99080083 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILUINDDRESS: SANITARY NO. APPLICATIONSUIEV
/ ATE
OWNER'S NA/: PHONE: ONTRAMOR'S NAME': LIC NO: ���•
�0N ftldSour rlir 6 Z 3 3 99 NIC coNTROLk
HITECTIENGINEER: LIC NO: A
/C`F4f�UR' S �, ❑
oNTACI': PHONE: 8 WG PERMIT INFO
36.5'166, ❑ Cansultant Fees Paid by Applicant(Initial) BL eLECf PLUMB MECH
�eo oNr
TPE ❑
LICENSED corocorpAtTORS DECLARATION . QTY. ELECTRIC PERMIT FEE
1 barmy arum that 1 am Reenaw antler provitiana of chapter 9(commencing JOB DESCRIPTION
oCZ with Section 7")of Division 3 ofthe Business and Professions Code,and mylicenseie RESIDENTIAL;
�� null l orce and ellec PERMIT ISSUANCE
aUV License s tZ '6233F1,J ❑SFDWL [I KITCHEN REMODEL
yG4 Date �NComry^-• s A O/L� APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECT'S DECLARATION ❑MULT6UNIT ❑STRUCTURAL
Z p y 1 understand my plans shall he used a public records PANELS M' U N
CZ—Q UP TO 200 AMPS ❑INTERIOR MNEY REPAIR
Licensed Pattessional 201-IWOAMPS IMPROVEMENT CJSWIM INGPOOIS
aC JJJ OWNER-BUILDER DECLARATION G BATH REMODEUREPAIR ODEMOLITION
6 1 hereby aam excmp
ffirm that 1 r from rhe Ci m uch.es License Law for the OVER["AMPS
6 U following rea (Section ectiousi
n]031.5,Bness and Professions Crab:Any cit,nr cnvnt, SIGNS ELECTRICAL ❑OTHER
1x13 LLQ which requite a permit to conswct,alter.Improve,demolish,or repair any stmctum
p~puLO.i prior to its issuance.also requires the applicant for such permit to file a signed statement SPECIAL CIRCUITIMISC.
iyy that bels licensed pursuant lithe prnvisionsof the Cuntracmr's Liren.>e Luw lChap¢rH
0 (°"sentencing with$ection]011fp mf Division3nfthe Business and ProfessionsCNe)or TEMRSIFTERORPOLE ST. COMMERCIAL:
6 q Y that he is exempt therefrom and the basis for rhe alleged eumprion Any violation of ❑NEW BLDGIADDITION ❑DEMOLITION
iWf YN.
section 7031.5 by any applicant for a permit subjects the applicant a civil penalty of POWER DEVICES El TENANT ❑FOOD SERVICE
F Z y nm more than five hundred dmlurs(95110). NT
p 6 E]1.as costumed he property,or my employees with wages as their war compensation, SWIMMING P CELE IC
2 will duthe work,and theswmme is not inlendWmoficred fur saleSer. Busines HER
0. and Professions Code:The Contractors License Law does not apply to an owner of OUTLF7 -SWITCH - list
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements an not intended or offered for NE ESIDENFOAL ELECTR Q
sale.If,however,the building or improvement is sold within one year ofcompletion,the ,I�FL(IDR�REILJUJU�� hil SQ.Fr.
owner-builder will have the burden of proving that he did not build or improve for par- ' buu 11 11
pose of sale.). I
TOTAL'
0 L as Owner of the property,am exclusively contracting with licensed contractors to t r�
construct the project(Sec.]044,Business and Professions Code:)The Contractor's Li- r671
use Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE I r6
who contracts for such projects with a contrvcror(O licensed parsaant to the Com user's
License Law. PERMIT ISSUANCE
❑ Iaa,marptundef See. .B&PCforthisreason
Due. ALTER-DRAIN&VENT-WATER EA) VALUATION
owner
WORKER'S cOM of ijuryon DECLARATION BACK FLOW PROTECT.DEVICE /
I hereby alRmr under penalty of perjury one of the following declarations:
03
,,have anJwillf binaCeni37M of the Labor Coda.far
the Wmkeracef,he URAINS-FLOOR,RODE ARLA,COND. TOkIES TYPE CONSTRUCTION
tion,us pmvidhi for mi Section 3](N1 of the Labor Code,for the pcdonnence of rhe p t� \i N
work have
this maintain
issued. FIXTURES-PER'fRAP tVsi OC 9
❑ 1 have and will ode,fon Workeror anceo the w rkfor hi h required by Section
3](X1 of the Labor Code,for nM1e performance of the work for which this permit is issued, GAS-EA.SYSTEM-I INC.4OUTLETS OCC.GROUP APN
My Work CpTpimrWN^ceFameveoMYNrynymbesme�9y. GAS-EA.SYSTEM-OVER41EA)
Camiee ��11 1I�s 11'' GG1I OO YY ee C JJ
CERTIFICATE OF EXEMPTION FROM WORKERS' •�D 2007
COMPENSATION INSURANCE GRGSFJINDUSTRL WASTE( RCF.PIOR BUILDING DIVISION FEES
(Thissectmi
ion need not be completed if the pcti is for one hundred dollars($100) GREASETRAP
or less.) PLANCHECK PEE
Icer( hat in the performanceofthe work far which this permit.,issued,l shall SEWER-SANITARY- RM EA.200F..
note.pl y person in any manner so as to become subject to the Workers'Camper ENERGY FEE
All
sari .aws of Cidt..nia.Date WATER HEATER W ENTIELECIB
plicum GRADING PEE.NOTICE TO APPLICANT.If,after making this Certificate of Exemption.you should WATER SYST (TREATING
come subject m the Wo laa's Compensation provisions ofthe Lamar Cole,youmust SOILS FEE
forthwith comply withsuch provisions orchis permit shall IN deemed revoked. WATER SF ICE
0
aZ CONSTRUCTION LENDING lend AGENCY NEW SIDENTIAL PCMB. SQ.FC PAID Date Receipt a
V p Ifhereby whichaffirm thmthem issued(rvetion lending agency fnnhe performance of
rhe work for which this permit is issued(Su.JW).Civ.C.)
� Lender's Name TOTAL:
Lender's Address TOTAL: BUILDING FEE
tF+'•'' I certify that 1 have read his application and stale that the above information i>
TSA cancer.l agree to comply withal]city and county ordinances and sham lawsrelating to QTY, MECHANICAL PERMIT FEE
LJ z building construction,and hereby authorise representatives ofthis city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE
(WO,agree to save,indemnify and keep harmless the City of Cupertino aguirsm
liabilities,judgments.casts and expenses ishkinnray in any way aveme against said City ALTER OR ADD TO MECH.
in consequence of the granting oftM1is Ferrol. PLUMBING FEE
APPLICANT U' ERSTANDS AND WILL COMPLY WITH ALL NON-POTNT AIR HANDLING UNIT(1'0 MOM CFM7
SOURCER CATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10, FM) CONSTRUCTION TAX
nature of Applicant/Contrecmr Data EXHAUST HOOD OVMUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle bazxrdous material HEATING UNIT(TO I(N), BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,end the Health and Safety
Code,Section 25532(a)? HEAPING UNIT(OV , BTU)
E]yrs ❑No 1001100 VENTILATIONP (SINGLE RF.SID) PAID Date R eiptM
AML Will the aPplium nor future building occupant use equipment or devices which
nil h:Will Es air commharms as defined by the Bay Area Air Quality Management BOILER-C P(3HP OR 100,1X1!1 BTU) T a
isaic0
0y. ❑Nn BOILER OMP(OVER 100.000 BTU)
I have read the haystdous materials r�la months under Chaprtr 6.95 of rhe Cull- AIR NDITIONER ISSUANCE DATE
forma Health&Safety Cade.Sections 2550,25533 and 8534.1 understand that if the W RESIDENTIAL MECH. SQ.Er.
building does naavtmn0y ha a enam,thit is my respmslbilitym notify the Occupant
ierrrents which m. met no rssuana of a Ceai man,of Ocramucy.
Owner or amhoriuA wra Dam TOTAL: ISSUED BY:
OFFICE