99110021 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
•CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
RUILDING DIVISION APPLICATIONIPERMIT ['LOATHING-MECHANICAL
IIUILDING PROJECT IIIEM'IF'ICA'I'ION
BUILDING ONS: e /� Z/ ' // �k�. ��/� SANITARY N0. APPLICATION SUBMITTAL UA'I[
OW ER'SN3E: / �/ �O ONE' ��� CON CTR'S�NVxAh1E:C'� �� I.ICV6-_ NIC CONTROL#
AR CHIPEECCUENGINEE : LIC NO: ID ' S: ❑
e
corvracl': Pxorve: BUILDING PERMIT INFO
- 0 ❑ Consultant Fees Paid by Applicant(Initial) Ill ELECT PLUMB MI CH
El
LICENSED CON'TRACTOR'5 DECLARATION QTY, ELECTRIC PERMIT FEE rLrJ/
I hereby ararn Nat I n n Ecmnad ander pmvinlan%ar Chapiar 9 wammenhg JOB DESCRIPTION
Coy thSee, n700 Division 3oflha Bail nm..nd PmfessionnCedc,and my uceoai. RESIDENTIAL:
=� : walull fmv,,LmJ PERMITISSUANCE
�U� in halal Cb... f W C 61.ic.# ❑SFDWI. ❑KITCHEN REMODEL
6 U APPLIANCES ❑ADDITION ❑PLUMBING RE-PIPE;
yah Ualc '- CUnlmdor
FDL ARCH]'1"ECTS DECLARN'ION PANELS ❑MULTI-UNIT ❑STRULTURAf.
O Z o I unJerswnJ my plans shall he Iliad an public records MODIFICATION
UP TO 21XlAMY3 (]INTERIOR [3 CHIMNEY REPAIR
F�I:ual Licensed Pmfessioml 201-10N)AMPS IMPROVEMENT SWIMMING POOLS
OWNIiR-BUILDERDECLARA'fION OVERI(NX)AMPS ❑BATHREMODEfJREPAIR ❑DEMOLITION
C W a I hereby of rat that 1 am exempt from the Contractor's License law fm the
�LEt, M U following«umn.(Section 1131.5,Business end Professions Code:Any city err County SIGNS ELECTRICAL ❑OTHER
❑13 W F which requires.permit to con.tme6 alter,improve,demolish,or repair any structure
prior to its issuance.also requires the applicant far such pennino file a signed statement SPECIAL CIRCUTUMISC.
fyy that he is licensed puauunno the provisions,of the Contractors Licence Law(Chapter 9
� p0 (wunq,endng with Section 9(X)0).f Division Sot'the BladneanaP
nd r,fes...n%Core)ar '['EMP.METER OR POLE INST. COMMERCIAL:
d Xa that he is exempt therefrom and the ILI for the alleged exemption.Any violation of ElNEW BLDG/ADDITION ElDEMOLITION
LL• Section 7031.5 bny applicant fora pe , suhjens app
the licunl too civil Penalty of POWER DEVICES
.Mo, mit []TENANT [I FOOD SERVICE
F. nal morn that,five hundred do ors y amp. SWIMMING POOL F,LE
Z>' IMPROVEMENT
Sa QLo the%ork.the property.o[mycmntended wiNwages a.ale(Sac.r sole compensation,
will dolhewo[k.Code
Me Care is BotLicense Le does
Illy to a. Business El OTHER
tail^m and Pmfeah b C«lor imp stersContractors License law Jces nm apply m,an owner of OUTLE'T'S-SWI'(' FIX'1'l1R
his,"Ll,own who builds or improves i and who docs such work himself or through
sal awn employees,e barldi g nonsuch mens iu olare not intended or a0cnd for NEW RIiS1UFiNT L I!LI!CtR S
owne f,however-bukhr w ll have the himlmpmvemeng t roaddidwithin one build
in improve
the SL IT.FLOOR AREA ,S/SQ.EI'.
cr-,milder will have the burden of proving Lha her did not build m improve for pur-
pose of salol.
❑ I,as owns of the properly,70b ala exclusively contracting with I,renaex.contractors m TO
outran the project apply
to an unaBusr i ss and rly who tui builds
The contractors Li-
cause Law does not aPPlyman awneconarePeny whnrod pimimalothe .aricund QTy, PLUMBING ERM( SEE
who umtmew for such pmjeca with a cummefor(.)licemed Pureuam r,the Commends
License law. PERMIT ISS CE
❑ 1 mer exempt ander Sec. .N k P C for this nauseaIf
R-DRAINK -WATI!N
Date VALUATION
WORKER'S COMPENSATION DECLARATIONBACK I _ IR(IIECT.1 Cli
Iherehy a[firan under Penalty nl'pwjury one of the following deulumliorw: p
Q l have and will maintain a Certificate ofConsem e,sit insure fav Workers Co.,.- DRAINS-FLIX. OOE,AREXND. STORII!5 'TYPE CONS'["RUCTION
seeon,as provided our by Section 3900 of the Lubar Code,[(it the patrimonial u[the
work far which this permit is issued. FIXTURES-PER TRAP
E]1 have and will maintain Worker'.Compensation Insurance.as require)by Section
3100atlhc label Code.for the Ke &maance of the work for which,hi,pcimit is issued. GAS-EA.SYSTIiM-IINC.40 OCC.GROUP APN /�
My Worker's Ca tp lsatioq carat scarier unJ Polkyl Utah�lr yyqpk ee[n�/
Carriee Policy Nn.: /L/Y�V(9d Y/ GAS-EA.$YS'fEM-OVER4(EA7
CEftt'IPIC OMP EXGAON INSURAN WORKF,RS'
COMPENSATION INSURANCEGREA US'1'RL WASTE INTF.RCEI'TO
(This section newt nm Mcomplwed ifNe permit is Tanana hundred JndollarslE(SIM) OREASIi ETRATRAP
BUILDING DIVISION FLH.3
or kiss) 1'LANCf{ECK FEIi
I eerily that in the arfurtmare ofine work for which this Permit is issued.I%hill SEWER-SANITARY-STORM EA.200 FT.
not employ any pers%m i.......er so asn,beeson,ubjmlm the Workers'Compeer- ENERGY FEE
ZZ octan Laws ILL CLIN sin Dam WATER HEATHR WNEN'UELECI'R
Applicata GRADING FEE
to N[ICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER S1;STEStwtEATING
1-5 become subject to the Walker,Cron Ilion f the labor Code, 1 mite SOILS FEE
penia arov,hol o yo,
forthwith comply with such Provision.ar this permit.oull be dcrntm invoked. WATER SERVICE
7z CONSTRUCTION LENDING AGENCY NEW RISIULNI'IAL PLMII. SQ.1.1', PAID
V O Iherehy affirm that them i.%ncausw<tiun lending agency fmtlau,soormanceof Data Receipt#
the work for which this permit is issued(See AND,Co.C.)
I"v Leaped,Name - 'I'UTAL:
L.1 Linda,Address TOTAL:
1 certify that I have read this application and stale that the above Information is BUILDING FEE
F h concur I agral in comply wiN:J1 city and canny m1naloces rand state law,reltting m QTY, MECI IANICAL PERMIT FEE
U z building consuuction,and hereby immunize representatives of Nin city to enter upon the SEISMIC IEE
above memionW pmpery for inspection pumoac PERMIT ISSUANCE
(We)agree to%ave,indmnaify and keep ha iall,the City of Cupertino against ELECTRIC PEB
habil'anx.judgments,costs and expemes which may in any way accrue against said City ALTER OR ADD TO MECH. -
in consequence of doe granting of this permit, PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WI If ALL NON-POINT AIR HANDLING UNIT Of 01 Onk)CFM)
SOURCE.REGULATIONS. MIiCHANICAL FEE
AIR HANDLING UNIT RIVER 10,000 CPM) CONSTRUCTION TAX
Signature of ApplicanlCommicmr Data EXHAUST HOOD(Wmducr) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stoic or handle h toodom%material I(EATING UNIT G 0 100,1100 BTU)
Las defined by the Ce,artinu Mi mcipat Code,Chapter 9.12,and he Health and Safety
Coda,Scciion 25532bo? ( HEATING UNIT(OVER 10131 01i'TO)
0n
❑Yee 0N
VENTILATION PAN(SINGLE RLSID) PAID
Data NettiplN
Will the applicant or future building meupmm use egoipmenf or devices which BOILL'k-COMP(JHP OR 100.0X1 BTU)
it hanoNnun tar nnlumimm�s as ddined by the Bay Arm Air Quality Management
TOTAL: b
District? BOILER-COMP(OVEN 10110IYJ I1'I'U)
]Yea Fl No
AIR CONDITIONER
I have mad the h ode S.materials requirement under Chapter 6,95 of the Cali- Q //' (SSU^NCE I]�TE�
fomia liealm&Safety Code,Se 'ons 8505,25533 and 25534.I uidemmnd Nut if the NEW HIi51UEN'1'1AL MECH, S fT. 3 c7�
tui ',gdocvnat um:nt uI, a n a,Nmll,,at n.pnnsi, ,Iy lanoli'y then cupnm
of Cf Ur.in lncnss Wlllt (prior ala GcrtiBC' C py
Norized a rat lute TOTAL: ISSUED BY.
OFFICE