99090109 �APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY P
BUILDING-ELPICTRICAI, -
CITYOFCUPERTINO APPLICATIONIPERMIT PLUMBING.MECHANICAL
BUILDING DIVISION IIUILDING 1'NfIJ I:CT'IUEN'flPICA'TIUN
SANITARY NO. APPLICATION SUBMITTAL DATE
BUILDING ADDRESS: �� ^� _ J�
/D 6S CSA K /J _ TIC NO W AME: AC /A L JI 1i: C() IRACI0 '1 Ms.�� gyp N/C CONTROL#
CI ITECI'/ENGINEER: J fI'.I(e"o. ' p0 era ❑
e1 F- BUILDING PERMIT INFO
CONTACT: PHONE:
❑ Consultant Fees Paid by Applicant(Initial) B,hA-,C�{ ELECTPLUMB ME�CrH�
L41d"'- IJ ❑ lS
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT PEE JOB DESCRIPTION
1 hereby aRrm that 1 am licensed under pmvivions of Chapter 9(commencing RFCI�AL_
Qaz with Section7000)of Division 3ofthe Business and Professions Gde,.nd or,Teeple is PERMIT ISSUANCE ❑SFDWL ❑KITCHEN REMODEL
ILL-
WOO full force and a act.
aWr rn' AI'I'hIANCIS-NIiS1D1iNTIAL []ADDITION [I PLUMBING RE-PIPE
Q U U License Class Lic.p
i-zw Date Contractor ❑MULTIUNIT []STRUCTURAL
rn 6 L ARCHITECTS DECLARATION PANELS MODIFICATION
0�Z Iunderstandmyplansshallbeuael-a Public records UPT0200AMPS [I INTERIOR '❑,�/CHIMNEY REPAIR
,Z NT IQoWIMMING POOLS
.N.F Ltd Licensed Professional 201.1000AMPti
Y
.] OWNER-BUILDER DECIARATION OVER 1000AMPS ❑BATH REMODEUREPAIR El DEMOLITION
S W U 1 hereby affirm that 11. exempt from the Contmcuro a:Any c Law div the [I OTHER
O LL U following ream.(Section] Basila end improve,
d nio demolish.
Code:Any cin in county SIGNS ELIiLTRICAI,
LL O N which req.ircs a permit poh.t construct,aper.improve,demolish.or repair any structure
C, proms fievoled roam-1I.he mvixim,of Torsion Licensle e aw(Cha ter9ant SI'IiC1ALCIRCUIT/MISC.
G� dot he itcingwit pSmtion70he pm visions 3the Continem, License l,aw(CM1apar9 R
moo
(commencing with Section]gM bf Divisionlofthe BusinesP and Pmfc-ainnsCode)or TI MP.MhTER OR OLE INST. WBLDG/ADDITION []DEMOLITION
W Nat he is exempt themfmm and the basis for the alleged exemption.Any violation of
y
Section 7031.5 by anyapplicantfor a permit subjects the applicant to a civil Penalty of POWER DBVICES ANT ❑FOODSERVICE
FZP no,more than Eve handled dollars($500). IMPROVEMENT
ESaO ❑La owner of the Property,or my employees with wages as their sole emnpensation, SWIMMING POOL ELECTRIC OTHER
(., will do the work,and thenmchne is net intendelm,iff mad for-[a(See 7) .persinesn OVTLIi S_SWITCHES
W 3 and Professions Code:The Contrsnor's License Law docs not apply to an owner of
pmpeny who builds or improves thereon,and who does such work himself me through NEW RESIDE TIAL ELECIE SO ET
his own employ.,.provided that such Improvements are not intended or offered for SQ.IT.FLUOR AREA S/SQ.FT,
sale.If,however,the building or improvement is sold within one year of completion,the
wne-builder will haw the burden of proving that he did not(wild or improve for Pur-
pose of sale.). TOTAL:
Fl I,s owner of the property,am exdusivdy rontracting with licensed contncmrs to
command use project(Sec.7014,Business and Professions Code:)The Iona o's Li PLUMBI RMIT FEE
t.Law does not apply m an owner of property who builds o improves overran,and QTY,
who mamma far such projects with a contractual-)licensed Personal o the Contmcmrs
License law. PERMIT ISSUANCE
1 an exempt under Sec. .B sa P C for this moon
ALI ER-DRAIN&VENT-WAT17R(EA) VALUATION
net Dale �f1 /lea
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE I Qa yp vy
w I hereby affirm under penalty ofperjun one of the following deellostronc
❑Ibave end will maintain aCenifcam of Consent to sdGinsure fur WorkcYs Coogan- DRAINS-FLOOR.ROOF AREA,CORD. STORIES TYPE GON$TRDCfIQN
an ion,a provided far by Section 37W of the Labor Code,fur the pa fomanue.f the FIXTURES-PER TRAP
wok for which this pernot is issued.
❑I have and will maintain Workers Compensation Insurance as myu toed by Section GAS-EA.SYSTEM-]INC.40UTLHL'S UCC.GRUUV APN
37W ofthe Labor Cads,for the performance of the work for which this Permit is issued. tee/
CyWod,f. Compen,liaq A/W cA —a Poky `c rt GAS-PA.SYSfEM-OVER4G3/G
n� CER IICCA'EOF EXEMPTION FRO�ER� GRIiASI%INDUS'FRI.WASTEIKMRCI7P1 R
COMPENSATION INSURANCE: BUILDING DIVISION FE-ES
lTbis merlon n«dnotMcomplemdifthe permit is forme humloxIchi islS100) GREASETRAP PLANCHECK IME
o less)
I cenifythetinthe perfr mance of the work for which this Permit is issued,lzhall SEWIiR-SANI'I'ANY-STORM EA.2lp Ell ENERGY FE[
not employ an'
[e^ �aa��Y as a�kn be bi t e Worked Campen-
Z tion Laws eR .D a mer x:Y cryys��k lh WATER HEATER WNEN'T/ELECTR GRADING FEE
z N6TI am Y xon T7
NOTICE TOA ,.Koro onmarf csions of
Labor Csh,you
WATER Sys'1'Ehl?R(iA'fING ITS FEE
f, become subject y the ch pre Compensation provisions d the labor Cute,you man
forthwith comply with hpmvisiom or this permit shall he deemed mvokeJ. WATERSERVICE t .,
PAID
CL.
!1----
CONSTRUCTION NEWRESIDENTIAL PLMB, SQ.FT. tr pp 1^Dp �I I, ccetptp
Q. fl 4
L)QI hereby affirm thin there is a construction lending agency forthe peffnamnce of
the work for which this permit is issued(Sec.3097,Civ.C.) L/� TOTAL:
ULender's Name TOTAL:
WLenJds Address BUILDING FEE
Its 1 certify that I have read this application and state that's,chase information is
rN correct.I agree to comply with all city and county ordinances and state laws returngm QTY. MECHANICAL PERMIT y
V Z building eonsuuelklm and hereby anchone,representatives alums city to enter upon the
awsm-mentioned progeny for inspection purposes. PERMITISSUANC17 ELECTRIC FEE
(We)agree is,save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments.costs and expenses which may in any way accrue agaiosuaid Cin ALT ER OR ADD TO MECH. PLUMBING FEE
in ouseyuence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITOO 10.000CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
Signore of ApplicentrContracom Data EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hvnrdous material I EATING UNIT'(TO 100,000 BT Of
as defined by the Cupenlna Muniso aI C hapmr 9.12,and the Health and Safety II RATING UNIT(OVER 100,000 BTU)
Code,Section 25532(a)T k
❑Yes VEN'TILA[[ON BAN(SINGLE RESID) PAID
a Date R
Will the applicant or future Willing occupant use Noipment or device-which BOILER-COMP OMP OR 100 OW B'TDI
mit humrdous air conuminums as JyIYteJ by the Bay Area Air Quality Manxgenmm
Distncf! moi/ BOILER-GQMPIOVBR I(NI IYJB RTUI
❑Yes
AIN GQNIJIT TONER ISSUANCE DATEVQ
I hvvc rwJ the huwrJnus tnatuiuLv reyulrcmuae coder Chapter fi.95 0l the Call-
total.H afety Gde,Soetiuns 2551 S,2.5533 and 25534.1 understand that If the NEW Rli51DEN"I'1A),MPCU, SQ.FI'. h
buil - gdoes not neatly havPaleumll itis my in",adilitym nobly the occupant
meals which, n •mat a of a Cunllicate Oce ,
Own of, ".eJ agent Once r 'IUl'AL: ISSUED BY:
OF IC