99080123 APPLI9ANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY I < CIO 1 {r
CITY OF CUPERTINO BUILDING-ELECTRICAL P N
RUILDUsG DIVISION APPLICATION/PERM[T PLUMBING MECHANICAL
BUILDING,PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY IS APPLICATION SUBMITTAL DATE
/
OWNER'S AM- HONE: C, sACTOR'S N,M LIC NO: NIC CONTROL If
AM
Mem, '� 4 e e Z-5—J.'57
RCHITECTIENGINEER: LIC NO. AD}QRESS: ED(L'S0 �InCo�h alit",
NTACT, PHONE: BUILDING PERMIT INFO
01,k,f y �.L ./Y 7O� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB SUCH
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�QZ with Section 7000)of Division 3 Dobe Basins and Professions Code,an it my license is RESIDENTIAL'
Fy�W 0 in full force and eft sot G 3 PERMIT ISSUANCE ❑SFDWL Ll KITCHEN REMODEL
Q VZ U License Cla s ` d Lla#
ti6d Data C%Iowmr APPLIANCES-RESIDENTIAL ❑ADDITION [_1 PLUMBING RE-PIPE
ARCHITECT'S DECLARA PANELS El MULTI-UNIT E3 STRUCTURAL
C,an Z 1 understand my plans shall be used as public records MODIFICATION
OZ^O UP TO 2(A)AMPS El INTERIOR El CHIMNEY REPAIR
Licensed Professional 201-1000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION ❑SWIMMING POOLS
'a I hereby affirm That I am exempt from the Contractor's License Law for the OVER!tall AMPS ❑BATH REMODEUREPAIR D DEMOLITION
W'3 a F following rancor,(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL. ❑OTHER
W O¢ which polities a permit to construct,alto,improve,demolish,or repair uny nmemre
��m,.i prior u,its issuance,also acquiree the applicant for such Farman file a signed stamment SPECIAL CIRCUIT/MISC. ✓ .
S�ru�a�y that he is licensedpusuantR.theprovistone.ftheCorporate,LicenseLaw(Chapter9 � �JIr/
00'."00 (commencing with Section 7000)of Division 3 tithe Business and Professions Core)or TEMP.METER OR POLE.INS9:
COMMERCIAL:
C.y o eL that he is exempt movement and the basis for the alleged exemption.Any violation of ❑NEW BLDGIADDITION ❑DEMOLITION
iuCl IL SAditn 7031.5 by any applicant for a permit subjects the applicant to a civil penally of POWER DEVICES ❑TENANT ❑FOOD SERVICE
5y not more than five hundred dollars($501).
Q I,as owner ofthe rt,or employees with woes as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
O ❑ theme Y Y p Y 6 P
F 'll do be work.and lhenwewmis not intendedomffered for sale(Sec.7044,Business OTHER
63toand Professions Code:The Contractor's License Law does not apply to an awncr of OUT -SWITCHES-FIXTURES 47
property who huilds or improves thereon,and who does such work himself or through
his two employees,provided that such improvements are net intended or offered for NEW RESIDENTIAL ELECfR SQ Fr.
sale.If,however the building or improvement is,old within one year of completion,the SQ.FT.FLOOR AS $/SQ.ET.
neebuilder will have the burden of proving that he did not build or improve for Pur-
Pse rfealo).
❑I,as..on of 0m property,am conclusively red,..in,with licensed emaulamrs m TOTAL:
anarral the tom.(Sec.7044,Business and Professions Cade:)The Contractor's LI-
rise Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such project with a comproca (s)licensed pursuant to the Contractor's
License Law. PERMIT ISSUANCE
11 Iamexemptunder Sea ,B&PCforthisreason
Owner Date
ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE (� �1
I hereby affirm under penally of perjury one of the following declarations: - J CJ
Ih 11 and will maintain n Corti ficale of Consent to self-insure far Worker's Compen- DRAINS-FLOOR,ROOF.AREA,COND. STORI TYPE CONSTRUCTION
which
m.provided for by Section 37M of he Libor Code,for the performce anof the
which this permit is issued FIXTURES-PER TRAP
or hove and will maintain Workers Compensation Insurance,as required by Section
3700.f the Labor Code.for the peffrrmanceof the work for which this permit is ismed. GAS-G.SYSTEM-1 INC.4 OUTLE IS OCC.GROUP Pym
My Workers Ctrpe tion{�M acej dPut icyq� V
Cartier: f N/H(( JTe Policy No.:�I�r.< GAS-EA.SYSTEM-OVER4(G)
CERTIFICATE OF EXEMPTION FROM WORKERS' Q
COMPENSATION INSURANCE GRGSEIINDUSTRL WASTE INTERCEPTOR BUILDING)[VISION FEW
section need nal be completed if the pernh is for one hundred dollars pi IW) GREASETRAP
rales')
PLANCHECK FEE
1 certify that in the performance at work for which this permit is issuer I shall
not employ any person in any manner sons It become sub)wnn the WorkersCompete- SEWER-SANITARY-STORM G.200 FT.
- ENERGY FEE
zZ cation Laws of California.Date
O Applicant t WATER HEATER W/VENT/ELECTR ,LZRADING FEE
h NOTICE TO APPLICANT:If,after making this Certificate of Lincoln.,you should
(~ become subject t0 the Ww'kers Compensation previsions of the Labor Cale,you most WATER SYSTEM/I'RGATING r 'SOILS P'E�\
Wfarthwilh comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
U O CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMR SQ.FT PAID Uele Recei NI'i
[hereby affirm that there a concoction lending agency for the performm c t, 1
W the wod for which this perm,is issued(Sao.3097,Civ.C7 - 11
�� (
Lender's Name
Q U T AL
0W Ixndu' Address TOTAL:
I
L1t certify that I have read thirty and county
drum that the above information is BUILDING FEE
rrn� correct.I agree to comply with all oily and county oNinancee and stain Inws relating m QTY. MECHANICAL PERMIT
V 4 building constriction,and thereby authorize representatives ofthis cilyto camp upon the "SEA
F4 shave-mernoned pro for inspection purposes. PERMIT ISSUANCE �"-��-.,,ry
intoeii
',(We)agree sad indemnifymrd keep aytoan they sof Cupertinoagainst ELECTRIC FEE
u ities,)Jtl is; expanses which may in any way nccmongainsl said City gCTF,ft OR ADD TO MECH.
To of he of lM1is permit PLUMBING FEE
f AP UND NDS AND WILL COMPLY WITH ALL IN N�POPNT AIR HANDLING UNIT(TO 10,000 CFM)
1 I C, sDO S ����/� MECHANICAL FEE
AIR HANDLING UNIT(OVER IO,lgO CPM) CONSTRUCTION TAX
Signatureof Applimut/Contmetor Dote EXHAUST HOOD(WIDUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant or future building occupant store or handle hamrdous material HGTING UNIT(TO 100.000 BTU)
as dented by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety
Cade,Section 25532(a)I HEATING UNIT(OVER 100,000 BTU)
❑Yes PAID
VENTILATION FAN(SINGLE RES ID) Date Receipt#
Willheappllrnmorfurore building by affirl the
eea Air Crd art Manaevices gement
BOILER-COMP(3HPOR 100,000BOi
tit mzeNous o,mmmminnnta as eA by the Be,BArca Air Quality Menagemem
TOTA
.mnP BOILER-COMP(OVER 100,000 BTU)
❑Yes r
I hase_Not e u us materials re uirements under Chapter 6.9S of the Cali- AIR CONDITIONER
4 P key ISSUANCE DATF� ^
old
ash Sa ty z astern 25505 25533 and 25534.I understand lhm if the NEW RESIDENTIAL MECH. SQ.PI'. /I de.t tcu i e alenamJbel ills my rtsp(Inclblllly to roti theme an !/it rents unbemelprimmiseumceofa Cenifi file a 19
ramhori.doccur d (Da TOTAL: ISSUED BY:
OFFICE