99100117 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY �C� r O'O
CITY OF CUPERTINO BUILDING-ELECTRICAL i-- 'RMII NO.
BUILDING DIVISION APPLICATION/PERMITPLUMnINc-MF.CDANICAL. S0001
177-1i . '.BUILDING PROJECT IDENTIFICATION*{ ,p^"`
ILDING ADDRP.SS: y SANHARYNO. APPLICATION SUBMITTAL DAPI
BU
10 5511 13F)P.l4KP_T C7 , leZ,o f
WNER'S NAME: R PHONE: CONTRACTOR'S NAME: LIC NO: WC CON]BUT,
CHITfECf/ENGINEER'. • ���� L 'NO: I ADDRESS: ❑.
CONTACT: PHONE. -.'BUILDING'PERMIT INFQ
❑ Consultant Fees Paid by Applicant(Initial) - BLDG ELECT PLUMB MITCH
El El ED
LICENSED CONTRACTORS DECLARATION QTY 'r I v}ECLQTRIC PERMIT(, I f FEE'j
I horehy alum Than 1 ],,,.,cd d v f Chapter 9 roam rte g f.. .i JOB DESCRIPTION
{A{s�aZ win Section 9000)at Division 3 of the Busses,and P fission,Code and my lican4e is P1iItMIT ISSUANCE. RESIDENTIAL'
F�5 in lull force and affirm El SFDWL ❑KITCHIiN REMODEL.
CF UZ�y U License Cls Lia N
APPLIANCES-RhSIDEIA. PLUMBING RE-PIPE
LIADDITION
W Dee Cardruchn
[:IMUUH-UNIT ❑STRUCTURAL
F=to ARCHITECT'S DECLARATION PANELS
y I understand my plans shall be used as pub.is records MODIFICATION
ozr�IG UP TU 2W AMPS '
�IN'IT;RIGR El CHIMNEY REPAIR
I-i�EC'W License.]Preardannl OWNER-BUILUF:R DECLARATION
201-1000AMPS - _ IMPROVEMENT E]SWIMMING POOLS
2,-1
tK'4 OVER 1fH10 AMPS ❑BATH RI?MODELIRFXAIR ❑DEMOLITION
d 1,herhy n(B+m that 1 arm exempt fmm the Eoineemrs e Any a Law re lly
4 U following mawa(Section 9 o L5, h ante, and improve,
de io demolish,
Gds:Any city nr couury 1'5
ELECTRICAL
❑(1fHER
[x13 W 1"' which requires perms t t t Etc p J m I.Irepairany.' stare
prior t t I. q thef such permit t rilesttement CIRCU I'UMISC.
P.
hot he licensedp continue p DI Committees L L (Chapter9 COMMERCIAL' -(
(ear c g ithS 1 90(0) 1D i fn B .- dprofession;Cde)or ETER OR POLE INS'I
d Ihm ho s exempt therefrom and the basis for the alleged exunpt on.Any violation of ❑NBW HLDG/ADDITION ❑DEMOdA NON
Section 90315 by any applicant lot o permit.subjecn'heopplicamno a civil penalty of DEVICES []TENANT ❑FOOD SERVICE
i. not more Than free hundred dellarx 15500). IMPROVEMENT
SG ❑1,as ownerofne propcry,or my employees with wage,as'hcirsalepEEBemlon, ING POOL ELECTRIC
fCAi F.. will dothe work.and the stmcmre is not intended mofved Tarsal"(Sea.9M4,Business El OTHER
1 m nail Professions Code The Conn,,.,a License Low docs not apply m an owner of S-SWITCHES-IHX'I'URP.S
property who builds or Improve,semis,and who doe,such work hinew f ofthrough
his own employees,provided that such improvements are sat intended or offered for SIDENTIAL ELECTS,
soleif,however,ncbuildfngor improvement fssold wish one year ofconipletion,the SQ.FT.FLOOR AREA S/SQ.FT.
twner-buflder will have rte burden of proving that he did not M1uild or improve for pur-
pns xowne TOI'A
�I r anhe prapertr,am exclusively mmmetimg with licensed cammnar,m
ongrun rte pmjem(Sec 9004 Bui rasa 1 P f:.' e 1�)TI c t '1 L .. •), sr S. F t
e I d 'apply to fproperty 1 bodies 1 mere d QTY' O+PLUMBING PERMIT'rt:)1'wnsedp u 0 Carer ' -
Lic eL' ISSUANCE❑I am exempt+derS . .B&P C for the reaten -URAIN&VENT-WATER(P.A) VALUATION
Date
WORKPT'SC MPENSA I]ON DECLARATION BACK FLOWPROTECI'.DEVICE
I hereby affirm and ren to of perjuryono of the following declarations'.
Ilove and wnllmaintnin a Certificate"'Carl-,'m self mems For Worker,Comper- DRAINS-PL OUR,ROOF,AR EA,GOND. STORIES TYPE CONS"IRUCTIOT,
senior,as provided for by Seat..3700 of the Labor Code for he podorman a of tire
work for If this pami'is issued. FIXTURES-PER TRAP
1 have and will aeimoin Worker,Compensation Insurance,as no,fired by Section
3]IXI"CneLwd,mCde,f..rtrfo
e pennameof rte work for which If,,per
i, mit i,issued. CAS-F.A.SYSTEM-I INC.40UTLETS OCC.GROUP
My Worke2s Compen,ntinn Insurance artier and Policy numM1er arc'.
Carrier Policy No. GAS-EA.S0'S"fEM-0VHR 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERSGR17ASFJINDIJSTRL WAS'T'E IN TERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
Tlhi-tehimveednm be un toward If pemen hLane Inn doaddollars($nMB GREASETRAP
nrlees.l PLANCHECK FEEIcertify'he home pedormnnceoflework forwhioh lhkspern'iGs fssled,]shop SEWER-SANITARY-STORM EA.200FT.
am employ any perms in any mnn
aer sn a„”becnew sable, tar rte Workus'Camper- ENERGY FEE
0Z cation Laws of Cal`fterho Data WATER HEATER W/VENT/EI.ECTR GRADING FEE
ZQ Applicant
ti 09 NOTICE TO APPLICANT:IL nf'er marking this Cerilicem of F.sen'ptian,you should WATER SYSTEMn BEAT INC.
become nNeat Tender Workers C"mpcmmhnt p...I,mns of the Labor Code,you mud SOILS I'EE
try fonhwifhurmply with such provisions ar this pemorvhift hedeaned mvakwl.' WATER SERVICE -.-.-.-.
CONSTRUCTION].ENDING AGENCY NEW RESIDENTIALPLMB. SQ,FT. P 1
U
(hereby effivn nnt'hare is neonstiudinn lennngagenry[or 0m performance of 'j �� IDaR.- .. Rd's pt%
rte ustal,fwhich n I Y ueJ(See 1099 Ci,,Cr TO
d Name
LaralwasAwidneq, TOME
Chi aZ ' F ' i ' ECHANICAL'PqRM.IT FEE
IBUDCFFEat
1 rythtII ddul pp ' Lt' 0euh b information 199
V) correct.l s t pry 'm all city d county t a f t I t g t tl t
U 7bildhocirsu f dhereby roe p ...rase,ofThis city menertlan lies 9
t ra t SEISMICfill,
nboSn-mentioned p upery for in,pccuor purp"ses. PERMIT ISSUANCE t
• (We)agree to save,indemnify and keep harmlos the City of Cupertino against I. PD.ECTRIC P5F.
ithilities,judgmwns,costs and expenses which may in anyway ammo agninsuaidCity AI:fP.R ORADD'fO MECH. PLUMBING I'IiF:
III nsegmencc of the granting of'his Sonit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0,I00 CPM) MECHANICAL FEE
SOURCE REGULATIONS. '
AIR HANDLING UNIT(OVER 10,000 CFM) + CONSTRUCTION TAX
mamreaf A,h,MCa ea Units EXHAUST HOOD(W/DUCT) - HOUSING MITIGATION FEB
A' RDOUS MATERIALS DISCLOSURE ,
Willneap card or future building ocoupant sore or handle hmnnd"us material HEATING UNIT(70100,000 BTU)
as defined by the Cmperinn Municipal Code,Chapter 9,12,and the Health and Safely
Cade,Section 25532(x)'! HEATING UNIT(OVER IQ)B00aI'U) -
❑Yes FN. VEN'T'ILATION FANS INGLE.RESID) PAID
Date Became W
Will The applicant"r Tatem huildfng nccupe t arse eyuipmenf",deck,which BOILER-COMP(3HP OR IMonti BTU)
nit hazordmis air continuou's as defined by the Bay Area Air Quality Management TOTAL' l�
t„de9 ' HOLLER-COMIIDW
P(OVER I , U HIV 1
p yea ❑No
1have,ad The h ode Se material, 5,25533 a under4T and rsta of the Ifthe
AIR CONDITIONER ISSUANCE DATE
build"Health&Safety Code,a It urn,25505,is re,end 25534.,understand b sat if the NEW RP.SIDENTIAI.YIECH. SQ.Pl:f 2�
building dons no'enrunly hovevtenant,that itis ar o,al sCani to esnmify c aaeupxm �-
o he mquimmant,wAich xt M1e mm priorto lsamnce nix Ca'ifiemeof Occupancy.
Owner nr authorize gem Du .TOTAL: + ISSUED BY:
OFFICE