99110147 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
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CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL SOOOI
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANTT TARY NM APPLICATION SUBMITTAL DATE
101 3 Lie\ c 2
OWN/�E�R'S NAME: PHONE: CONTRACf`pR'S NAME: LIC NO:
l�Y \k - -Z-SBU(J (J�ZAL •ZS G7 N/C CONI ROLp
ARCHUEC OENGINHER: LIC NO: ADDRESS: " 11 ❑
IM FCONTACT' PHONE: BUILDING PERMIT INFO
El Fees Paid by Applicant(Initial) BLDDG/ ELECT PLUMB MECH
M! __"AVO,L Id ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm Wm 1 am licensed under provisions of Chapmr 9(commencing JOB DESCRIPTION
0*4Z wiW Sation](I00)ofUivisiun3ofthe Buiness end Ftofcssimns Cade.and my li RESIDENTIAL:
F-Iy0 in full tone nnB �Z G-S PERMIT ISSUANCE
�U�j Libros Class Lic.p S ❑ADWL El KITCHEN RE-DIEL
PZW Date Cammcta API'LIANCFS-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
ARCHITECTS DEC A A' [I MULTI-UNIT []STRUCTURAL
Z p h Z 1 u almdand my plans shell M tiJ az P orris PANELS MODIFICATION
O Z.co-- UPTO200AMPS
H'�I'0 ❑IN
Licensed Profcxsionol - TERIOR ❑CHIMNEY REPAIR
G 201-IOWAMPS IMPROVEMENT SWIMMING POOLS
C kd==-1 OWNER-BUILDER DECLARATION OVER IWOAMPS ❑BATH REMODE•UREPAIR [I DEMOLITION
6 1 hereby alErm that 1 am exempt from the Commcmr's License Law for the
K3 L U following mason.(Sation]031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
W W which requires a permit to construct,Offer,improve,demolish,or repair any structure
0 prior to its issuance,also requires the applicant for such permit nn file a signedamtement SPECIAL CIRCUIT/M ISC.
F,yy that he is licensed pursuant)the previsions ofthe Contractor's License Law(Chapter 9
00_00 (commencing wiSmtion]010)of Divlsion3 offleBuxinesxand Professions Candor TEMP,METER OR POLE S'
a e eG do,he is csanpt methre
frnm and the met,for the alleged exemption. ❑Any viohnion of NEW BLDG/ADDITION El DEMOLITION
la,
^m Simon.]031.5 by fora permitsuts n 1'ene
bjecthe.,Oman,tocivil ltyof ES POWER DEVICE'S anym, ❑TCNANT ❑FOOD SERVICE
FZi- trot more Won live hundred dollars($500). IMPROVEMENT
f a0 ❑ Lm ework,We do muctor myotimmomn wifhwagesoxsle(Sm. 044,8 sines SWIMMING POOL ELECTRIC
_ will Jo the work,mJc TheConttenor irncndW aoRe does
apply to an comm
❑OTHER
63 and t§nfessions Cale:The Contractors License Law does not apply toot owner of OUTLET SWITCHES-FlX'NRES
property who build,or improve,thereof,and who does such tints himself sn through
his own emplaImes,the building that such imbui,emenb art not intended m offered for NEW R 1 IAL ELECI'N SQ PT'.
camerLinder will hhutheIorint of
)that he id nodeyemoi improve
the SQ.FL FLOOR AREA SISQ.FT.
owner-builder will hove doe bunlen of proving Wut he did not buil)or improve for Pur-
co 1, owner of the property,nm exclusively contracting licensedamtrum '1'OTA L
construct We project(Sec.]044Business and Professions Code:)The CmnVacfu's Li-
cerise :
'
law does not apply to an owner of Property who builds or improves thereon.and QTY. PLUMBI s PERMIT FEE
who contracts forsuch bmjeets with a contnctotls)licensed pursuant to the Contractor's
License law. PERMIT ISSUANCE
I am exempt under See .B&P C for this reason
Owner Dam ALTER-DRAIN&VENT-WATER HIA) VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECE DEVICE 1 /, �y\ . /\�
1 hereby uffrrm under Penalty of pmijm,one of the following declarations: `V �(X) lJ
❑ Ihave and will mainmina C<ni0mm ofCminno sl(-insure for Wotkefs Compcn- DRAINS-FLOOR,ROOP,AREA,GOND.
ration,us provided for by Section 37W of the Labor Code,for the Performance of the STORIES TYPE CONSTRUCTION
work far which this permit is issued. FIXTURES-PER TRAP
❑ 1 hove and will maintim Workers Compea,mart Insurance,ax required by Secfiun
3]OOofth a Code, a the performance ofthe work for which this tis timed. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APj✓.�
My Works it n n stance earrim and Pol i r U6 PY/
Cnmcr: PolicyN ((ice V GAS-EA.SYSTEM-OVER4(EA)
CERDSATI?OF EXEMPTION FR MW�KE
COMPENSATION INSURANCE CC GREASEIINUUSTRL WASTEINTERCEPTOR BUILDING DIVISION Ir131S
(This section need not be completed ifthe permit isforoneh ndnd dollars($100) GREASETRAP
m less) PLANCHECK FEE
I certify dont in the perfomunce of We work for which His permit is issued.:shall SEWER-SANITARY-STORM EA.20a)FT.
not employ my fiction in any mnnner,o as m becomu xuhjecuo the Workers'Com m- ENI7RGY FEE
ZZ sation laws of Colifomio.Dam WATER HEA]ER WNFNT/ELECTR
O Applicant I GRADING FEE
NOTICE TO APPLICANT.If,afar making this Certificme Of Exempoun,you should WATER SYSTEM/TREATING
a become abject.We Wmkcex Cion,ma tion provisions of the Lobo,Code,you must SOILS IEE
forthwith comply with such provisions or this permit shall be Jremed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL?LMB. SQ.FC PAID
LJ0 l forbynlBmitharmiti isscd(See i30 len Jing agency for the perbvmunce of Date Receiptp
k H the work for which this permit is issued(See l09].Civ.C.)
ULender',Name 'TOTAL:
w Lender's Address TOTAL:
1 certify that I have read Wis city
nc and,Ince Wut doe above information i, BUILDING THE
Z builder lagmerocomply nd Worby cityund countyoNinancesand siren lawsminingUpon the QTY, MECHANICAL PERMIT FEF-
U Z building conswaion,and hereby uuthnriae represmetive,of dots city to enter Upon the SEISMIC FBI?
above-ru ntiatim .,dy for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep hismless the City of Cupertino against ELECTRIC FEE
luddlami.jud it exports which may in y accrue almns,said City ALTER OR ADDTO MECH.
immmcecdoe tingmf Wis pcwL PLUMBING FEE
APP ANT l 'RSTANDS AND WILL WIT LL NON-POINT AIR HANDLING UNIT(TO 10,(00CFM) MECHANICAL FEE
S RCERE ATIONS.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Si o Applic HAZAhactnr Dam EXHAUST FOOD(W/DUCI) I IOUSING Xu ITGATION PEE
HAZARDO . MATER IAISDISCLOSURE
Wilhe ytepplicammfMuni building e,Chaptstore er
and
Health and
HEATING UNIT(TO 100,011)BTU)
n defined by the Cupertino Municipal Cede,Chapmr 9.12,and We Health and Safety
Code,Section 25532(0)] HEATING UNIT(OVEN 100.0401 BTU)
❑Yes ❑No PAID
VENTILATION PAN(SINGLE RTSIU) ])are Rcccipt
Will the applicant or future building occupant use equipment or devices which
emit hnmdous air contaminants a,defined by the Bay Area Air Quality Mmagcmem BOILER-COMP(3HP OR 100.000BTU)
AL'
District? BOILER-COMP(OVER 101,0041 BTU) -
❑Yee Fl No
AIR CONDITIONER
I have read We hemNous mamrials mgo:mments an apmr 6.95or the Cali- ISSUANCE DATE
Tania Hcslth&Safety Cade Smtions 25505,8573 and 5 .I u erxmnd that if the NEW RESIDENTIAL MECH. SQ.F1'.
buildingdeesn n eotemnLlhatitomy mibility notify the occupant
of the eats must he met priorm rotor or.Cert' um of Occupancy.
naor
to gem Dom TOTAL ISSUED BY.
OFFICE