby affirm that 1 am exempt from the Conh'aner'x Idccnxe Law fur the
following reauon. (Section 9031.5, Rosiness and Profession Cade: Any Illy or county
which requires a permit to conxuuct, alter improve, demolish, or repair any xlruemm,
prior,, is isrvance.alm requires the ap,llwnl for such permilm fileu.igned.lmemmal
that hu is licensed pursuant o the provisions ofthe Contractor's License Few (Chapter 9
(commencing with Section 7000)of Diviumo 3 ofine Business and PmPosmen, Qxle)ur
_
PANELS
UPT0200AMPS
20140NAMPS
OVER IIXp AMPS
SIGNS ELECTRICAL
Slrl'.CIAL CIRCUI'I'MISC.
2
TEMP. MI LEE OR POLE INS,
COMMERCIAL:
P., o C
n
1-�G
O
W52
d 3 -'
Ilml he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section WU 1.5 by unyulmlieant[ nrapennil suM1leed the applicammn civil penalty of
, are than Eve hundred dollars ($500)
CI 1. as owner of the property. or my employees with wages as their sole compcnssinn,
willdothe work, nndlhcstruamrelsam intended orolTered fmmJc(SCC 9044, Business
and Rofcssions Cade: Ty, Cariracmrs License Lw does not apply to an owner of
property who builds or improves Ihemon, and who does such work himself or through
❑ NEW BLDG /AUDITION ❑ DEMOLITION
❑TENANT E3 FOOD SERVICIi
IMPROVEMENT
E3 OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES- FIXTURES
his own employees, provided that such iminvocmems ore not intended or offered for
sale, If. however the building or improvement is sold within one yearofcompletinn .roc
NEW RESIDEWIALYLECTR SQ PP.
SQ, FT FLOOR AREA
$/SQ. W.
owner builder will have the burden of proving that he did not build or improve for pur-
pise ofsme),
❑ I, as Tow net of the property, am exclusively contracting with licensed contractors a,
,
TOTAL,
consumer the project (Sea 70,14, Business and l mfe .' : C ale) The Commetor s L
s la due, nt apply an owner nip pe ty n Id, or'mpm,o, me
who contracts for such projects with a cxntrcmr(.$) licensed pursuant to the Contractor's
.
1, .-
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i .i -/ ; t u , xt- ,l.f-
{ �PLUMBINC PPR
., •e:.
f1. I'FF'j
FLESH F ISSUANCE
Licene [a,
C] I am exempt under Sec. ,B& 1' C liar this reason
I r Doe
ALTER - DRAIN & VENT - WATER (EA)
VALUATION
Al
WORKER'S COMPENSATION DECLARATION
BACK FLOW PROTECT. DEVICE
I hereby atOnn under penalty of perjury one of the following declarations:
D RAINS - FLOOR, EDGE, AREA. COND.
Ihave and wil l maintain a Ccnlficate of Clinical ulfornae for Worker's Compiler-
as provided for by Section 39111) of IM Iahnr Code, for sun performance of the
STORIES
TYPE CONSTRUCTION
or to, which this permit is issued.
FIXI USES -PER TRAP
i] I have and will maintain Workers Compensation Insurance, as required by Section
3700 of the laoor Code, tor perfortence of the work on which Ibis Permit is issued.
My Workerla CangmnsSionhtsuntnco, carrier and Policy number arc:
Cartier: Policy No:
GAS - HA. SYSTEM -I INC. 4 OUTLETS
OCCGROUP
APN
�7 /
3S /
GAS - GA. SYS'IEM- OVFR4(EA)
CERTIRCAI'E OF EXEMPTION FROM WORKEI25'
COMPENSATION INSURANCE
(Tties section need not b, completed Tme perm is for one hundred dollar, CH 0)
or 4:..)
GREASPJINDUSTRI . WASTF, INTEItCBI'TOB
• DIVISION FEES '
GREASETRAP
vBUILDING
PLANCHECK FEE
I certify thwln the pedurnnmecofmc work GnwhieL lhispennit isisxued .[,hall
not employ any person in any number so as to become subject to the Workers' Crimper-
SEWER - SANITARY - STORM FA. 200 FT.
ENERGY FEIi '
WATER HEATER WNENTIELECTR
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scion Laws of California. Dale
Applicant I
GRADING Fill.
NOTICE TO APPLICANT: If, after making Ibis Ceinfica a of Exemption, you should
heartne subject m me Workers Compensation pravi,ioras of ale Labor Code, yon must
fonhwilh cmnply with such pfovisiens or this permit shall be Deemed looked.
CONSTRUCTION LENDING AGENCY
Ihemby affirm thnl d¢me ixaemmxlmnlnn lending agenu forme Inmwnco of
y per'
the work far whlchmis pemmt ix issud(Sem. 3099, Civ. C.)
Lenders Name
WATER SYSTEMoTRPTI,NG
SOILS FT.E... s.__...
WATER SERVICE
1. u
PAID
D r �e -" Receipt
IJam
I
NEW RISIDESDIAL FINE, SQ. FY
�" Al.
AUG 2
L.endcrs Address
-
QTY'
TOTAL:
MECHANICAL, PERMIT`•' `
'::[.
or - r
T +;a'FEE.:;
BUILDING FEE
I certify met I have read this npplication and state that the above inforramom is
correct. l agree m comply with all city and county ordinances a ad smm laws reluingm
building construction. and hereby amberlae representaivex ofthls city to enter upon me
ISE I11C PEE
PERM IT ISS DANCE
-
LLECTRIC�F!E"�'_ -�-
da vo-memumed papery forin.pr,l i proposes.
(We) agree ,, save. indemnify and keep moment the City of Cupertino against
ALT ER OR ADD It) MITCH.
PLUMBING FEE
liahilities. judgments. costs and expenses whiclm may in any way acrneugain.l cam City
In annseyuence of mu granting n1' Ihix pennil.
AIR HANDLING UNIT(TO 10.000 CFM)
MECHANICAL LEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATE S. q
i GI rF 9
AIR HANDLING UNIT (OVER IB,IXIO CFM)
CONSTRUCTION TAX
pp- Con or Date
HANZ RDOGS MAZER LS DISCLO URE
E:KHAUS'P HOOD (W /DUC'1)
HOUSING MITIGATION FEE?
Will theapplicaut futurchuildi cupum store or hnndla huenrdnus mamrial
HEATINGUNIT(TO100,00(i
as Defined by the Cop anar.' a Code. Chapter 9.12, and the Health and Safely
Cade. Section 25532(u)'! /// ///
HEATING ON] '1'(OVER 100.000 BTU)
���
i]Yet No
Will the applicant Tor ibt re building occupant use a rent Tor dvwiees which
Pp goo` 1 9mP
tit hbzmdous air eo ant or to, os uilding by me nay Are Air Quality Make, which
smIIT ��� ��,
❑ Yes ' 1<1—
^rdous'
PAID
VENT I IATION FA N(SING LE RESID)
Dec Rmeipt %
BOILER - COMP QHP OR 100,00E BT U)
TOTAL_
BOILER - COME(OVER 100,(1(10 BTU)
AIIt CONDITIONER
1 have dad the Ccore. us materials requirements under Chapter 6.95 of the Cali-
famia Health
nsi c. Codovea tions255B5. is myrmd'5534.I Undem:md that irate
building does nmcu uv utenunt, own it is my respnaihiliry (to nmifyt coaeupam
ISSUANCE LATE
NIiW RLSIDF:NI'IAI. h1ECll. .5Q . >L
w
oflherequircme nor tN�mou ph enificat '� e
l
Owner or path nri enl G
'
TOTAL:
SSUED BY:
_ �/ r OFFICE