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99080011 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY D J CITY OF CUPERTINO - BUILDING-ELECTRICAI, PERMIT NO. BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL . BUILDING ADDRESS: BUILDING PROJECT IDENTIFICATION SANITARY NO. APPLICATION SUBMITTAL D. io3f8 ©�D HArl3oR A-vt � OWNER'S NAME:- PH � r F� 00 912 CO RACTORS NAME:, y1 ,nom S^ 11/NO: G � � � ALL/r Iv D �( 6 O" /A OSAL IfCrg1/✓4 /'r/M1 b OC r / N/C CONTROLN RCHITECT/ENGINEER: LIC NO: ADDRESS: - El 67 Cffc�c'ie 13�vSSor� t. cfT� CONTACT: PHONE: l BUILDING PERMIT-INFO Ao;�0 SA L ,J/I#J-of f ❑ COn idtant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MEECCIH� LICENSED CONTRACTOR'S'DECLARATION 0 0 11 Va I hereby affirm that I am licensed under provisions of Chapter 9(commencing11OUTETS ELECTRIC PERMIT FEE JOB DESCRIPTION WOWQZ with Section 7")of Division 3 of the Business and Imcsslnns Code,end my license is F W S full farce and effect IT ISSUANCE RFAID NTI G O U License Class_ .,�hie.b �S�e`tl / ❑SFUWL ❑KITCHEN REMODEI FZW Damy� ,a Common, - .e ANCES-RESIDENTIAL yQ4 a �' I-) vl+-z-Ir-- C1 ADDITION 11 PLUMBING RE-PIPE [F-,, ARCHITECT'S DECLARATF0 PANELS ❑MULT6UNIT ❑STRUCTURAL ZO p h.Z. 1 understand my plops shall be card ve public records MODIFICATION 200AMPS F.`n..�tO� Licensed Penitential ❑INTERIOR El CHIMNEY REPAIR .1 0AMPS IMPROVEMENT M_SWIMMING POOLS � „I OWNER-BUILDER m Ce ConfuON 1000 AMPS y W Q 1 M1ereby.(firm that I am exempt from the Cssions o License Law co the El BATH REMDDE 'REPAIR DEMOLITION x 3 4 F following reason(Section 7831,5,Business and Professions Code.Any city or evenly W W which requires a ELECTRICAL ❑OTHERags F O mQis issuance,permit re conswcL alter improve,demolish,or repair any twment y.] that hor eslicesedppuralssuant requires prevision of for such permit License Law L CIRCUIT/MISC. yr that he is licensed pumuanuo the provisions of We Contractors License Law(Chapter 9 ad (commencing with Section 9000)of Division 3 of the Business and Professions Code)orMETER OR POLE INST. - L a e C that he is exempt therefmor and the basis for the alleged rxearmion.Any violation of NEW BLDGIADDITION IX M h Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty ofR DEVICES EIDEMOLTDON y not moa than five hundred dollme(35M). TENANT ❑FOOD SERVICE £SQn �I,asowner of the proper,or my employees with wages as the irsoloo mpensatim, ING POOL ELECTRIC IMPROVEMENT y.� will do the work,and the structure isme intended.Coffered forsale(See 7044,Business ❑OTHER — and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements are net intended or offered.foo-—l"' NEW RESIDENTIAL ELECTR SQ ET. .wls.If,however the building or improvement is sold within one year of completion the SQ.FT FLOOR AREA &SQ.FT. owner-builder will have the burden of proving than he did not build or improve for per- ' posturing), ❑L as no,of the progeny,am exclusively contrarring with licensed contractors tat TOTAL: construct the project(Sao 7044,Business and&ofessions Corti)The Connacters Li tome Law does not apply to an owner of property who builds or improves maram.and QTY. `PLUMBING PERMIT FEE who contracts for such projects with a contmmmr(s)licensed pursuant to the Crntmemds License Law, ❑ 1 am exempt under Site ,B&P C hands.,on PERMIT ISSUANCE u Data ALTER-DRAIN&VENT-WATER(EA) VALUATION con WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE I hereby affirm under penalty of perjury one of me following declarations: ❑I treated will maintain a Certificate of Conserv to self-insure for Workers Compen- DRAINS-FLOOR,ROOF,AREA,GOND. cation,as provided for by Section 3700 of the Labor Code,for the performance of the EOCC. RIES TYPE CONSTRUCTIO! work fill which this permit is issued. FIXTURES-PER TRAP ❑I have and will maintain Worker's Compensation Insurance,as required by Section 3]00 of me Labor Cale,for me performance of the work for which this permitisissued. GAS-EA.SYSTEM-I INC.4 OUTLETS My Carrier Workers Into lnsyciNiN erand Pan No.y"/}' ibo b � b '-'f� GAS-EA.SYSTEM-OVER4(EA) ROUP 5-60-9 yFlJ CE TIFF7L F, PTION FROM WORKERS' Yt COMPENSATION INSURANCE GREASPIINDUSTRL WASTE INTERCEPTOR (This section need not to completed ifinepermit Is Pompe hundred dollars a q a.18UE,DINOATJIJrIB10 or less.) GREASE TRAP I comity that in me performance of the work for which this PLANCHECK FEE Permit Woo issued. per. SANITARY-STORM EA.200 FT. of employ any person in any manner co as m become subjecnm the Workers'Compete SEWER- ENERGY FEE Q z Appliance Laws of California.Date WATER HEATER WNENT/F,LECTR z O Applicant GRADING FEE NOTICE TO APPLICANT:IL after making n pr Cisions of of Exemption,you should WATER SYSTEM/TREATING H became subject y it Workers Compensation provisions of me Labor Code,you moat L>: forthwith comply with such provisions or this permit shall be deemed revoked. SOILS FEE W Q WATER SERVICE 'z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.ET PAID U 0 I hereby affirm that mere is a interactions ran rsions lending agency for the perfonceof Dam Receipt it CTs (~ the work for which this permit is issued(Sec.3097.Cr,C.) Q U Lender's Name {la Lenders Address ,TOTAL TOTAL LL I cenify that I have read this application and state that the above information is BUILDING FEE UzW) correct.l agree to comply with all city and county industries and state laws relating to QTY, MECHANICAL PERMIT FEE building construction,and hereby autharize representatives ofthis city to enter upon the ra obove-mentioned property for msperpo corm purposes. SEISMIC FEE (We)agree to save,Indemnify and keep harmless me City of Cupertino against PERMITISSUANCE ELECTRIC FEE liabilimes,judgments,costs and expenses which may in any way accrue against said Cityin ALTER ORADD TO MECH. consequence of me granting of this permit PLUMBING ME UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,0011 CFM) S REGULATIONS..' MECHANICAL FEE ,✓ �' AIR HANDLING UNIT 10,000 CFM) (�ly�1 p��a CONSTRUCTION TAX 9ignamfe of ApPlicaor-mamemr �d1, (EXHAUST HOOD(W/DUCT) HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE Will the arginwamor future building cacupants'are or handle lactation,material HEATING UNIT(TO 100,000 BTU) as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety Coda,Section 25532(a)P HEATING UNIT(OVER 100,000 BTU) L]Yes VENTILATION FAN(SINGLE RESID) PAID _ Will me applicant or future building occupant use equipment or devices which Data Receipt M min hazarduue air contaminants as defined by the Bay Area Air Quality Management BOILER-COME3HP OR 100,000 BTU) Danis f ❑Yes BOILER-COMP(OVER 100,000 BI'U) TOTAL. I have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER fomin Brands&Safety Code,Sections 25505,25533 and 25534.I understand that if the ISSUANCE DATE building does nm currently have a tenant,drat it is my responsibility m reify me occupant NEW RESIDENTIAL MECH. SQ.FT, of thmeets whichmnat ma poo laissuancemfaC 'fi to mf OccupIcy . y 7 Owner rauthonud agent eta TOTAL ISSUED BY: OFFICE