99090046 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUn,IHNG-ELECTRICAL ERMIT o.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BU ILDINGADDRIiSS. SANITARY NO, APPLICATION SUBMITTAL DATE
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WNE :'SAMA: PH lis CON'I'RACfOR'SNAMB ` LIC NO,
• J 0 r R ��i G6MUNIC COM'ROLM
CHITF;Cf/ENGINEEH: LIC NO: ADDRGS �-4 \ ❑
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CONTACT: PHONE: BUII,UWG PL-RMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) LDG ELECT PLUME MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby amrin fort I am licensed under prn.i:ioaa mf CM1apter 9¢rnnmeneinx JOB D CRIPTION
WQZ with Senior 9007 of Division 3 ofthe Business and professions CMe.and my howl.is RR IDENTIAL
H W O in full force end officer. L-�,/�r� Q`1 PERMIT ISSUANCE.
aUU Lmense Clu - - Lic.p ", - ❑'FOWL. [I KITCHEN REMODEL
v W hate Contracnrz APPLIANCIiS-RESIDENTIAL El ADDITION El PLUMBING REPIPE
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
Z O`=Z I understand my plana shall be used as public renals PANELS MODIFICATION
OZ— UP TO 200 AMPS INTERIOR FI CHIMNEY REPAIR
QL!tw Licensed Professional 201-IWOAMPS ptBATH REMODEIIREPAIR El DEMOLITION
IMPROVEMENT (]SWIMMING POOLS
C Y E� OWNER-BUILDER DECLARATION
C Q I hereby effno that I um exen,pl Iran,the Rmlmclu,License Law for the
OVER❑MN)AMPS ay
x 3 Billowing reason.(Section]0315.Business and Professions Code:Any city or county El OTHER
which require, t m conoto ahcr.in, p y s SIGNS ELECTRICAL
.F7=06 Ttu its Ihcu applicant G�nuchemnEl mfilm air an fracture
prior quires pp permit geed alutemem SPECIAL CIRCUIT/M LSC,
d that he is licenced pursuant to the provisions of the Contractor's License Law(Chapter 9
�IYO� (commencing with Section 7000)of Division 3 of the Business and Professions CaM)or TEMP.METER OR POLE INST. COMMERCIAL:
a Fe ,bar he is eaofmpr frmfrom and fe basis for,he alleged exemption.Any violation of El NEW BLDG/ADDITION D DEMOLITION
Irl�m Snlmn Al31.5byanyapplcunt far.pconil s.hjccts the applicant to a civil penaltyof POWER DEVICES I ❑TENANT DFOODSERVICE
Srot more than fisc hundred dollars(5500).
p ❑1,as aawmcrof the praMnX or my employees with wages as fcirmle compemmion, SWIMMING POOL ELECTRIC IMPROVEMENT
F. will dothe work,and thestrueture isnot intended-offered fnrvale(Sca]Ond,Business ❑OTHER
W3w and Professions Code:The Conti tor.License law does not apply to an owner of OUTLETS-SWITCHES-FIXTURE
property who builds or improves mercon,and who does such work himself m through
his awn employers,provided that such impmvcmcros are nm,intended or offered for NEW RESIDENTIAL F-LEC R SQ F .
sale.If,however,the building or improvement is sold within one year ofcompletion,the SQ.FT.FLOOR AREA LSQ.EE
caner-builder will have f<burden of proving that he did not Wild or improve for pur-
psx of sale.). f
❑ 1,as owner of the property,um caclusisely contracting with licensed contractors n,
nmgmct the project(Sec.7044,Busines and Professions Code:)The Camrnmor s Li-
censeWwdoes not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT E
who cor mels f pmjoa,with a Factors)licensed pursuant to the Conaamor's
License law. PERMIT ISSUANCE
1 am eaempr under Sec. ,B&P C for reams 7 J
DateALTER-DRAIN&VENT-WATER HEA) VALUATION a
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affimt under Penalty of perjury one of the following declarations:
❑ Ihave and will maintain a Ccnifmrtc of Consmnmsclf-macro fur Warke,Canape.- DRAINS-FLOOR,RIDGE,AREA,COND, 1 CONSTRUCTION
scion,as provided for by Section 3900of the"nor Code,for the performance of the
weak far which Tis permit is issued. FIXTURES-PER TRAP
❑I have and will maintain Worker's Comped-don Insurance,as etaired by Section
ISM at tire Labor Code,for the performance oflhe work forwhich,his panni,is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Worker's§otltpe qsvuop¢,jtpp rancyCumer and Policy nu J 't�T�ap �- I/�/06(4
MyW it'Y`CA Policy No: LU334y'� CAS-[A.SYSTF,M-DVER4(F;A) l'/1�11�v""v
CF.RIIFICAI li OF EXI?MVI[ON FROM WORKERS'
COMPENSATION INSURANCE GREASUNDUSTRL WASTE INTERCEPTOR
his aec,imn revision he comploi ifthe permit is furore hundred dollars(51001 BUILDING DIVISION FEES
or less)(thisGREASE'1'RAP PLANCHECK FEE
I eerily fat In the performance ofthoi forwhich,hispenni,is issued,i shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so avsubject o become subjeco the Workers'Counter- ENERGY FEE
Z ouior lawsof California.Date
O WATER IIIiATER WIVBMIELECTR
z O NOTICE GRADING FEE
.a p] becomeFsu j APPLICANT:If,after making mice Cisions of of Eacmption.You should WATER SYSTE.WI'RLATING
IX ? become subject m the Worker's Compensation his provisions of the devoted
CMe,you must SOILS FEE
W Tonhwif mmPly self such pnrvinimta lir his penin,shall he decmcd mvnked. WATER SERVICE
a �
,UO CONSTRUCTION LENDING AGENCY NIiW RESIDENTIAL PLMB. SQ.FT. PAID
IM1errwhich mnM1almit I iaaed(Sec.30lending agency forthepedonnunceof Date RecciplN
� U the weak Ba which this Permit icisauedfSec.3f19),Cie,CJ
O lender's Name TOTAL:
L7 Levi Address TOTAL:
yL b,,,Iy In.,I have lard this application and smc that the about Infnrmullnn is BUILDING FEE
V) correct.l agree mcomply with all city and county ordinances and state laws mining to Q7ry, MECHANICAL PERMIT FEE
V Z building ronswainn,and herby amhomx representatives ofthis city mentor upon the SEISMIC IEE r
above itunaoned nmpeny for inspection purposes.
(Wel agree as save.indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC I'EE
Iiabilities.judgmenrs.cases and expenses which may in any way acerae against said City ALTERORADDTOMECIF
in consequence of the arming if Tis prrmir PLUMBING FEE
APPLICANT Uy DER TA IS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) 1 /
SO t j,GO ATI! S. MECHANICAL FEE
• 9--7- 7 9 AIR HANDLING UNIT(OVER 10,000CF10) CONSTRUCTION TAX
Signature of ApdicnN on,rat Dat EXHAUST HOOD IW/DUCT) HOUSING MITIGATION FEE
HAZE )US MATERIALS DISCLOSURE
Willie applicenta few buildmgocruprnl, icor handle hn'andomtrourna1 I MATING U N IT IT'0100,000 BTU)
as refined by the Cupertino unicipul Code,Chapter 9.12,and the Ilcalth and Safety
Code Section 25532(4)? HEATING UNIT(OVER IRE000 BTU)
[]Yes J)(No PAID
lr VENTILA'I'[ON FAN(SINGLE RESID) Date Receipt p
Will the applicant or future building occupant use equipment or devices which
emir Fastidious air contaminants as defined by the Bay Area Air Quality,stnmgemem BOILER-COMP(3HPOR 100,000IF U)
Di.arima TOTAL
❑Yes RNo BOILER-COMP(OVER I do BTU)
I have read the haccolara reurnals rcuiremenls under Chapter 6.95 of the Cali- AIR CONDITIONER
9 ISSUANCE DATE
Irmo.Health is,Safe,,Ocefina,25505,25593 and 25534.1 meur,,and ran if fe NEW RESIDP.NTIALMECH. SQ.ET.
buildingdoenot curtcnetenertfat it is my responsibillrym notifythe occupant
offe hemmpnofle,"alien fa Cerif of Occupancy.
Ownerm rah riz a t Dale TOTAL: ISSUED BY:
OFFICE