99090014 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI TY OF CUPERTINO BUILDING-ELECTRICAL E MI
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. AP LICATION SUBMI DATE
40 e.vr T L •►�
NrERR'S NAME PHONE: C/O,N,TR R'S NCpME:J LIC NO: -
y A (A/p .l �TCMJ Q NIC CONTROLp
• ARCHITECTMNGINEM: LIC NO: ADDRISSg,yy Zal ❑
CONTACT PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
ID aX ❑
LICENSED CONTRACT'OR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm Nat I am licensed under provisions, m
of Chapter 9(comencing JOB DESCRIPTION
C5z wth Section 700))of Division 7 ofthe Business and Profession Craft,and my license is R - ID NTIAIz
+„100 t PERMIT ISSUANCE
ty r m full tone and effea.� ❑SFDWL E3 KITCHEN REMODEL
�U[�JJ License I. Li<.# APPLIANCES-RESIDENTIAL. ❑ADDITION PLUMBING RE-PIPE
f-Zul Dine Commcmr
ARCHITECTS DECLARATION ❑MULTI-UNIT STRUCTURAL
Z p on2 I understand my plans Shull be used as public records PANELS MODIFICATION
OZ�G UP TO 200 AMPS E3 INTERIOR El CHIMNEY REPAIR
-b]W Licensed Professional 201-1000AMPS IMPROVEMENT (]SWIMMING POOLS
cry OWNER-BUILDER DECLARATION OVER lot)AMPS
O BATH REMODEUREPAIR ❑DEMOLITION
K 1 hereby affirm that I am exempt from the Contractor's License Law for the
xxd O6 U following ream..(Section 7031.5,Business it Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER 0
W O E' which requires a permit to common,alar,improve,demolish,or repair any structureIN.y. prior to its issuance,also requires the applicant for such permit m file a signedstatement SPECIAL CIRCUTVMISC.
2�{y that he is licensed pursuant to the provisions of Ne Convector's License Law(Chap....
W BGG (commencing with Section 7000)of Division J ofthe Business and Professions Cade)or TEMP.METER OR POLE INST. OMCOMC hIFRCIAL:
a o y thin he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
^tis Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES TENANT ❑FOOD SERVICE
~=Cnor more than five hundred dollars(8500). IMPROVEMENT
❑ I.as owner ofrhe pmpeny,or my employees with wages as their wile compensation. SWIMMING POOL ELECTRIC�$ OTHER willdothework,andthe structure is notimendedmefferedfmmle(Sce.7044,Business
and Profe.suors Code:The Contractors License Law does nisi apply m an owner of OUTLETS-SWITCHES-FI%'TURES
1 property who builds or improves thereon,and who does such work himself or through
his own employees,provided thin such improvements are,not intended or offered for NEW RESIDENTIAL ELEI SQ FT.
sale.If.however the building or improvement is sold within one year ofeomplerion,the 7 $JFL FLOORAREA $/SQ.FT.
mer-builder will have the burden of proving that he did not build or improve for put- i/fa
pose c f rale.). -
❑ or
1,as owner of the property,am exclusively contracting with licensed contortion to TOTAL'
amsvuct the project(Sec.7I44,Business and Rete orm,Code:)The Co......'.....
cense law does not apply to an owner of property who builds or impruvea hereon,and QTY. PLUMBING PERMIT FEE
who comracu fo weli p jects with a contmcror(s)IiecnsW punuanuo Ne Commemes
ansa Law. PERMIT ISSUANCE
I vm exempt under Sec. .B&P C far this moron
ALTER-DRAIN&VENT-WATER III VALUATION
Owner Date
• WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE /(/AO �.
1 Urehy affirm under penalty of perjury one of the following declarations (J V/
(have and will maintain a Certificate of Consennoself-insure for Worker's Compete- DRAINS-FLOOR.ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
s radon,as provided for by Section 37M of the Labor Cade,for the performance of the
work for which this pemtit is issued. FIMRES-PER TRAP
I have and will maintain Worker's Compensation Insurance,us required by Section
]700 of the Labor Cwle.fonhepMormance of rhe work for which this permit is issue.). GAS-EA.SYSTEM-1 INC.40UTLETSOCC.GROUP APN
M TWorkvj oto nsario w nye cartierPo dY Ntcy nu her ere: ��-�`��-{p- GAS-EA.SYSTEM-OVER 4(EA)
.77 CERTIFICNE%EMOTION PR5� -I 3103011
COMPENSATION INSURANCE
GREASF/INDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
('Ibis section tecdnot bccompleted if,e Permit is fortune huMreddollars(5100) GREASETRAP
ter less) PLANCHECK HE
certify Nm in be perfommtce of the work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 FT.
.at an,[,any person in any manner so as 1.become object o be Workers'Compete- ENERGY FEE
O Z an ..Laws of California.Data WATER HEATER WNEN TIELECTR GRADING FEE
z O Applicant
NOTICE TO APPLICANT:If,after making this Cenifcam of Exemption,you should WATER SYSTEMrTREATING SOILS FEE
subject to the Worker's Compensation provisions of the�bor Cade,you must
forthwith comply with such poison......his permiuhall he dcemedrevoked. WATER SERVICE
Vn' CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.PI'. PAID Date Receipt#
ti m I hereby aRrthat then is a construction lending agency for the performance of
the work for which this permit Iv issued(Sea.3097,Civ.C)
IL (~ Lender.Name TOTAL:
{Vg1 Lenders Address TOTAL:
y 1 certify that I have read this application and state that the above information is BUILDING FEE
iF.t fn correct.I agree aN comply with all city and county ordinances and state laws relating to QTY MECHANICAL PERMIT FEE
C.) ,Z building construction,and hembyamhoriu representafives of this city feet,,upon the SEISMIC FEE
above-mrntioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to.save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgmcnts,toms and expenses which nary.....way nceme against said City ALTER OR ADDTO MECH.
in consequence of gram 11 of this permit PLUMBING FEE
APPLICANT :RS NDS AND W .COMPLY WITH ALL NON POINT AIR HANDLING UNIT(T010.000 CFM) MECHANICAL FEE
SOURCE: TI S. ` 7/ f
AIR HANDLING UNIT(OVER 111,gN1 CPM) CONSTRUCTION TAX
Sig arc of Appbcand ommnor Date EXHAUST HOOD(WMUCD HOUSING MITIGATION FEE
HAZARDOUS MA'L'. L. DISCLOSURE
Will duapplicont or future buildingece m store or handle hazardous material HEA'L'ING UNIT(TO 100,011)BTU)
refund by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
e.Section 25532(.)? HEATING UNIT(OVER 100,000 BTU)
❑Yes FIN. VENTILATION PAN(SINGLE RESID) PAID
• Dam R ipt
Will the applicant m future building occupant on equipment or desires which
emit hazmilous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(JIIP OR 100,00001V) T L
District? BOILER-COMP(OVER IM."BTU)
❑Yen [)No
I have tend the ha/�Nous m,riuls requirements under Chapter 6.95 of he Call- AIR CONDITIONER ISSUANCE DATE
fom'a Health ty�J tions 85 25533 and 255,14.I understand Nat it the NEW RESIDENTIAL MECH. SQ.FT.
building ort a am^yJ� nirmyrespomflublyto d rhe coupon
ofr�fF� trN LAiI�f ro issuance of a 'n of cu cy.
'I
TOTAL: r
Ow rvTdw7 red agent me - ISSUED BY:
OFFICE