99070058 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF.CUPERTINOHUILUING-ELRLTRII'AI. PE
BUILDING DIVISION APPLICATION/PERMIT r_G,MBIN;-MECHANICAL
BUILDING PR(IJECf IDRNI'IPII;AI'IUN .
BUILDINGA`DRESS: SANI'T'ARY NO. APPLICATIONS D/
OWNER'SN ME: HONE: ZS— CO RACTOR'S NAME: e S LIC NO:
�j ,
D00 NEC CONGROL#
CHITEC O NGINEER: LIC NO: ADDRESS:
CONTACT PHONE: BUILDING PERMITINFO
❑ Consultant Fecs Paid by Applicant(Initial) BOG ELECT /PLUMB MECH i
LICENSED CONTRACTOR'S DECLARATION [2 j•y ELECTRIC PERMIT PEE � Trim✓
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
�pZ with Section RXlo)of Division 3 of Ne Buxinessind Pro(cssions Code.and my license's JOB DESCRIPTION
Ed- RESIDF.NTIAI:
yyII - in f.111m. ndefet PERMI'TISSUANCE
<U�) License Class "-� Lic.# Z ❑SFDWL ❑KITCHENRHMODEL
�4 WM Date�_Cantractor APPLIANCES-RISIDENf1AL ❑ADDITION ❑PLUMBING RE PIPE
RCHIIII DECLARATI
yoyZ l understand my plansshall he used as public ret Jx PANELS ❑MULTI-UNIT ,, , ❑STRUCTURAL.
MODIFICATION
UI"T02110AMIk5
LPcenseJ PmlexsPnnal ❑INTERIOR .l•1 ❑CHIMNEY RITAIR
IMPROVEMENT
OWNER,exempt front
OVER XIX)AM [I SWIMMING POOLS
y�u�l G 1 =so,(fat on 1 um eBasipt.rum the Contractor's License Law Im the OVER ItXXIAMI'S C BATH REMODEL/RITAIR I]DEMOLITION
>� 6 U following=son,a (Section Jo3L4 Business and Pmfdemols Cute:Any city structure ❑OTHER
3 a SIGNS ELECTRICAL
O which requires a permit m amxwct,idler.improve,demslish.ar repair any structure
m pnnnoit issuunca alsnnqulre.vtbe appliwm tnrsuch lrvrmlua fica.vigndl ammmcn TSPFC1ALCIRCUI'UMISC,
F.u�} that he is licensed toommno thepeovisions ofthe Comoma's License Lear(Chapter 9
ad PYg0 (commencing with Section 7M))of Division 3 ofthe Business and Professions Cdc)ot TEMP.MEI'EROR POLE INST COMMF;RCIAI,
d fy=y
that he is,rxatttpt therco-am midtha basis for mo alleged escmprmr Any violation of El NEW BLDG/ADDI'fl(lN 1:1 DEMOLITION
lull m Section 7031.5 by any applicant for a pit.v
ennuhjmts the applicant m a civil penalty of POWER UIiVICES
FZ} t more than fee hundred dollars($300), El TENANT ❑FOOD SERVICE
❑ 1,us owner sr the property,or my employees with can c pens.. IMPROVEMENT
rt C,
will do the work,and the structure is not intended rofiend hostile(Sec,BMU Business SWIMMING PO(Ih F,LECI'RIC - BOTHER
4 3 and Professions Cook:The Contractor's License Law does not apply to an owner of OUTLETS-
SWI T CHES-FIXTURES
property who builds or improves themnn,and who Jocv such win himself or through -
his own employees,provided that such improveurents am not intended or offered for NEW RESIDENTIAL ELCCTR SQ FF.
sale.IT,however,the building or improvement'.sold within one year annpletisn,the SQ.?OOR2��nerbuilder will have the burden of pmvimgthm he did not build rte Improve lce poo-
post m aale.).
❑I,as owner of the propcny,nm exclusively canmeting with licensed contractors to TOTAL: D
construct the irolvet(See 7044,Barities.and Professions Cma)'Fon
he Contactor',Li- J
Low w
dues not apply to an ans ofpropeny obs builds or improves thereon,and QTY. PLUMBING PERMIT FEE JUL 2g 999-
who contracts for such pnslect with a comments)licensed pursuers to the Contractors
License Low. 1'FRMIT ISSUANCE
I stn exaopt under See. ,B&P C far mos reason
Owner Date - Al:1'ER-DRAIN&VENT'-WATER(EAI140 IN
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICEy
I huehy affirm under penalty of perjury one of the following declarations _t
I have and will maintain a Certificate til'Comical to sell-insure for Workers Compen- DRAINS-FLOOR,ROOT(AREA,COND.
saloon,av provided for by Section 3JW of me Labor Code,for the pcAomtance of the STORIES TYPE CONSTRUCTIOF
work far which this permit is i...sed. VDCI ORES-PERI'RAI'
❑1 have and will maintain Workers Compens..tlnn Insurance,as requimd by Section
37W f,ha labor Cale,fur the performance fthe work fur which this ponot is issued. GAS-h.SYSTEM-I INC.4 OUTLETS OCC. �/ APN
My Worker tion in or, mmrricr and Pollyn sD
Carriar. tan notion w„__„IdicY No.: Z���y�� GAS-EA.SY9'fHM-0VL'R 4(EA) D��
CERTIPICATC OAF EESEME ION FROM WORKERS'
COMPliNSA'I'ION INSURANCE GREASIJINDUSTRL WASTE INTERCEPTOR
(Cas—It--need not be completed ifthe permit is force hundred dollars Ol IIB) I UILDIN(T DIVISION FEES
or less.) GREASE'IRAP
PLANCHECK FEE
I employ
that in the pay manner
olast work foe which this the W is issued,I pall
nottetnLaw any person in any mannerm as to become subject to WorkerA Campem SIiWEk-SANITARY-S'1 ORM HA. PI'' ENERGY FHE
Z ration Laws of California.Date
C,
Q Applicant t WATER IIIiATER WNBN'I'/ELECI'N GRADING FEE
h
NOTICE
rom,,TOAPPLICANT.esafter making mi,wWar,of of Iiacmpfindyou about d WATER SYSTEM/IREATING
become subject to the Workers Compensation this emit al of me Inbar Coke you nwm SOILS FEC:
IF3�7 forthwith comply with such provislore nr this puna shall he Jeanud revoked. WATER SERVICE
Q Q
Uz CONSTRUCIIONLENDING AGENCY NEW RESIUFiN'UAL PLMR. SQ.FT. PAID
I hereby which
th:nouti there ix..edconstruction lending agency linthe perlamwncc of Umc Receipt#
U.0 he work for which this permit is issue)(Scc.IWJ.Civ.C.)
Lenders Name
0 TOTAL
V LcnJcr'x Address 'R)TAL:
F y 1 certify that 1 have read this application and suite that the shove infunnatian is
_ BUILDING PEE
N correct I egret m comply with all ciry and county oNin:uues and sate Incas rotating to QTy, MECHANICAL PERMIT FEE
V z building conP.Wdion,mW hereby uuthariv.c represcntativux of thh city to enter upon the , SEISMIC FEE
mow-mentioned property for inspection purposes. _
(We)agree to save,indemnify and kap harmless the City of Cupertino against _i/_1 PERMIT ISSUANCE ELIiCIRIC IgiE
liabilities,judgments,casts and expenses which may in any way mcac against said CityALTER OR ADD TO MECH,
consequenceg
nsequence of the aming of this permit PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HAN DLING UNIT(10 1 DUN)CFM)
SOURCEREGU "IO M UCI IA NICAL FET?
94 �J +l rs1 CJ AIR HANDLING UNIT IU.(Mp CFM) CONSTRUCTION TAX
Signabo ApplicanVContractor ,/-"`` Dum EXHAUST HOOD(WNUCT) HOUSING MITIGATION FEE
MATERIALS DISCLOSURE.
Will the applicant or Boom building occop:mt.aore or handle hazardous material H17ATING UNIT('10 IW,SX)BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532hd? HEATING UNIT(OVER 100.000 BTU)
p Yes [DNo
VCNTILA'1'ION PAN(SINGLE kI?SID) PAID
W II thea applicant or future hit din t use a One Rece' t p
pp d by the
a Air mot devices which BOILER-COMP t
mit htnnrdaun sir containments as patine)by the Bny Area Air Quality Munugensm 1.HP OR I W,UNI BTU)
U¢Wcl'1
❑Yes ❑No BOILER-COMP(OVER I00.000 BTU)
I have read the hazds
aroumaterials A111 CONUI'1'IONIiR
regtiremcnt under Chapter 6.95 of the Culi- ISSUANCE DATE
forma Health&Safety Code,Sections Z5505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECIL V SQ.FT
- building does not currently have a tenant,that it is ay responsildloy to nntifythroccupont
a,Os rtqu' wh' ipnonoiswunce til'n CeNfule^f(kfgpancy.
Qwnar ands rzed agarol Dute TOTAL: ISSUED BY: - +%
OFFICE