99120100 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY O 7 O
CITY OF CUPERTINO BUILDING-KLECTRICAL PERMIT NO.
BUILDING OlVIS10N APPLICATIONMERMIT PLUMmNC,.nlEcxnNICAL
BUILDING PROJECT]DEN'PIFICATION
4A.C.ITEC
` ^ e SANITARY NO.
APPLIC9ATION SUBMI�TT�ALcDAT[
/L —�
PHONE: CONTRACTORS NAME: LICNO.
N/C CONTROL N
F.R: LIC O: ADDRESS: Y`b ` �1 C ❑
CONTACT. PHONE: S G LAI ",yye BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECTPLUMB MrnEECCIH
0 `� ❑
LICENSED CONTRACTOR'S DECLARATION QTY, ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby affix that lam licensed under rmvisinns of Chapter 9(commenting
O0Z with Section ID00)ofDivi,wm3afma Businessland Prefesslons Code,aMmy liceaseis RESIDENTIAL,
IAO PERMIT ISSUANCE
W4l in full force and e�lec�t. - OSFI)WI. ❑KITCHEN REMODEL
<UU Licenm °� y�7 tLLic.p APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING REPIPE
rF G L Dam Commnnr
ARCHITECT'S DECLARATION ❑MULTI-UNIT O STRUCTURAL
PANELS MODIFICATION
Z p r2^ 1 undersand my plans shall be used as public records UPTO 2IX)AMPS
OZ..O ❑INTERIOR ❑CHIMNEY REPAIR
Licensed Professional 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
�W�; OWNER-BUILDER DECLARATION OVER IIXX1 AMPS O BATH REMOUEUREPAIR O DEMOLITION
C Q 1 hereby elfin Ihat 1 am exempt from
the Convector's License Law for the
iqqiS5 O y U following ream".ISeation 1031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
t++3 W E which minims a permit m convect,allm,improve,demolish,or repair my immure
0 prior to its issuance,alsomquiremthe applicant farmah Fame, t file asignedstatement SPECIAL CIRCUIT/M ISC.
that he is licensed pursuant to the omissions(if the Conmctols license lsw(Chapter 9
41CC (commencing wiN Section l(NNp of DivisinnJaf the Business end Pmfessinm Csde)a 'TEMP'.METER OR POLE.INST.
d y rL that he is clients Ihemfmm and the basis far me alleged exemption.Any violation of ❑NEW BLDG/ADDITION 0 DEMOLITION
4X1 w Station 1031.5 byany applicant form penoitsubjeen,theapplicant oacivil penaltyof POWER DEVICES OTENANT OFOOD SERVICE
t more than Ove hundred dollars($511!)). IMPROVEMENT
p„z^,O OLosowneroflhepropeny.nr mycmpinyees with wagesammeirsolecnmpensation, SWIMMING POOL ELECTRIC -
iW will do dwavork,and the stracture is not hounded or offered for sale(Sm.1044,Huainess OOTH2R
4a1 m mrd Professions Code:TTc Commcmrm License Ism docs not apply to an owner of OUTLETS-SWITCHES-FIXTURES
propeHy who builds or improves thereon,and who does such work himself or through
his own empi'mi,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR
sale.lf.however.We M1uildingaimpmvemem is sold within one year"!completinnJhe SQ.FT.FLOOR AREA $/SQ.FT.
wner-builder will have the burden of prising that he did not build or impnwe for on,
pose of aleJ.
O I.as Owner of the pmllrm,ar,exclusively contracting with licensed conmemrs u
construct the project(Sec.]INJ,Bn sines and Professions Code:)The Contractors Li-
cense Law does not apply usanowner ofpmpenywho builds or improves thermal.and QTY. PLUMBING PERMIT E
who amvecs far such project&with a mmmcta(s)licensed pursuant m the Contractors
License Ww. PERMIT ISSUANCE.
❑1 am exempt under Sec. ,H&P C for this reason
ALTER-DRAIN S,VENT-WATER UI O VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT'.DEVICE O
I hereby affr ueder penalty of perjury ane of Ne following declamations:
O l brimmd will maintainaCenifmamof Consenuosdf-insure fm Wod:er's Compen- DRAINS-FLUOR,RWH AR G.CONU, STONES/
TYPE CONSTRUCf101
motion,as provided for by Section 31(X1 of the Labor Cede,for the performance of the
work for which this Femur is issued, FIXTURES-PER TRAP'
I have and will maintain Worker's Compensation Insurance,as required by Section
3100ofthet�bur Cmb,forthepeffomanceof Ne work far which this asissucit GAS-FA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP IFN
My WnrkeJkJ:ympcns�o lisutm(dc caroler and Policy GAS-EA.SYSIfE OVER4(CA) / [� Q S
Carrier. ''``''CC.� /`11✓✓ Policy Nrx: tJ
CERTIFICATE Or EXEMPTION FROM W r 'T-5- - 7 7 GREASF%INDUSTRL WASTE INTERCFFfOR
COMPENSATION INSURANC BUILDING DIVISION FEES
(TTissmfian taednot be completed if Ne penis is future hundred dollars($100) GREASE TRAP
tar less) PIANCHECK IEE
Imotify that in the performance of the work far which this permit is issued l shall SEWER-SANITARY-STORM EA.2W IT.
not empann
employ my person in any manner am as mim
biome subject m the Workers'Camper- ENERGY FEE
Z ,Z smlon Lo s of Califamia.Data WATER IIEATER W/VENT,11=11 GRADING FE-E
Q Applicant \
na H NOTICE TO APPLICANE If,after making this Certificate of Exemption,you should WATER SYST E-NITREATING SOILS FEE
a bucome subject to the Workers Compensation provisions of the Lahr Code,you must
Forthwith comply with such provisions or this peril shall he dccmed revoked. WATER SERVICE
J Q t1
CONSTRUCTION LIiNUING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. I);�Als II`
L)QIhemhy.firm that there is a construction lending agency for the performance of Date_" Reccipta
the work for which this t is issued 300,Civ.C.) f'+
4. (✓ Fermi I II ALI
0 V Carders Name
L51 Lenders Address TOTAL:
Pi
1 certify that I have mad this application and,state that the alive mfonnmion is IN
F-i V7) conect.l agree to comply with all City and county ordinonccs and state laws relating to QTY MECHANICAL PERMIT FEF.
Ur7 banding consmctioa.and hereby eumaise rep-mlidives of this city a enter upm the Si MIC FEE
above-mentioned pmpcny for inspection purposes. PERMIT ISSUANCE E Err--11AIC FEC
(We)i gmr m save,indemnify end keep hamdcss the City of CupcNna against G
liabilities,judgments,cmsaund expenses which may in any way uccme agaioducid City AIM ER OR ADD TO MECH. PLUMBING FEE
eon, uece of Ne gmmi f thus permit. .
APPLI ,VT UNDERST NUS WILT.COMPLY WITH ALI.NON-POINT AIR HANDLING UNIT(TO IO."CPM) MECHANICAL FEF.
Soup A / � �kJ
'�A y� ♦1 - - - �►^ AIR HANDLING UNIT(OVER 10.000 CI M) CONSTRUCTION TAX
S gnaturc of ApplicaMCumracnu ���, `Dm�e E%IIAUST IIOOD IWIDUCT) HOUSING MITIGATION FEE
HAZARIX US MATERIALS DISCLOSURE
Will the applicant or future building Occupant sorem handle hosmdnus mamrial (s HEATING UNIT(In IN),"BTU)
as defined by the Cupertino Municipal Cale.Chapter 9.12,and the Heath and Safety
Code,Section 25532od? BEATING UNIT(OVER 100.001)BTU)
❑Ves 0 N VENTILATION FAN(SINGLE RFSID) PAID
--
Rcptk
Will the applicant or future building ramparts use equipment or devices which BOILER-COMP(3HP OR 100ON)RTU)
emit Incautious air contaminants as dead by the Bay Area Air Quality Mam
nageent TOTAL
phufcl! k
❑Yes ON.
BOILER-COMP(OVER IOD,INN)BTU)
I have read the hamNous atedoIs requirements under Chapter 695 of the Cali- AIR CONDITIONER ISSUANCE DATE
Tom eaith&Safny Cale,Se Liu rr..��5505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. 7 /'�7�
build g car rurmly hove: a at, Iitarlyrespmnalb itymnilifytheeccu m C—
ot e q Ips ich mast D m pdo o issuance of a C ifcale f omm
wne......hotiud agent Data�c TOTAL: ISSUED BY:
OFFICE