99090032APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT. PEN ONLY
CITY OF CUPERTINO BUILDING. RLEGTRIC L -� —e
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROjEc T IDENTIFICATION
'ERMI NO.
BUIL(l AD�fIES.S: W x�
SANI'TANY NO.
APPLICATION SUBMI'1'1'AI. DATE
NER'(S,iJ//VM/E88 PHONE:
a1G �/;1 C
%' J
C ALTO N
NIC
❑
CONTROLp
if] TEC VENGINEEW LIC NO:
ADDRE S-
coNTAcr: PHONEBUILDING
PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECTPLUMB MECH
❑ ❑ ❑ L7
LICENSED CONTRACT ORS DECLARATION
1 hereby affirm that I licensedBu undo provisions of Chapter 9 (wmmerseff
.. .t ,.
QTY. El.ECPRICPERMIT t FEE ' ,
JOB DESCRIPTION
with Section IIMIeffece visinn3ofthe Business and Pro s ,and mylittnse is
n 3
Infall bvice anJ elfccyq .1d
Licens I: t� Coal
Uete Conunctor
PERMIT ISSUANCE
RESIDENTIAL:
❑SFDWL ❑ KITCHEN REMODEL
❑AIIUITION [I PLUMBING RE -PIPIT
ElMULTI-UNIT❑ STRUCTURAL
MODIFICATION
APPLIANCES-RESIDEN'I'IAI.
ARCHITECTS DECLARATION
I understand my plans shall be used as public record
PANELS
UPT0200AMPS
[I INTERIOR El CHIMNEY REPAIR
IMPROVEMENT E]SWIMMING FOOLS
❑BATII REMODEUREPAIR El DEMOLITION
❑OTHER
Licensed Professional
OWNER- exemptiNDECe Curn ON
I hraso affirm that em exempt from the Gnsions C's License Law for the
following reason. (Section ] Business andmp Professions Code: Any city or
201-IOWAMPS
OVER Iffy) AMPS
SIGNS ELECTRICAL
which requires common. neffe,
permit re comtma, ul¢c, improve. demolish. or repair any nmemre
SPECIALCIRCUIT/MISC.
_
poor to issuance. of for such smtcnmm
theres the tofile aicense
that heslits esedpalm«qo
Contractor's
thin he is licensed pursuant ro the provisions of theaBasinLicense Law Chapter 9
provisions Law
'I EMIR MP.'TER OI<POLE INS'1',
COMMERCIAL:
(wmmcncing with Sectinn]gMp of Division Jofthe Business and Professions Ctde)rr
that he ix exempt therefrotn and the basis for the alleged exemption, Any violation of
❑ NEW BLDG/ADDI'TION ❑ DEMOLITION
POWER DEVICES
Section 703 L5 by any applicant for a permit subjects the applicant to a civil Penalty of
no, more than five hundred dollars ($500).
I. aswPuterofthe Pmormy employees with wages as their sole compensation,
❑o
will do the work, and the sttucwa is not intended oreffered for sale (Sec. 7044. Business
❑ TENANT El FOOD SERVICE
IMPROVEMENT
❑ OTHER
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
and Professions Coda The Contractor's Li«nse Law does no, apply m ua owner of
property who builds or improves thereon, and who does such work himself to Through
his own employees, provided that such improvements arc not intended or nfle e l for
NEW RESIDENTIAL ELECT R
SQ. FT. FLOOR AREA
SJSQ. FT.
sale. If. however. the building or improvement is sold within one year ofcompletion.the
wncohni did will have the burden of proving that he did not build or improve for pur-
pose of sale.).
I, as owner of the prnporty, um exclusively contracting with licensed wntracmrs ro
TOTAL:
csat thepan(Secand Pro ws Tphe CrmmannLI-
-.
law does not apply toan ownerof pmpeny who builds orimroves thereon. and
,. TFEEause
QTY. PLUMBING PERMIT
who contrmus for such projects with a ciat racmgs) licensed pursuant to the Contractors
PERMIT ISSUANCE
License law.
❑ 1 am exempt under Sec. B & PC builds reason
'
ALTER -DRAIN & VENT - WATEIT (EA)
Dam
WORKER'S COMPENSATION DECLARATION
VALUATION
/j]
O
BACK ROW PROTECT DEVICE
1 hereby affirm under penalty of perjury one of the following declarations:
1
❑ (have and will maintain a Certificate of Con.scnt to self-insum for Workers Coroner-
sation, as provided for by Section 37M1 of the Tabor Code, for the performance of the
DRAINS- FLOOR, ROOF. AREA, COND.
S O S
I YEE CONSTRUCTION
w k1tirwhich Thispermif is issued.
FIXTURES - PER TRAP
have and will maintain Worker's Compensation Insurance, as requimd by Section
HM,,fthe Lebo ode, nt urfarmanc f the work for whichmispermit is issued.
My Wor 'a n pens' t I n r nd Folic
Cameo olicy No. T
GAS -EA. SYSTEM -I INC. 40U'TLETS
OCC GROUP
APN
GAS - FLA. SYSTEM .OVER 4(EA)
CERTIF .A'I'EOF WORKERS'
CREASE/INDUSTRL WASTE INTERCEPTOR
EXAM INSUON RANCE
COMPBNSAq'ION INSURANCE
1'Ifiis sections«tl not M: cnmplemd if the permit is fnnme hundred dollars ($1 W)
or IessJ
GREEASETRAP
B ' - P 'BUILUINO DIVISION I''s1iBSl jg =
PLANCHIiCK FEE
SEWER -SANITARY -STORM EA. 200 FT.
I certify that in the perfnneance f,ha weak for which Nis permit ix issued, Ishall
not employ any person in any manner so as to become subject m the Workers' Compen-
ENERGY FEE '
WATER I WATER WNENTXI.F.CTR
sation Laws of Culi6mie. Date
Applicant
GRADING PEE
NOTICE 10 APPLICAN'11 If, after making this Cenitirmc of 17 cropland, you should
become subject to the Workers Compensation provisions of the Labor Core, you man
WATER SYSTEM/TREATING
SOILS FEE
forthwith comply with such provisions drunk permit shall be deemed revoked.
WATER SERVICE
CONSTRUCTION LENDING AGENCY
PAID
NEW RESIDENTIAL PLMB. SQ. PT.
Ihereb ffirm that mere is a constmalnn Pendia -
y n g ogendy for the palunnance of
me Recti tM
the work for which this permit Is Issued (S«.3(197, Gv. CJ
Lender's Name
t�n I:
6I IL'EING etliW
Lenders
TOTAL:
- t )
«ArtArtlessrre
re
iry that I have ad this application and store that the about information is
correct. ) agree to comply with all city and amity ordinances and state laws relating to
building construction. and hereby aumorim representatives ofthis city to enmr upon the
QTY, T' MECHANICAL. PERMITFR s
- I
SEISMIC FEE
,PERMIT ISSUANCE
above-mentioned property for inspection purpsnes.
(We) agree to save, indemnify and keep hmmless the City of Cupadirn against
ELECTRIC FEE
ALTER OR ADD TO MECH.
liabilities.judgments,coo,madexpens; which may in any way acwrcitu nst said City
in emaequenem of the granting of this permit.
PLUMBING FEE
AIR HANDLING UNIT (TO 10,000 CFM)
MECHANICAL FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE RI{5U S.
AIH HANDLING UNIT(OVER IO,CPM)
TYJO
CONSTRUCTION TAX
2 �
Station, ol'Applm Conductor mat -fie
HAZARDOUS MATERIALS DISCLOSURE
17XIIAUST HOLD(W/DUCT)
HOUSING MITIGATION FEE
1117ATING UNIT (TO 100,0011 B"IIB
Will me applicua or forum building necupaut nom or temple haamdeus n aerial
as defined by the Cupertino Municipal Code, Chapter 9,12, and the Hcalth Tmd Safety
Code, Section 25532(x)]
HEATING UNIT (OVER 100,001 BTU)
❑Yes ONo
Will the applicant or its aoom building by the B use equipment of devices which
it hueurrnus air conmminantn m defined by the Bay Area Air Quality Munnganent
District
C] Yes (]No
PAID --
Dam
VENTILATION FAN (SINGLE RFSID)
BOILER -COMP QHP OR IW.000 BTU)
TOT I. s
BOILER - COME (OVER Im),IMM)BTU)
AIR CONDITIONER
I have read the hamNous materials iblulrements under Chapter 6.95 of the Cali-
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. EL
out i Health &Safety Code. Seniors 25505. 255J3 anJ 25514. 1 undersmnr that if the
he dccupent
out line
� nventenanT. that hisuance
requi ,a Crlltymnotif
of the aqui mawhlcbn sl he met pain eo(uCMi& oncy.
�. O -7
�
ISSUED BY:
Owner oraumotized egcare
TOTAL:
OFFICE