99110060 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY OO U
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUT D1146 ADDRESS: SANITARY NO.
V ` A CATION�Sq/UBMPTAL9ATE
OW R' IsA O NTRACfOR'S NAME: LIC NIT
NIC CONTROL#
ARCHITE .NGI[JEER V L C NO: ADDRESS: ❑
CONTACT: 1\V\ P�Mlfpp7711;Lr ¢!•
6 B ILDING PERMIT INFO
\AyL� 2.w11TA� 3I b ❑ Consultant Foes Paid by Applicant(Initial) BLDG ELECT' PLUMB MECH
GµIRj ���'rt`1VIV J V (i T ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I 1 hertby arum mat I am reen.ed under pmvio.m.f Chapter 9(commencing JOB DESCRIPTION
CaZ with Section 0000)of Division 3 ufthe Business and Professions Code,and my licca is RESIDENTIAL:
µµI100 PERMIT ISSUANCE
1-1y— in lull farce and el feet. ❑SFDWL [I KITCHEN REMODEL
ULicense Class Lic.M
vs6U Date APPLIANCES—
Contractor RFSIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
ARCHITECTS DECLARATION ❑MULTI-UNIT []STRUCTURALZ O m Z 1 understand my plans shall be used as public records PANELS MODIFICATION
OZ O UP'I'G200AMPS
F"m Licensed Professional [I INTERIOR [I CHIMNEY REPAIR
TUI-I(Mq AMPS IMPROVEMENT ❑DEMOLITION S
yp OWNER-BUILDER OECLARATI
OVER IIIOOAMPS C1 BATH REMODEIJREPAIR CD DEMOLITION
tY Q I hereby affirm thin I am exemvt from the Com a Laor
�06U which imquimsn ranitt BIJLS,Business and Yrofemio iry S L DOTTER
ter which rcyuircs a permit In mnstrvn,aline imvmve,dem tan m
prion.im issuare,Am requires the applicant for suchpert cu m L
�y that he is licensed pursuant to the pro visionsofthe Contractor's enseLaw(apter
I Q0 (commencing with Section 7000)of Division3 afihe Business fessss@@@ TEMP.MET R COMMERCIAL:
d y
that he is exempt therefrom and the basis Int the alleged exel i on ❑NEW BLDGIADDITION []DEMOLITION
_Y• Section 2031.5 by any epplicval fora peril mbjects the upPll ®Ivty ooff
V' t mom Than five hundred dollars(SSW). eENANT ❑FOOD SERVICE
^Z T IMPROVEMENT
Q ❑ Laaownecofthepropm,tarmy employees with net elecompensution, ID
0 well do the work,and the slrvcture is not imm�deJ.toff o InQne
❑ HER
and Professions Cade:The Conuumor's License La t aITCHES—FIXTURESac o IfIrlmen I >CSQ FT
sale.If.however,the building or improvement is add within one year ofcomSQ.FT.FLOOR AREA LSQ.PT.
owner banner will have the burden of proving that he did not build or improve for pur-
pose of sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL'
cease nelLa the es not (pea o an Business and property
whobuilds
Cade i The Contmmon,Li-
c Lawduesnsuapply r man with
of Propcns who sedporim to the themoComma,end QTY. PLUMB RMIT
wbt eonuects for such projects with a ttmtra<mr(s)licensed pursuant to th<Canlncmr's
Lamm Lew' PERMIT ISSUANC
❑I um exempt under Sec. ,B&P C far this rcamn 0
Owner Date ALTER—DRAIN&VENT 'ER ) VALUATION
WORKER'S COMPENSATION DECLARATION BACK PLOW PROTECT.DEVIC v Jl p
I hereby affirm under penalty of pc jury one of the fo[Iswing declarations V
❑ I have and will maintain a Conificam ofComent to self-insure for Workers Camper-
cation. COSTORIES as provided for by Section 37M of me Istor Code,for.the performance of the
II work for which this Permit is issued. FIXTURES—PER TRAP
❑1 have and will maintain Worker's Compensation Insu nine,as required by Section
TI00ofthe Labor Cod,forthe rformance.fthe work for which his tis issue, GAS—EA.SYSTEM-'INC40UTLETS
pe peri -GROUP P
Myler.Workers Compensation Insurance carrier and Policy number arc:
Carrier. Policy N..: GAS—EA.SYSTEMOVER 4(FA) S.3
CERTIFICATE OF COMPENSATION
FROM WORKERS'
COMPGNSATION INSURANCIi GREASFIINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This section need not he completed if the peril is for one hundred dollars(5100) GREASETRAI'
.r IessJ PLANCHECK FEE
I mealy that in the performance of the work for which this permit is issued,Ishall SEWER—SANITARY—STORM EA.200 Ff.
not employ any person in my manner so as to become subject in the Wnrkeri Compen- ENERGY FEE
� Z ration Laws of California.Date WATER HEATER WIVF.NTIELECTR
Z Applicant GRADING FEE
aha NOTICE 1'0 APPLICANT:IL v0ennalting this Cenifica¢of Exemption,you should WATER SYSTEMaREATING
become subject.the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
foMwilh comply with such provisions or this pennit shall be deemed revoked. WATER SERVICE _
Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,FI. PAID
U Q I f which
that there is issued
constructionlendingagency for Performance of 111 �f—Davie URecnpl11
r
He work for wldsN Nis peril is issued(Sec.309],Civ,CJ 111
lender's NameRAWI
lender's Address TOTAL: Ir
I cenify Nat I have read Nis vpplicmion and sem¢theuhe above information is B E
VW correct.l agree to comply withal[city and county ordinances and stale laws relating to QTY. MECHANICAL PERMIT FEE
U Z building construction,and hereby authorize representatives of this city to enter upon the SEISMIC HE
above-mentioned property for inspection purimes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against G�ELECI'RIC FF.E
liabilities.judgments,costs andexpenses which may in any way acerae against mid City ALTER ORADD TO MECH. !.�
in c.nseyue.ce of the grumtng of Nis permit. PLUMBING FEF.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,004 CFM) CONSTRUCTION TAX
Signature of Applican✓Contructor 'Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO I00,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 912,and the Health and Safety
Code,Section M32pd? HEATING UNIT(OVER 100,000 BTU)
E]yes ❑N. PAID --
VENTILATION FAN(SINGLE RESID) Dale Receipt
Will the applicant or future Wilding occupant use equipment or devices which BOILCR—COMP(3HP OR 1fN1,I1f108TI1)
mit hazardous air commit nams es deli.W by the Bay Area Air Quality Management L
District?
❑Vas El No BOILER—COMP(OVER 100,000 BTU)
I have read the haraJou.s materials requirements under Chapter 6.95 of the Cali- AIRCONDITIONER ISSUANCE DATE
fu niu Health&Safety Code,Seep...25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.Ff.
building does not currently have a term,that it is my rellsisobllity mainly the oc mpam
of the ne utrememts which must he met prior to Notmnce of a Certificate of Oseep ria,
Owner or authorize agent Dae TOTAL. ISSUED BY:
OFFICE