99110169 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 47g 01 &q
CITY OF CUPERTINO BUILDING-ELF.C'I'RICAL PERMIT O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
t'BUILDING PROJECT IDENTIFICATION
IIDILDING ADDRCSS: SANITARY NO. APPI.ICA'I I 'SI )ATI
:2 0 _4 n/ o n) Or�� �,✓4 LN/T
OWNERS NAh1Er � HONE CON'I'RACI OR'S NAME: LIC N(1: _
l!/1 O NIC C� CONI'12UL#
1RCH" O (NEER: LIC NO: ADDRESS: ❑ / 7 .R1
CONTACT. PHONE: - - BU ILUINGPERMITINFO. 1
O-30 C9 ❑.Consultant Pecs Paid by Applicant(initial) B,LDDG ELECT PLUMB MECH
tl LJ Q^- 2— ❑—
ICENSI D Cf RACIOR S DLCIARATION QTY .ELLCTRIC PERMPF FEE
1 herehy afntro th t I licenced under r if Chapter 9(comma ing - 11
JOE DESCRIPTION
QAC wiW Sat on]IIIIU)niD 3 fthc Bus'nex.end Cn anA tylica use ie PERMIT ISSUANCE L
F W F in full tome and Rca s SFDWL ❑KITCHEN REMODEL
�UU Lcenxc Cl hic.N APPLIANCES-RESIDENTIA1. ❑ADDIT[ON ❑PLUMBING RE-PRIF
N Q 4 Dale TS DEtnr
ARCHI'I£CTS DECLARA ❑AfU1.TI-UNIT ❑STRUCIVRAL
PANEL'S
Z o 4 X 1 understand my plans ansa rK aced as public records MODIFICATION
a -
OX -Q UP T02m AMPS El INTERIOR ❑CHLMNEY I2Ei'AIR
F+rG)k'W Liccn.N Pmfessiond 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
gxN; OWNER-BUILDBR DECLARATION OVER 1000 AMPS El BATH REMODEIJNEPAIR El DEMOLITION
CCd thin aRnn'M1Iran exempt from the Cnntmcmr's License Law for the
6 U fnllowin Section]031.5,Business and Pries.....Cute:An cit tELECTRICAL1 ❑OTHER _
guires a.( 3 Y or county SIGNS
3 W ya priori requires n permit re uirmnn,alter,improve,demolish,or repair any swcmrc
prienni'sis.umt e.purstorcyuire.tbovisiosofe appheram toe such Connector tofile aicense signed(Chapler) SI'IiCIAI.CIRCUIT/MING.
SS } that he is licensed pursuammthe provisions of the Connectors License Law(ChuPter9
y..f6C, (tutmmancingwin Jcclimn]I1051n1'Dlvisi..n Sol he Budnosx and ProEr,omrs Ovu)or TEM P.M BTER OR POLE I NSMAY 1 COMMERCIAL:
46 a 'bat he is exempt therefrom end the basis for the alleged eaemption.Any violation of ❑NEW BLDG/ADDI'HON ❑DEM(J1.1'1'PON
Section 70315 by any applicant for a permitsubjec's mcapplicaut to a civil penaltynf POWER DEVICES
µ1.+y _ TENANT ❑FOOD SERVICE
FZY nn'
p Q aregan rive hundred sml' IMPROVEMENT
7Lus owner oftM property.or my employees
with wages as their olc a,mpcnxaion, SWIMMING PIX)L F.LIiLTtIUILDI
2 0 will dothewnrk,and the he Conference,
,Licedo Law does o,apply
to an -act
❑OTHIeR
and Profession.Gran The Contmerco License Law does not apply m an owner of OU'TLEfS-SW ICliliS-PIX'IVRIS
]properlyits own who builds or ided]that
there..i and who improvements
s each work led o f o erectfthrough
bis own however,
the prilding d+a'such improvements arc not intended or offered for NEW RfiSIUEN'TIAL IeLECI'It SQ PI'.
'
sale.ll;however,the hmilding(it impnrvemem is odd wi'Lin one year of cnmpininn,the - SQ.FT.FLOOR AREA LSQ.14.
owner builder will Lave the burden of proving that he did pol build or improve lin pur-
pase"Oule.).
[:] I,as owner of the pminlicensedy,am excluxively contracting ith licensed contricmt.to TOTAL. /y O
con to t thep j t(Sec ]BM,Buaneu d P f. .C,de)The Conawa .L' _ [j1
i d t applyman nw to n'p p ty h h ILnr mprnvox'be. d QTY�' r,PLL RMIT� ';f„ , FEE
who contracts for such Projects with a ennvecen(s)licensed pursuant to the Contractors
Licence Law. PERMIT ISS ANCE
❑I am exm.pt under Sec. .B A P C ti,r this rens... _
ALTER-1 AI -WATER(EA) VALUATION
Owner Dam
WORKF.NS COMPENSATION DECLARATION BACK Fl-&i'NOTF,QI'.1 CF.
have
and wuffirm under Certific of e ps,ofCon mi of be fnsum or leclar's Co V-^'v
❑ Ihavc and will maimei Se Cenificateof he Labor
ode.for the fforman Confiner- DRAINS-FLOOR,RU(SF,AItEA,C 3, S'I'ONIES 'TYPR CONSTRUCTION
satin..,oc provided for by is
3IIX10(the Labor Code,for Ilia pedittmanee..(the
work for which this permit is issued. FIX'I'UltiiS-PER TRA 11,
❑1 have and will maintain Worker's Compensation Insurance,m required by Section
J]m of Ncl Come,for tM1epe 'ornun of'M1c work for which tRis-p - it idlxsued. GAS-P.A.SYS'PP.M-I INC.iOUTLETS; OCC GROUP APN
My We, do tt c an t er
Carrier: s ora ma Stt . . GAS-EA.SYSTEM OVER4(EA)
CL T TEYII',FJ( 1PT N 10 RK '
41.�R I GREASFANDUSTRL WASTE INTERCEPTOR
This secdnnn no.Mwnnplet if the Permit i.forme hundmd dollars f5100) BUILDING DIVISION PERS
or less.) GREASE'I RAI' PLANCI ilLCK FEE
I cenlfy that in the performance(tithe work fnrwhich this permit is issued,l shall SEWER-SANITARY-STORM i?A.200 PI'.
not employ any pern in any marine, it as to hccomc s.bjcm to the Workers'Cornier. NERGY FEE
O � nation Lows of Gd;forms, Date WATER II EATFR W/VENTIELEC'III EE
Applicant GRADING F
NOTICE:[()APPLICANT:IL..Ref,making this Cenifeme of Exemption,you shmdd WAFER SYS'IENbTREATING SOILS FEE
> become subject to the Worker's Cnmpensadon provisions it the Luhnr Com,y..0 nmst
LWY forthwith comply with such provisicntodri,per¢it shall be deemed revoked. WATER SERVICE
a
CONSTRUCTION e,jim le AGENCY NEW RG5IDF,M11A1.I'LMIi. SQ.Irl'. PAID
r� z Dale Receipt p
C.) QI frwhichrnt permit i iesmn(See.397.Cng urgencyfnr]he Ncdovnuncc of
the work for which this permit is issued(Sec.3097,Civ.C.)
u" U Lenders Name _ TOTAL:
0 L.endcr's Address TO'T'AL:
p, 1 certify that I have read this application and state thm the vMwc information is _ BUILDING Fill:
Yn correct.I agrccnatmpty with all cnynaeeaamy nrdirence.tnd.tate rows rehiring to QTY. MECHANICAL PRIZMIT ,PEE.,
V 7a building constriction,and hereby authorize rcpresctna'ives ofthis city to enter upon the SIUSMIC FIE
ubavo-mentinned progeny for inspection purp(tres 1'I!RMI T ISSUANCE:
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELIiCTItIC PEI?
liabilities,judgmnn.,costs and expenses which may in any way acemeagainst said City ALT ER OR ADD TO MECII.
in comeque yr1lif the,mar ng of this smntit PLUMBING TEF.
APPLICA 'I I(NDERS'MNDS AND ILL COMPLY WITH ALL N N-POINT AIR HANDLING UNIT(TO 10,M)CFM)
S(1lJRC' i rr H.xrhONS. s /� 1P a MECHANICAL FEE
R�Is�]" /� �( /h///z ) AIR HANDLING UNIT(OVER IQWOCFN) CONSTRUC71ONTAX
Si&natu dApp teant/Cnnrmc !!!///D�o(/(�/v EXHAUST HOOD(WNUC'1')
11(IURING MITIGATION FEEHAZARDOUS MATERIALS DISCLOSURE
Will the npplicam or fmmre building occapom cmor handle hommouc material I]PATI NO UNIT(TO I00,IXIf)BTU)
as defined by the Cupertino Municipal Calc,Chapter 9.12,and the licalth and Safety
Crude,St 25532(¢)'! HEATING UNIT(OVER 100,050I1.1'U)
❑Yes -
VENTILATION, ION FAN(S[NOTE RIS ID) PAID
9f Date Reay,,a
Will the applicant or more,building occupant use cgoip cent or devices which
'emit husnrdnus it,wmumim, I ys Jahned M1y the Bay Arca Air Quality Management BOILER-COMP CSHP OR[00,00 BTU)
District? !,.-I(/r,- BOILP.R-COMP(OVER 100,000 BTU)
Yes
AIR CONDITIONER
I have natat,1t ;eafmm m:ncduls requirements under ChaNcr 695 oftbe Coli- ISSUANCES DATE
tori.licand&S-t/Iy1 de,Scdimt.25505,255}3 and 5534.1 mulcts' d that if the NEW RESIDIiNT1Ah MECII. SQ.PI'.
buildingdnesn cu n,yhaveateman, tl'' y responsibility to folif the.c pant
offfs"equice eau /UU�h tittle o u oft: iSartlli
Owneroraw I���^aVgwt Diftc TOTAL: - ISSUED BY;
OFFICE