99120113 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY q Ian i I
CITY OF CUPERTINO BUILDING.ELECTRICAL J 14 T�TTi ,
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL ply`
BUILDING PROJECT IDENTIFICATION
BWLDINGADDRESS: 7SANflARY NO. APPLICATION SUBMITTAI.DA'
NE M is-a ^9
OWNERS ME: PHONE: C CTO ' NA LIC NO:
I'd lei Jr A i� k CONTROL#
CHITECf ENGINEER: LIC NO: AD BESS
E
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT MECH
❑ ❑ ❑
Lm that IDCONTRACTORS mber,o ECLARATION QTY ELECTRIC PERMIT FEE
O Z I hereby affirm that 1 am licenud under provisions of Chapter 9(commencing JOB DESC IPTION
�O withSectionV0effim DivisionJaf the Business and Professions Code,and my license is PERMIT ISSUANCE RESIDENTIAL'
E n fall forces eBect.
G Vz U License Class Lie,N ❑SFDWh [3 KITCHEN REMODEL
yQL Date Contractor. APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
ARCHITECTS DECLARATION PANELS ❑MULTLUNI'T []STRUCTURALZ O Z I understand my pa s
lanhall bo used as public recv,M,
O Z- 9 MODIFICATION
DPT0200AMPS
1-, �O Licensed Professional ❑INTERIOR ❑CHIMNEY REPAIR
Q ='�, 201-100DAMPS IMPROVEMENT
pd k -q OWNER-BUILDER DECLARATION E]SWIMMING POOLS
^y W 6 I heresy affirm that 1 em enempr from the Commemr's License Law for the OVER IOOU AMPS ❑BATH RFMODEVRE U. OLITION
1!O
t 3MV following reason.(Section]IUL5,13udne,s and Pmeoin e,Code:Any city or county r
a SIGNS ELECTRICAL El which requires.permit to nmstma,abet.improve,demolish,o!repair any sweats
N primrm irn issuance,also requireanc�epplicam far such permiuo file a,igneJ stmement SPECIAL CI RCUTOM[SC.
�p.. that he is licensed pursuant to the provisions of the Communes License Law(chapter 9
co6y'p0 (commencing is ith Section 7")of Division 3 ofthe Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL
that he is exempt therefrom end the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
m Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
F Z?� not more than Ove hundred,atlas(E500). ❑TENANT ❑FOOD SERVICE
a < ❑I,as owner of the progeny,or my employees with wages as their role compensation, SWIMMING POOL ELECTRIC IM V
C will do the work,and the anwors isms imeadedoroRered for.vale Sm.70,W,Business ❑ /4. 1 W
W3$ and Professions Cade:The Conwemrs License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURESit. �
propeny who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or alfendl for NEW RESIDENTIAL ELECTR S
salt.IL however.the buildin8 orimpmvemcm is mid within one ycaaf completion,the SQ.FT.FLOOR AREA SISQ.FT.
wner,milder will have the burden of proving that he did not build or improve for par-
pox of sale.).
[11I,as owner of the property,am exclusively conuavedr,with licensed counselorsm TOTAL:
muccu t the p j.(Sec.7W,Business and Professions Code:)The Comractmrs Li-
c u Law dues not apply to on owner of progeny who builds or improves thereon,and QTY, PLUMBING PERMIT FE
who contracts for such projects with a con melons)licensed pursuant o Hie Canonici Q
License law. PERMIT ISSUANCE
❑ 1 am exempt under Sec. ,B&P C for this mason
ALTER-DRAIN&VENT-WATER(EA) as O ��
Owner Dam UA O
WORKERDEC a'S COMPENSATION DECLARATION BACK FLOW PRIJI'ECT.DEVICE
it I hereby affirm under penalty of perjury one of the following deck mrioms:
Ihave end will mainminaCmiOcnm ofConunuo mlLinsurt fm Workers Cooper- FLOOR,ROOF,AREA,COND. STORIES YPE CONSTRUCTION
sawv,m provided for by Section 37M of the Labor Core,far the performance of the
work for which this permit is issued FIXTURES-PER TRAP Y.
❑1 have and will maintain Workers Camperosaion Inmranm,as room ed by Seetion
37W of the Labor Code.Inr Hic pert Trounce of lhu work fnrwhich this permit is ixaucd.
GAS EA.SYSTIiM-I INCA OU'1'LLTS OCC GROUP AI'N
My Warkees �SBu In—su�^Jce carnet and Policy number are:
Came,.— Policy Nn.:�_ SYSTEM-OVER4(EA)
CERTIFICATE OF EXEMPTION FROM WORKS 5
COMPENSATION INSURANCE DUSTRL WASTE INTERCEPTOR
(Mil action bond not W completad if Ne permit is formic hundred dollars($1ItBUILDING DIVISION RIBS
ter IcssJ RAP PLANCHECK FEE
l certify that in the penlunnancenOhework for which Hiispermit isissued,Ishall ANITARY-STDRM EA.2W Irl'.not employ any perms in any manner so as to become subject to the Workers'Crimper- ENERGY FEE
,aria.Lows mf California.Dam
O A licant I ATER WNENTELEMRZPGRADINGFEE
STEM,TRFATING
ta' become.abject it the Workers Compensation provisions of the labor Cale,you mus SOILS FEE
a Q fonhwith comply with such Provisions or this permit shell W deemed revoked.
WATER SERVICE
Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.EL PAID
V I hereby affirm that hem is a consmmtion lending agency for the performance of Data Receipt
LT. (•' the work for which this permit is issued(Sm.3090.Civ,C.)
ULender's Name
Lenders Address 'TOTAL: TOTAL:
0. I ccnify Him 1 have mad this application and state that the above information is BUILDING FEE
V) correct.l agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE.
building consmmum.and hereby authadu reprcumatives of this city m th
enter upon e SEISMIC FEE
shove-mentioned pmpeny for inspection purposes,
(We)s to save,indemnif p y o pc g PERMIT ISSUANCE( gree y and which
harmless the Cit f Cupertino s cannot sty ELECTRIC FEE
incoiuea,judgmeas,Remain,of this permit. ALTER in my way a<ttuc against said City ALTER OR ADD TO MECH.
comscquenoe of the gashing of this permit. PLUMBING FEf?
APPLICANT UUPEMTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO HL000 CFM)
gUURCP 5. /.Iv�^ia MECHANICAL FEE
``�I AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
awre ol'Appli ontraclor Date EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building occupant store or handle larallous material HEATING UNIT(TO 10.000 BTU)
m defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Core,Section 25532(a)? HEATING UNIT(OVER 100,000 BTU)
C3 Yes, [IN.
VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant uset or devices which Dae Rcerips#
cgmpnu:n BOILER-COMP 3HPOR 100,000 BTU)
Tit hazardomx evaluation.air coaminants as defined by the Bay Area Air Quality Management
auin? TOTAL:
❑Yea []No BOILER-COMP(OVF.R IW.IXp B1U)
I have rend!me haardoas amentila AIRCONDITIONEk ISSUAN EDATE
requirements an u2553 Chapter Ii.95 d t the if the
InmiegdoeHealth&Safety CWe.Seainns 25505,25533 and 255]4.1 undemranJ that if the NEW RESIDENTIAL MECH. SQ.FT.
baildinepuremmes windy have eiemmp that.ismy ce of.lcri mmadrythenmaapanr
of rhe rtgmimmants wM1icM1 must Lie
prior m issuance mf.a CRrtifcam of Occupancy.
Ownermrauthorized agent Date 70TAL: ISSUED BY.
OFFICE