99070013 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPWCATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATIONSUBMITTALDATE
LZ avid/ Sir• 7- 2- !` 9
OWNER: MIs: _ Q PHONE: CONTR CTO R'S NAME: N/C CONTROL
AKCHH'ECT/ENGINEER: LIC NO: DRESS: ❑
CONTACT: PHONE: - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby aRrtn Nm 1 am IicenxJ under pmvisions of Chapter 9(commencing _ JOB DESCRIPTION
WOZ with Section 70ata ofDivision3 orthe Business und Professions Codu aiW my license is RESIDENTIAL:
WOO ^ PERMIT ISSUANCE
C-F in lull forte erb cl. `7� 0SFDWL 0KITCHEN REMODEL
aUV Licene Lic.p gYPL1ANCEs-RESIDENTIAL ❑AUDITION ❑PLUMBING RE-PIPE
rl"a 6 i Uute 0e Contracror
ARCHITECTS DECLARATIONOMULTI-0NIT []STRUCTURAL
yp=Z ]understand neff.r darl W codes public escorts PANELS MODIFICATION
OZ , UPT02MAMPS ❑INTERIOR ❑CHIMNEY REPAIR
[=�F"; Licensed Professional 201-1000AMPS IMPROVEMENT C]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 1000 AMPS 0 BATH REMODEUREPAIR 0 DEMOLITION
w 6 1 hereby affirm that 1 am exempt from the Contractors License Law for the
X 36 b- fallowing mason.1Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL 427C 097 119"1
[I OTHER
W fi y which mquircs a pitman in connma,alter,impnwe,demolish,or repair any strucmm
I"'t=06 prior to its issuance,also requires me applicant forsuch Permit file a signed smmmant SPECIAL CIRCUODMISC.
WhWy, that he is licensed pursuant to the pmvisions of are Contractors License Law(Chapter 9 ati
y�o (commencing with Section 700(hof Division 3 of the Business and Profensluns Code)or TEMP.METER OR POLE INST. COMMERCIAL,
a L c
that he is exempt therefrom and the basis for are&]legal exemption.Any violation of0 NEW BLDG/AUDITION 0 DEMOLITION
K^� Section 0031.5 by any applicant far a Permit subjects me applicant to a civil penalty of POWER DEVICES
[]TENANT El FOOD SERVICE
not more Nun five hundred dollars(55 W).
E Z Y 1 IMPROVEMENT
wi hazoe w.k. mithemeny,ormyemployees wim tmdIasmeir sole compRustiess SWIMMING POOL ELECTRIC
W will dolhcwors and theswdure a tors Licenseereed Law
does ade of apply o art Boniness []OTHER
W 3 m and erty who
Cole:The ayes thereon,
tern License law dans not apply to lf owner of OUTLEtS-SWITCHES-FIXTURES
his own who boils,or improves therton,and who docs such work deed or m through
his own employees,provided thio Bach inrpmvemmnp me not intended or offered for NEiW RIiSIDENT'IAL ELECI'N SQ let.
fl
sale.If.however,me building or improvement is sold within ane year of completi0n,me D SQ. RAR IfISQ.fT.
owner-builder will have the harden of proving that he did not build or improve for pur-
pose of sale.). I
0 1,as owner of the property,am exclusively counted g with licensed carecaremrs m TOTAL: JUL 2 2 III
construct the project(See. .Business and Professions Cob:)The C+mu1999
Contractor LI- - - I
cense Low it,.,ma apply to an ow net of property who builds or improves thereon,und QTY. PLUMBING PERMIT FEE 1s7s7A /
who commit¢for such projects with a con metor(s)licensed pursuant to the Committers
License Law. PERMfr ISSUANCE O
I am exempt under See .B&P C for Nm
is ason y
ALTER-DRAIN&VENT-WATER(EA)
Owner Dale
• WORKER'S COMPENSATION DECLARATION BACK FLOW PROTE(Z .DEVICE
I hereby affirm under penalty of perjury one of the following declarations:
[have and will maintain aCenilicateof C'onsem to self-insure lin Worker's CumNn- DRAINS-FLOOR.RODE AREA,COND. STORIES TYPE CONSTRUCTION
sation,as provided for by Serum 37M of she Labor Coder.for me performance of me
work for which this Permit is issued. Il%TURES-PER TRAP
0 1 have and will maintain Worker's Compensation Insurance,as required by Section
37M ofine labor Cmde.far the Performance of are work for which this Permit is issued. OAS-EA.SYSTEM-]INC.4 OUTLETS OCC.GROUPI PN
My Worker's Compensation Insurance comer and Policy number are: F'J
Carrier: Policy No.: GAS-EA.SYSTRM OVER 4(RA)
CERTIFICATE OF MEMPTION FROM WORKERS'
COMPENSATION INSURANC17 GREASMNDUSTRL WASTE INTERCEPTOR
(This seedma need not tr cantplaeJ Lane permit is foron<hundreddollars(SIM) 9UIL.UING DIVISION FECS
or less.) GREASETRAP PLANCHECK FEE
I certify that in the performance afthe work par which this permit isianal.I ehall SEWER-SANITARY-STORM EA.2(M1 FT.
not employ any person in any manner so as to become subject o the Workers Coni ENERGY FEE
Z
ration Law�ggo��f Cubf Ua WATER HEATER W/VENT/EI,[CTR
z O Applicant XI f C Z A. - GRADING FEE
rex NOfICE'O APP.I AN'f:If.f S king I s Cenifcate of Exemption,you shmuld WATER SYSTE UTREATING
abecame subject to the Walker's Compensation provisions of the Labor Code,you must g014ti FEE
C17 forthwith comply with such pmvisions or this permit shall be deemed revoked. WATER SERVICE
CONSTRUCcIONLRNDlNG AGENCY NEW RESIDENTIAL PLMB. SQ.IT. PAID
a t
(-)0 Thereby affirm that there isncunswction lending agency for me perfomwnce of Date ptp
W P the work for which Nis permit is issued(Sec.3097,Civ.C.)
p Under's Name 'TOTAL:
r W Lenders Address TOl'AL: e
I cenify that 1 have mad this application and stale that the move information is BUILDING F -
o-Ei T0.d cotmn.1&gree m amply with all city and county ordinances and ,are laws relating to QTY. MECHANICAL PERMIT FEE
V Z building construction,and hereby aathots representatives ofthis city toenterupon the SEISMIC
above-mentioned property,for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep launders the City of Cupertino against ELECTRIC FEE
liabilites.judgments.costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in asequence of the grants n6 of this permit. PLUMBING 4
APPLICANT UNDERSTAN S AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT ITO 10.000 CFM7
SOURCE REGULATIONS �� 1100 MECHANIC E
/ AIR HANDLING UNIT(OVER 11). CFM) CONSTRUCf10 AX
III at reof�can on e Date EXHAUST HOOD ACMUCT)
HAZARDOUSi ATI:RIALS DISCLOSURE HOUSING MITIGA ON FEE
Will are applicant or future building occupant store or handle Innovators material HEATING UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Calc.Section 25532(x)7 HEATING UNIT(OVER 100.1000 BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RESIU) PAID _
lotWillthe applicant or future building occupant use equipment or devices which BOILER-COMP pHP OR I W.glo BTU) Date Reccipt M
.fit h mmodous air conmm anon an defined by me Bay Area Air Quality Management
TOTAL:
' JunictY BOILER-COME(OVER IW.IXIa BTU)
El Yes C3 No
1 have read the h ramdous materials requirements under Chapter 6.95 of mCall,e CaAIR CONDITIONER
ISSUA E DATE
fumia Health&t currently
Cale.Seasons 255at i 2553)and 25314.I understand motif me NEW RESIDENTIAL MECH. SQ.FT.
building Jssesmmut fachtr trust
mount,mut it is my responsibilityrto commnotify the receptor
of mere ui nts susses must net prior ofu Certitic&m of OuvpunNic
cy.
er or aid orf ed agent Dale TOTAL: ISSUED BY:
OFFICE