99080130 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY jADDRESS
RTINO BUILDING-ELECTRICAL. PL MI NO.
BUILSION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILDING SANITARY NO. APPLICATION SUBMITTAL DATE
8 /6 - ? 7
OWNEPHONE: CO�[jRnSTOESNANfwn ,R,f �'C ND: � N/C CONTROLM.RCHITER: LIC NO: ADD1R•EISS:, A'��^�' � sell . ❑
Aj� 94 Lis'
f CONTACT. PHONE: BUILDING PERMIT INFO
❑ Conaullant Films Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATIONt
QTY. ELECTRIC PERMIT FEE 106 DESCRIPTION
1 hereby shimmer 1 am licensed under provisions of Chapter 9(co
OW with Sation]IXq)of Division 3of she Business and Professions Cud e,and mRESIDENTIAL
W O PERMIT ISSUANCE
F in fall force and elle ❑SMWL ❑KITCHEN REMODEL
FIJV License Cy,`s.'"�Lic.g ' pppUANCCS-RFSIDENI'IAL ❑ADDITION ❑PLUMBING RE-PIPE
Z uull Date—K Co ❑MULTI-UNIT ❑STRUCTURAL
ARCHITECTS DECLARATIONZp7Z I understand my plans shall be used as public recordsPANULS MODIFICATION
t-E UP TO 200 AMPSOZ-0 1 ❑INTERIOR ❑CHIMNEY REPAIR
p-�Fal Lhensed Ponesslonal 201-1000AMPS IMPROVEMENT 0SWIMMINGPOOLS
OWNER-BUILDER DECLARATIONOVER IUIlOAMPS ❑BATH RENO EURE AIR D OL N 1 hereby aRum Thai 1 am exempt from the Convector's License LBATHd V .f plowing reason.(Section]OJLS,Business end Professions Gde:Any citSIGNS F,LECfRICALt�LL,asich requires a permit To mnswa,almq improve,demolish,or repair anh.] prior so its issuance,also requires Ne applicant for such permit'.flea signeSPECIAL CIRCUIDMISC.
x;!1} mnthcislicensedpu..ritu a,mvisionsofthe Canusemr's Liccnu low lChapmr9 COMMERCIAL,
_00 Irminnoncing with Section 7000)of Division 3 of the Business and Professions Code)or EVR POLE INST.
L a nm mat he is exempt rhemfmen tend TM basis fee Ne uH.End exemption.Any violation of ❑NEW BLDGJADDITION []DEMOLITION
y Section]011.5 by any applicant for a pertnis subjects Ne applicant a civil penalty of S []TENANT ❑FOOD SERVICE
g.
m more pun live hundred dollars(SSW), IMPROVEMENT
❑ Los owner of thepropny,ormyemployerswithwagesastheirsolecompensation. LELEC'IRIC ❑OTHER
will do pe work,and the swcmre is not intendmimoRead for ale(Sec.7044.BusinessWend Profssions Code:The Cmarecmr's License Low does nt apply ro sn owner of TCHES-FIXTURESpropeny who builds or improves paean,and who does such work himself or throughhis own employees,providedpas such improvements are nut intended or offered for IAL ELF.CfR SQsale.If,however,The building or improvement is sold within one year of compliance,theSQ.FT.FLOOR ARUA SISQ.FT.
wner-builder will have the burden of proving That he did nut build or impre for par.
poseof stele.).❑1,a owner of pe pmpeny,em exclusivity contracting wiN licensed contranors mTOTALons mer the project(Sec.](144,Business and Professions Code:7cense Law does not apply to an owner of property who builds or improves demon,and QTY. MBING PERMIT FEE
who contracts for such projects with a contractors)licensed pursuant to the Contractor's
License Law. PERMIT ISSUANCE
1 am exempt under Sec. .B&P C for this reason
ALTER-DRAIN&VENT-WATER(GAJ VALUATION
wner
Data ^1�
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE /_/_ s w
I hereby affirm under Penalty of perjury one of me following declarations: 1�L�
❑ I have and will maintain a Certificate of Consent to self-insure for Worker's Compete. DRAINS-FLOOR,ROOF,AREA.GOND. STORIES TYPE CONSTRUCTION
/ sz m,us pnrvld,d for by Section 3]00 of The Latae Code,far the famore term of the
!\ war for which this pemTit is ismed. FIXTURES-PER TRAP
have and will maintain Worker's Compensation Insurance,as required by Section
] of the Ldxe Code,for she perfotmearmid The work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP 7j�pb[ .Z
My Worker's Co^ 9�°sign(�nxynoncerm and Policy n //
Cartier:r-I tli'1 CAJAg Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERSGRHASFIINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
('Nis section need not be completed if the permit is porch,hundred dollen($100) GREASETRAP
or less.) PLANCHECK FEE
I citify that in she perfor once of The work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.2W FT.
not employ any person in any manner so as so become subject to the Workers'Comper- ENERGY FEE
O ,Z section Lawgy(Cal'ft?ia., WATER HEATER WNENTIELECIR
z camicutn� l GRADING FEE
Appb NOTICE TO APPLICANT:If,after making this Cenificate of Exemption,you shnulJ WATER SYSTEM/fRP.A'1"LNG
h ; be subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
ecom
r pnMwim comply with such provisions or This permit shall be deemed revoked. WATER SERVICE
p" CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB, SQ.FT. PAID Date ecei M
I herehy construction that Them is a consetion lending agency for The performance of
WO me work for which This permit is issued(Sm.301 Civ.CJ
Q U Leaden Name TOTAL:
fU Lender's Address ' TOTAL:
y 1 certify that I have mail this application and state met he above information is BUILDING FEE
fn correct.l agree To comply with all city and county ordinances and state laws Existing'. QTY MECHANICAL PERMIT FEE SEISMIC FEE
V building construction,and hereby authorim representatives of this city to enter upenthe
above-memmead property for inspection Timprus. PERMIT ISSUANCE ELECTRIC FEE
(We)ri'memilife.indemnify and keep harmless me City of Cupertino against
liabilities.judgmenL' Ctrs cs whi ay in any way uccme against said City pI tF.R OR ADD TO MUCH. PLUMBING ME
in onsequence of ng of sspermit.
APPLICANT F AND. AND WEI LY WITH ALL NON-POINT AIR HANDLING UNITGFO l0.0WCFM) MECHANICAL FEE
SOUR R L NS.
AIR HANDLING UNIT(OVER 10,00(1 CFM) CONSTRUCTION TAX
St mreof Apphean onirannr Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Wlfimes,licanmrfuwm Wilding occupant pore or hanJlc haxardeus mescdal HEATING UNIT(TO 100,000 BTU)
as de tied by The Cupeninu Municipal Code.Chapter 9.12,and the Health and Safety
Coda Secdnn 25532(x)7 HEATING UNIT(OVER 100000 BTU)
❑Yes No VENTILATION FAN(SINGLE RESID) PAID Date ReceiptN
Will she applicant or furore Wilding cecupaul use equipment or devices which BOILER-COMP OHP OR 100,000 BTU) �+
emit hicaEdous air contaminants as defined by the Bay Arca Air Quality Management TOTAL:
District" BOILER-COMP(OVER 100000 BTU)
❑Yes .(qct
I have read ar materials imm,ms under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forNa Healm&S t .S eons 25505 5 5}1.1 undersand That if me NEW RESIDENTIAL MECH. SQ.
budder x spun onefifydnecacculan, U
.fm ch .t Mme T is se,a Certific of Omupancy.
Ow er ar authnn agent 1,107 D c TOTAL ISSUED BY:
OFFICE