99110064 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUII.DING-ELECTRICAL N
BUILDING DIVISION APPLICATION/PERMIT PLUMBING'MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRFSS: SANITARY NO. APP N. BMMALDATE
803 ALVaS ID
(WNER'S NAM17 I PHONE: C(IMRACTOR'S NAME: LIC NO,
/� d _ 68� A _I N/C CONTROLM
II'TECI'/ENGINIEER: Lie NO: _z3 AD�DRCS�S,10 L.M� ❑
//II(.��'CQI S-A3
TFACF: PHo F� BUILDING PERMIT INFO
41� ❑ Cansaltant Fces Paid by Applicant(Initial) BLDG ELECT PLUMB MECIi
f i Pa 218' 1865 LrJ� LTJ( ff- Com/
LICENSED CONTRALTO ECLARATTON QTY ELECTRIC PERMIT FEE
I hereby affirm that l am liamed under provisions of Chapter 9(commencing JOB DESCRIPTION
FWOZ with Se(ia.Y[glgofD,,ixi( Sof the B.,inew'sand rade......Cod",andoty Ramse is RESIDENTIAL:
12 infui'liameand effect. PERMIT ISSUANCE
X a'F, ❑SFDWL ❑KITCHEN REMODEL
aUU Licen.w Class Lica 0 APPLIANCES-RESIDENTIAL ❑ADDITION F)PLUMBING RE-PIPE
z kill N Q 6 UatP Cnnl2Qnr vv
FU,� ARCHITECT'S DECLARATION PANELS [I MULTI-UNIT ❑STRUCTURAL
Zp,AZ 1 umleramid my plainshall beused as public records !I MODIFICATION
(JUP TU 2W AMPS El INTERIOR ❑CHIMNEY REPAIR
f7_F'j Lc e I 201-1000AMPS IMPROVEMENT SWIMMING POOLS
„� W U fill so
If
m 3 )t an I' ss hY SIGNS E�ECTRIGll. El OTHER
El BATH RESIDUE ❑DEMOLITION
W 31+-H which requires a permit to<omwcL alcor,improve,dermit4i,or m ma any ma
F�-06 prior 1:)ii, 'th t' we r le' ' mtement SPECIAL CIRCUITMISC.
"J that he is d tet r o 'rat s n hags
C�G� laommcn 6wnb t TX 1 J t ine Crolo or TEMP.METER OR PO COMMERCIAL:
moa
p.=2 C thin Ile is rase ufr h r a d n alinn of Q ❑rNE�W LDG/ADDITION ❑DEMOLITION
aXl_y Section]IDI 5 by any applicam rix a permit s.bjecls rhe app team m a ctvi penulry mf O T'ON'ER DEVICES L NANT ❑FOOD SERVICE
FZQ,
is f ) IMPROVEMENT'
_ en rr y I me d�o a n n t s SW'1MMING POOL ELECTRIC ❑OTHER
a3= "' °' ° I c t t f OUTLETS-SWITCHES-FIXTURES
progeny who builds or improves thereon.and who does sue work M1tmxI our tough
hlx own mnploymi,provided that.wch impnrvememe are not inlenJed nr offered for O NEW RESIDENTIAL IiLECTR SQ IT.
sale.If,bossism.the buildingor improvement is,sold within one yearnfcompletion,the SQ.IT FLOOR AREA $/SQ.FT
own
erbuild¢will have the burden of proving that he did.. build of impave for pur-
1,as owner of the See 704,,B exclusively cmfesar ng with licensed and
to in TOTAL:
amewn the projat(Sec.]DLT,Business and Professions CWe1 The Commaors Li-
se Taw does not apply to an owner of property who builds or improves thereon.and QTY. PLUMBG PERMIT FEE
who contracts for such pa vacs with a amanictorts)berried pursmnt In the Contractors
License Law. PERMIT ISSUA
❑I am exempt under Su.' .B&P C for this reason -
ALTER-DRAIN&VE - TE (EA) VALUATION
Owner Dae
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DE
t I hereby affirm under penalty ofpequry one ofthe following declzrnionr. 11-7 000
I have and will maintain a Certificate of Consentto self-insure for Workers Compen- DRAINS-F R, AREA, ORIFS TYPE CONSTRUCTION
as provided for by Section 37W of IM1e lalxx Code,for IM1e performance of the
r for which this permit is issued. ' 'IXTURES-PER TRAP
I I have and will maintain Workers,Compensation Insurance,us required by Section
W of the Labor Code,for are performance of IM1e%ark for which this permit is issued. GAS-EA.SYSTEM-1 INC.J 5 OCC.GROUP Z AJ
MyWaders Cooper...ion himamce corformd Policy number me: I�
Carrier: Policy No.: GAS-EA.SYSTEM-OVER J(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' O
COMPENSATION INSURANCE GREASUINUUSTRL WASTE INTERCE
(This section need not be completed ifmc,pemtit is for one hundred Jnlia-1$1110) BUILDING DIVISION FEES
ter loss.) GREASETRAP PLAN This
FEE
I rend,thin In the v rpormantt of the work far w'hic'h Chi.'erten is issued.I shall '
employ any person in toy manner so a".become subject the Workers Com SEWER-SANITARY-STORM EA.200'F7.
not
j gemENERGY FTE
Z .cation Laws of C.1der ia.Date
Z O Applicant WATER HEATER WNENT/GLECfR GRADING PEE
u NOTICE TO APPLICANT.IL after making this Can ifcate of Exemption,you should WATER SYSTEM/1'kEA'fING
h' , become subject to the Worker's Compensation provisions of the labor Cale,you mus SOILS FEE
fonhwilh,amply with such provisions or This gerail shall be deemed revoked O WATER SERVICE
a �
DZ CONSTRUCTION LENDING AGENCY NEW'RESIDENTIAL PLMB. SQ.FP. PAID
V. I far
rte thanherc isoc.d(Sea 30lending agency for the performarwe of Date Receipt is
W � the work tot which this permit is issued(Sec.309],CivC.)
Q IQ Under'.,Name TOTN:
Lender's Address TOTAL:
Fy I cenify that I have read this applirmi.and smte that the above information is BUILDING TEE
of roamer,1 agree tet comply withnal city and county mdfmmcen said ,are law,relating to QTY. MECHANICAL PERMIT FEE
V Z building ams.uaion.andbereby a.thoare rcpreacntiones ofthi.s city menterupon the SEISMIC FEE
abovcmcmioncd property for nspeefon pnrpwa,. PERMIT ISSUANCE
(We)agree to sale,indemnify and keep harmless rhe City of Cupertino against ELECTRIC FEE
liahilitics',judgmenu',mer.and espousewh,,hnt.y in any way acerae a,mia.aid City ALTER OR ADD TOMECH.
is
in asequence of the granting of this permit. PLUMBING 17EE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON'POINT Z AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS, v MECHAN
AIR HANDLING UNIT(OVER 10.0110 CFM) CO RUCTIO T
Ak
Signamrc nfAPPlicanVCuntmaar Dam EXHAUST HOOD(WgIUCT) HO SIN IT ATION
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building oceuponCstore or handle hazardous material O HEATING UNI'I(TO IW,R)d BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Coda.Section 255321x)? HEATING UNIT(OVER 1W,gM1 BT V)
Yes ❑No O PAID _-
VL'N'f1LAT10NFAN(SINGLERESID) Dom Rcceip
Will the applicant or future building occupant use equipment or devices which
mit firanlotuat,Ionian,hard,as defined by the Has Are.At,Quality Management BOILNR-COMPOHPOR IW."IBTU)
TOTA :
rict�lAI �No BOILER-COMP(OVER Taft( OBTU)
I have mud the hazardous neuritis requirements under Chapter 6.95 of the Cali- O AIR CONDITIONER ISSUANCE DATE.
Pereis Health&Sa@D'Code,Sections 25505,25533 and 25534.1 und,numd Into if the NtiW R13SIDENTIAI.MECH. SQ.FL
huilding Joe,nut cum:ndy have a mmol.Nat it is my aspmsibility w notify the accupant
of the requirtmnit whim mast be mel ganr sat i....nee of a Ceniliea¢office.......
Donator.mn
hozed agent Dam TOTAL:
SSUED BY
OFFICE