99090009 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL P MIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
1-',BUILDING PROJECPIDENTIFICATION:i,
BUILDING ADDRESS: -� SANITARY NO. APPLICATION SUBMITTAL DATE
WNER'S WAME: / PHONG: _ CONTR TOR' NAMtI� IC NO:
Z W NIC CONTROL#
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ADDRESS Cr. ( „(GC1VJ J(J� /,�J�r S� ❑ -
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COrvTACI': n A PHONE{{:��,,. ( ' • '- BUILDING PERMIT INFO
RON CAVO Lek q4.b&4x& ❑ ConSWtant Fees Paid by Applicant(Initial) BILLDDG/♦ ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION QpY.• t 4'1E RIGPERMIT'. .{ .' ''EEE
I hereby nrrrn that l licensed under-v fChapter9(comm¢ g s�. .r x S •i JOB DESCRIPTION
aZ with Smfim701)0)ofD .' r.3 titl,Bus ..and Profesxon de, n ylivense is
OO in PERMIT ISSUANCE RESIDENTIAL:
W u full force and cn�LN C'7 Qi ❑SFDWL KITCHEN REMODEL
�VV License la L -C7 Llu.# 7 APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
N L Dala�_Qinnucx.. gtj � (� ,5 -
ARCHfrEC'['SDECLA O 1I YY����pp El MULTI-UNIT ❑STRUCTURAL
�h Z I vndmsland m I hall he used as public re did PANELS MODIFICATION
ZOYPan.vs
OZ - UP T02fN1AMPS
A1 ❑INTERIOR El CHIMNEY REPAIR
H r�eR G Licensed Professinnul 201-1000AMPS IMPROVEMENT
,.) �SW IMMING POOLS
S4 C OWNER-exempt tr DECLARATION OVER IoW AMPS ❑BATH REMODEIJRAP 1 DEMOLITION
q I hereby affirm that[um exempt/from the fir,mumoos e:Any e law for the
at 3 W F following reason.(Section]031.5,Business anti Prnfeesbns Code:Any Illy or county SIGNS ELECTRICAL IS OT ER
F y which requires a permit to construct,alter,Improve,demolish,or repair any swemre
'I prior to its issuance,also reminds the applicamfor such pump to filen.vigaeJ statement SPECIAL CIRCUI'rIMISC.
r"[yy than he is licensed pursuantto the previsions of the Contractor's License l,aw(Chapter 9
W E5d0 (commencing with Section 7000)of Division 3 ofthe Business and Professions Code)or TEMP.METER OR POLE.INET. COMMERCIAL -
F y a y that he Is exempt therefrom add the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W o, Section 7031.5 by any applicant for v perninsubjects the applicant o a civil Penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
not more had live hu noted dollars E500). IMPROVEMENT
C ❑ I,as owner of the properly,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRI
will do the work,and the structure is not Intended oroffered for sale(Sea]044,Business ❑OTHER
Gam 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
his own Cmployecs,provided that such improvements am not intended or offered for NEW RESIDENTIAL ELECTR orSQ
sale.If,however.lbehuilding orimprovement is sold withinane yerimcompletirmund SQ.Ff.FLOOR A9EA S/SQ.FT.
oemer-builder will have the harden of proving that he did not hurt(]or Improve for put-
Eoxe of aOwne
09
❑ 1,u owner of ct Sec.property,am Business
confessions with:ieTheeC Contractor's
to T (�
construct thedoes
not(SIN ]IH4,Business n ad property
who
Code:)es or The es thecmr L --
eel.awdoeor suchplymair owner
ith acaprepord who bldpursuant
ursant to the Contra d QTY•' I 'PLUMAING PERIvll7 1 k:
t
who conlraels for such projects w'Ihawnlr teror(s)I coa6fd puesm 1110 the Comrneroes -,x
License Law, PERMIT ISSUANCE
1] 1 am exempt under Sm. ,B A,P C for this reason
ALTER-DRAIN Ar VENT-WATER(EA) VALUATION
rte Data ��/ ✓vV
Wm underSCOMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby ulRrm under Penally of perJury one of the follow ing dedemlions'.
I have and wil l maintain a Certificate of Consent to self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
arm a,as provided Furby Section 3700 of the Labor Code,for the performance of the
wad for which this permit is ossa¢(]. FIXTURES-PER TRAP
I have and will maintain Worker's Compensation hundro w,as required by Section
37 W flhe Labor Cade,fer'hc termone¢of thcarlePa"Irk I?'X
' hrs fir uis issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APNN �Y
Cartier: `len rFEXE rPIONI o.: OAS-F,A.SYS
USIR NvAsrE(EA)CERTIFICATE OP EXEMPTION PROMCOMPENSATION INSURAN � Y"/ GREASF%INDUS I'RL\VAS'rA,3NT5RCEPlOR`_
d//rrr 1 �A'x ' a 'BUR,151N0 DIVI6IONIFBEb 7 a x a e r
(This lianneed nmbeconaplenedifNepermitis faronchundreddoll s($It(p GRF.ASE'rRAY �_ L[ k
or le:.) PLANCHECK FEE
Ioyanythcointhe anymnenceuf stobecome
ec for which this the Workers
rissued)shall SEWER-SANIT I tSTORM EA.200 FT.
not employ any Person in any manverwr.6 na beeovle,object to the Workers'Campcn- �I I I ENERGY PEE
0 Applicant
Laws of Ceti!aia.Dam WATER 1{EATER NTI
f� Applicant GRADING FEE
(%j] NOTICE TO APPLICANT:IL rotor making this Cmtilifam of Examplion,you.should WATER SYSTE. ATING SOILS PEE
NF
had
eme.vuhm"m the Worker,Compensation Provisinnv of the Luhor Code,you most
fnflawlthmmply with.mch provisions or this Permit shall be deemed revoked WATER SERVICE
W Q
Va CONS'1'RUCfION LENDING AGENCY NEW RESIDENTIA --� .IT. PAID
Q I hereby affirm that hem iso constmclion lending agency for the performance of Date 1#
W L� Ncwoek foe which Nis pcnnif is issued(Sec.3097,CIv.C.)
O •`� Lender's Name TOTAL:
Lend .Add TOTAL
all
c pal i d 1 t ces BUILDING FEE
r
m
comet.l g t ply 're B city a county d' s i t I I I the
QTY `MECHANICAL PERMIT r ��FEB'
., a
V
building t had r,,and lvrebyauthofizc p scmmives oRhis eilymcnmr spot the • ,.i - / � ...?' SEISMIC PEP.
ubovamed)agreproperty rind inspection keeph,' PERMIT ISSUANCE
(We)agree to save,indemnify and keep hdmdess the City of Cupertino against ELECTRIC PEE
habilitice.Judgmenrv,costs and expenses which may in may wayaccnm against said City ALT ER OR AUDIO MECH.
consequencein of the granting of this Permit PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECLIAN[CAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER Writer CIM) CONSTRUCT ION TAX
Signature of Applicam(Conlmemr Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO I00.000 B'['U)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Surety
Code,Section 25532(x)) HEATING UNIT(OVER 103,000 BTU)
El Yes u VENTILATION FAN(SINGLE RESID) PAID _
Will thea licart,(fetor¢buildin u tuseaui 1 or devices which Dete Reeeip #
pp dbythen q Air
BOILER-COME(311?OR 100,00)BTU)
it hazardous air conwminnvts as def nes by the Hay Area Air Qualhy Management OTA s Q
District, BOILER-COMP(OVER 100.000 BUD
❑Yes
I have mad the hazardW' smy tents under Chapter 6.95 of the Culi- AIR CONDI'T'IONER ISSUANCE DATE
forms He fay 5533 and 25534.1 am ntn that if the NEW RESIDENTIAL MECH. SQ.FT.
buddm dre,nmcumm responsibilit to olffy e antfrom men afiefs ) p'
Ownerr authmieed ager. Uale TOTAL: ISSUEDBY:
OFFICE