99090026 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY Q 1O(j
CITY CUPBUILBING-ELECTRICAL ERMITN
BUILDIDI NG DIVISION
APPLICATION/PRRMIT PLUMBING-MACANICAI.
• 1'°'- I¢'BUILDIN(':PAOJF.CT @EF.NTIFICATION't,�'.�+;:u',f'
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
a -�
R' ME: PEON
CONTRACTORS NAME: LIC NO: /
N/C CON'IROLb
ITECT/ENGINEER: LIC NO: DOE ❑
l
t `.1'-, BUILDING PERMIT IN O r
COMI'AC'I`. PI10Nd: i+`� s
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUM MECH
.�y �� ❑ ❑ ❑
LICENSED CONTRACTORSDECLARATION QTY ELEGTRIG PERMPC 1V I{ ',,FEE'1 it
1 hereby arum that I licensed and provisions rChapter 9(urmmene' g ° _, f t : I ./t{ JOB DESCRIPTION
�00 with Section 7000)of Division 3 rthe Bnsln . de f.....ns Ctde.mcl my license is
F1_ in full farce and eBect PERMIT ISSUANCE
1U SFDWL El KITCHEN REMODEL
�UU [)cense Class Contractor
APPLIANCES-RESIDENTIAL ADDI�TIONN [_1 PLUMBING RE-PIPE
y 0. Uate Contractor
ARCHITECT'S DECLARATION [_1 MULTI-UNIT El STRUCTURAL
PANELS
Z p m'� 1 understand my plans shell be used as pontic reuuds MODIFICATION
OZ`_0 UP T02fN1AMP5 ❑INTERIOR El CHIMNEY REPAIR
F�.F",W licensed Professional 201-1000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION ❑SWIMMING POOLS
C y I hereby afftrm(hot 1 am exempt from the Com ❑ El License Law far the OVER 1000AMPS BATH REMODEUREPAIR DEMOLITION
Upool following reason.(Section 901315,Business ny and Professions Code:Aulty or county SIGNS ELECTRICAL HER
W 3u,F
,hielp or,mos, permit I :I t hc,,improve,denticlush,.,roppirmsy,unicharre
prion t Iso e
y-ep ppl c t brooch pe 'n file hrip statement SPECIAL CIRCUIT/MISC. '
gyqQ�p" Thoth 1 tip ecu: II th p of e t t L el (,C de).,
til�y''00 (cam g thSection twa and f Division or th the Bocincssand.n.A. vi Gde)or TEMP.METER OR POLE IN59: COMMERCIAL,
a.iC m W Sher he is exempt therefrom and In.iasis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
fR�1l rn Sediou"103L Eve onyapplieunin,($5elmit snbjeds the applicam mecivil penally of POWER DEVICES ❑TENA ❑FOODSERVICE
Cnet mom man Ove hundreJ dnlh¢s(5500).
iSG ❑ 1,as owner of the properly,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IM EMENT
CCCi444 will do the work,and the smocture is not intended or offered for sale(New.91004,Business ER
and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds orimproves thereon,and who does such work himself or through lop
his own employee.,provided that such improvements are not imended or offered for NEW RESIDENT Al.ELECTR SQ ET
cale.If.however.the building or improvement is sold within oneyenrof complaion,the SQ.FT.FLOOR AREA VSQ,FT.
er-builder will have the burden of proving that he did not build or improve Ru pur-
pose of ams).
❑1,as owner of the properly,am exclusively contracting with licensed contractors to TOTAL.
construct he p l ct(SW.7044 Business and Poofiessim,Code.,The Gmtrmmr L- - I - .
croon Law d I pplyl fp ponywhon ld:,rmproves thereon d QTY. PLUMBINCPERMIT=` .1.FEE 11 1 ,it
whecntraU'for such Dj ts with a eontml (s)licensed pursuant tothe Contractors
License Law. PERMIT ISSUANCE
E]I,mp.vpptunder Sec. ,B&PCfim1hisreavon
ALTER-DRAIN&VENT-WATER(EA) VALUATION
nor Dove
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
I hereby affirm under penally of perjury one of the fallowing declamtons:
I have and will maintain a Certificate(ofConueormolf-insure for Wmker's Camper- DRAINS-FLOOR,ROOF,AREA,CONU. STORIES TYPECONSTRUCTION
amici,as provided for by Swlinn 3"100 of the Labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
1 rasa and will main Win W..ker'x Compensation Income,¢,as required by Section
00cfthe Labor Cnde,fir,{ ¢pert fthe work for which this pemtit is issu GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP
My Work nn G caj 6 I ipc�e aced Polis
Co is,: Jac
UIJ Policy No GAS-EA.SYS'rEM-OVER4(EA)
CERTIFICATE OF EXEMPTION FRO WORKERS'
COMPENSATION INSURANCE GREASOINDUSTRL WASTE IN'[EST EEMSn a .4,a x b u r. y
(Has section need not be completed iftheEnron is rorone hundred dollars($100) - A ' HL dist j-Blp li 5 ,), Y
or leas) GREASE TRAP
PLANCHECK FEE
Isonify lcminthe pertiny armnw,,a lhewmk..embchthia lie WlisissuCompLJoml SEWER-SANITARY-
no[em to n STORM EA.2fN1 FT.
p y any person in ivy manner et,us to hewn a subJmt to Ire Wnrkerr'Cumpw- ENERGY PEE
O Z salon Laws of California.Date ATER HEATER W/VENVELECTR
Z Applicant GRADING FEE
y NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTEM/TREATING
ahecemesnbjee(m the Worker's Cum,enaction provisions of the Labor Code,,..must SOILS FEE
Fkl forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE �.
7Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLM. SQ.FE PAID
t hereby affirm[fiat there is a construction lendiagagency for the performance of I' Dme r.Rceeiplb
the work for which this perm,(is i...ed(Sri.3097,Civ.C.) -
LendersName \��j( TOTAU.
{11 Lends Addm s TOTAL.
� a
v) ' hn informations Is rt
BUILDING FEE ttfY thatIM1 rad this application d state that MITcorect I s t comply with all d county d and state I I i gm QTY FLZ building construction,and hemhy amhortze representatives of this city to enter upon We is
i SEISMICFEb 11,'
above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECIRICFEka
liabil itics,judgment,,ens le and expenses which may In any way asoma against Bald City ALMS OR ADD TO MECH. C.
in consequence of the granting of this permit. PLUMBING FE
✓'
APPLICANT UND STANDS AND WILL COMPLY WITH AL{�NON-POINT AIR HANDLING UNIT(TO I(I,IXIB CPM)
S RCE I�EGUL fl S. ^1 -\^ CONSTRUMECIIANICTION
PET
\"y11n` 1V)IL`L1,Lll„S/1'Vn1 AIR HANDLING UNIT(OVER IQ000 CPM)
T � CONSTRUCTION TA%
HAZARDOUS ATERIALS DISCLOSURE DI� EXHAUST HOOD HOUSING MITIGATION FEE
Will the applicant or furore building occupied snore or handle hazardous material HEATING UNIT(TO 00,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Heahh and Safety
Coda,Suction 25532(x)? HEATING UNIT(OVER 1011,000 IT
❑Yes ❑Nm VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or furore buildingconicalthe B A equipment or devices whims
Dam Rccci b
7wiapi
it hazardous air conmminm¢es JefineJ by the Bay Area Air Quality Mavagemrnl BOILP.k-COME(3HP OR 100,000 RTU)
isipi
strict? 'FOT L'.
❑Yes E_]No BOILER-COMP(OVER 100,000 BTU)
I have read the hazardous mmcrialsrequirements under Chapter 6.95of the Cal, AIR CONDITIONER ISSUANCE DATE
mia lien th&Safely de,Sections 25505,25533 and 25594.1 understand that if the NEW RESIDENTIAL MECH. SQ.ET. -9 A
ihimedocerotty py{rer amram,lhatilismyresponsibilltym notify(h occupant
the regwa�RRll�r YYYwYw emeSpriorto issuance of a C ofO 11
a ri dagent Date - TOTAL: ISSUED BY: C '�
OFFICE