99110150 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL C' e ^ A O
BUILDING PROJECT I EN IBICATION a �
d�LDINGADD�55', a� / J ^�al` SANITARY NO. APPLICATION SUBMITTAL DATE
7-75
ME /�1�a•�(J^LJ�L./F�J-P►T-Hfj-1,NE: 1/V) CONT TORENryytE ,L1�yQ J X2.2„
'1� .J ��(�/1 _ 1/ �1 i/�I q IS N/C CONTROL#
RCHITECT/ENGINEER: V�l LIICC,NOO.J w RES 4Y {T[ i u ❑
G.:. S. ..�-tea
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB IdECH,
LICENSED CONTRACTOR'S DECLARATION QTY, ELECTRIC PERMIT FEE JOE DESCRIPTION
I hereby affirm that 1 Cm licensed under provisions of Chapter 9(commencing
AO'z with Section 91100)of Division 3 oftbe Buslnas,mdPmEseiods Codeand my license is
X00 wt PERMIT ISSUANCE RESIDENTIAL:
F W F in full forcel f°rCe a° ��� ❑SFDWL El KITCHEN REMODEL
UZ U Licenser s Llc.N
y6G Dore Contractor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECT'S DECLARATION [I MULTI-UNIT ❑STRUCNRAL
PANEL
z p y z I understand my plans shall he used as public records MODIFICATION
c)z4 UP T02W AMPS 1-1 INTERIOR El CHIMNEY REPAIR
F_�J Licensed Professional 2UI-IOW AMPS IMPROVEMENT SWIMMING POOLS
SSerY't OWNER-exempt fate he DECLARATION OVER IWO AMPS ❑BATH REMODEL/REPAIR El DEMOLITION
aW'W I hereby affirm ter 1 em exempt Item the Cssion,C e License Law far tM1e
a F following meson.(Section 90315.Business and Professions Code:Any city nr wuntY SIGNS ELECTRICAL EICOHBR
which requires a permit m construct,alter,improve,demolish,or repair any slmclum _ 't ri d
F O prior to its issuance,also requires the applicant for such prompt it)file a signed statement I SPECIAL CIRCUTUMISC. C
pppp y
that he is licensed pursuant o the provisions of the Conaractors License Law(Chapter 9
QD (commencing with Section 91100)of Division 3 clubs,Baeinessand Professions Ctule)ar TEMP METER OR POLE INST. COMMERCIAL:
0. c C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION 0 DEMOLITION
h•
Section]O315 by any applicant for a permit wmed,the applicant m a civil penalty of POWER DEVICES
m TENANT ElFOOD SERVICE
not momthan rive the
dollars($500), PRO MENT
, A ❑Lo the work,the pro ert.orm p y gds ,Bsi '�
property, yam to ees whM1 coo as their sole cote tion, SWIMMING POOL ELECTRIC
will dathework,Code: he Co is mnetamended or offered for salepply ,1so Business
and ery who ns Cw1c The Comment's them's Licence Law sass not apply s if owner of OUTLETS-SWITCHES-FIXTURES
property who oyce,or improves thereon,and who does such nwork himself or through
his own employees,provided that such impmvemente are not intended or offered for NEW RESIDENTIAL ELECTR SQ IT
sale.IL hawevec the have
[Il burden pmvement ix at he did n t build or improve
vefor u t, SQ.PT.FLOOR AREA $ISQ.FT.
pass,o We.)rwill have Wr harden of proving that he did not build or improveforpur-
pose of sale J.
❑I,is owner of I'(Site ny,.B exclusivelyad Professions with:) no Cinsper contractors - TOTAL:
�.{const un thepmjem(Sec.91140.Business and Professions Code:i no es thereon, nd
u Lawdoesnmapp r roan with
rowner fpmpeny who
sedisds omento fac Compoetond QTY. PLUMBING PERMIT FEE
who amrrams for such projects whhurnnoacnm(s)lic sed pursuontm the Commcmr'x "
License Law. PERMIT ISSUANCE
❑I am exempt under Sec ,B&P C fim,his reason
er Date ACfHR-DRAIN&VENT-WATER(EA) �/ VAL/U�ATION�l
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT,DEVICE A zs,y• 0 D
jthereby ufOrm under penalty ofperjury one of Ne following deelvnrions:
I have and will readout n a Certificate of Consent to self-insure for Workers Comped- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPECONSTRUCTION
smioa,as provided Por by Section 3900 of the Labor G+de,for the performance of the
w k for whichmis per
is issued. FIXTURES-PERTRAP /
I have and will maintain Worker's Compensation Insurance,as required by Section
3 num de,Labor Code, nr the perfn manceof the work far e'hich this permit is Issues. GAS-EA.SYSTEM-1 IN0.6OUTLETS
My War'
kqr pey;l�o r dPolipyyytrypepsr,'M,1 VIP OAS-EA.SYSTEM Comer: t policyN
AAkk,i!!!,�/LL 1ch this
''000077 OCC GROUP A
CERTIF LATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
(This section need not be,completed Onto permit is faro is hundinddollars($100) BUILDING DIVIS108 PEES
or less.) GREASE TRAP PLANCHECK FEE
I certify that in the performance ofthe work forwhich this permit is issued,l shall SEWER-SANITARY-STORM EA.200 FP.
not employ any person in any manner se as to become subjecto the Workers'Comped- ENERGY FEE
Z sans.Laws of California.Date
WATER HEATER W/VENELECTR
� Applicant WATER GRADING FEE
rjI NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTF.MORFATING
become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
WQ forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
CONS'I'RUCTION LENDING AGENCY NEW RESIDENTIAL PLM B. SQ.ET PAID
V Q Ihmeby vfFlrm ohm Oiorc isomnswctinn lending agency for the performeuw of Date Receipt
[Ssw-t the work far which this permit is issued(Sec.3099,Civ.C.)
C) F Leaders Name
TOTAL:
WLendr's Addmse TOTAL:
I verify that I have read this application and slate that the above information is BUILDING FEE
r%j wrem.I agreemromply with all city indcounty miinumacomdmam laws relating w QTY. MECHANICAL PERMIT FEF;
U z buildinsenmwetion.ondherehyamhorizerepresemmivesofuniscity renterupon the SEISMIC FEE
above-mentioned propeny for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
Iiabilities,judgmets,costs and expenses which may in any way accrue against said City ALTER OR ADD'POMECH.
in asequence of the gconfrgof this permit. P UMBING'FE-1
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IEWO CPM)
SOURCE RgpGUL/!�/ONS. I/ �CHANICAL FEED 1
q ` , s 1 44 Q AIR HANDLING UNIT(OVER IO,WO CFM) C ,I$TRUCTION TA
Signature of Appli`-'n/UComencar /
Date L EXHAUST HOOD(W/DUCT) H U'INO ATI 8
HAPARDOUS MATERIALS DISCLOSURE,
Will the applicant or future building occupant store or handle hrcerdops material HEATING UNIT(10 100000 BTU) t
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Haom tad Safety
Cade,Section 15532(a)1 HEATING UNIT(OVER Usig1)BTU) ff _
F1 Vex E]No VENTILATION FAN(SINGLE RESID) PAIRPy --
Date� Receipt#
Will the or, oritio art fours building by the B use .Air a or dMana which BOILER-COMP CUP OR 100,000 BTU) `
rot hezmVous air,comaminems as defined by the Bay Afn Air Quality Management t
��
TOTAL
L]
/
L]Yes EJNo BOILER-COME(OVER 1110,00)BTU)
1 have rwd The hazardous materials rcquircmenu under Chapter 6.95 of 0s,Cali- IFAIR CONDITIONER ISSUANCE DATE
fomiu g does&Safety Coda,Sections 25505,25533 and 25534.1 i ndersmud that One NEW RESIDENTIAL MECH. SQ.PT.
bonding don not currently whih have a tenant,that o is ua c responsibility m notify the Occupancy.occupant
of the requirements which must he met Procne issuance o[a Certifc to of Oo�upancy.
Owner or amhorized agent Date TOTAL: ISSUED BY:
OFFICE