99100091 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY 1 ItibQc i
CITY DI CUPVISION nmLBING-MECIIRNCAL 11 rl:aM1
BUILDING DIVISION APPLICATION/PF,RMIT PING BING PROJFcr IDENTIFICATION
SOOO1
BUILDING PROBF,CIIDDNTIh'IL'A'FIUN
r. BUILDL G AI;DRM SANITARY NO. APPLICATION SUBMITTAL DATE
VNCR's NAME: ONI'RAf_"1'OR'S N LIC No
M NIC CONIROLa
xC111TECFlENGINEER: LIC NO: ADDRESS: �v��^��^ �� ❑
CONl'nCT: PHONE: 1 BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELEC9' PLUMB MECII
❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT' FEE
I ion,70.(fins that 1 an licensed under Omvi ficl of Chapter 9(commencingroi, JON DESCRIPTION
�„�Z with Senion](IOOI ofDivision Jofthc Husincos and l'rofcssians nnJ mylicenve is RESIDENTIAL:
f�= in full force d PERMIT ISSUANCE
,,,W= ❑SFDN'L OKI fCHIiN RIiMOD1iL
U�zuLicerysc let — Lic.N
h Ualo 1 Comm APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUM BING RE-PITT?
ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
ZZ n 2 I undersmad mnoy,lushalamed ll ed m public retards
UPTO200AMP5 MODIFICATION
O
O ❑INRiRIOR ❑CIIIMNEYREPAIR
awl",,; Licemcd Professional 201-I000AMPS ImpROVEMENT OSWI,MMINGPOOLS
Cafyd Ih.rchy aOinn
OWNER-BUILDER InE16e CmtraOor's License Law for the OVBR 000AMPS
❑BATA REMODEUREPAIR 0DFM01.1'TION
XB:
3 LLWa.U fallowing rcaan.(Section]031.5.Business and Pofessions Code:Any city ar county SIGNS ELECTRICAL ❑OTHLR
ya which requires a permit la construsv,:ther,improve,demalkh,ur ne,:tir any s.ucutrcAle E7.V
(��c..1 prior to its issuance.also requires the applicant for such permit to file asignedsmtemcnt SPECIAL CIRC 1 LSC.
wsssss'�} that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
tY no (commencing with Section70FE of Division 3 of the Business and Professions Code)or 'IEMP.MEI'EROR FR
a a e C Nm he is exempt therefrom and the buts fur the alleged uemmion.Any vioWtion of ❑NEW BLDG/ADDITION ❑DEMOLI'HON
bySaYinn 9o3L5 by vny applicant forupennit subjects theapplicantmacivil,enahy of POWER DEV
1 mare Nan five hundred d011urs(SSW). ❑TENANT ❑FOOD SERVICE
�ZG I.as owner of the norm laces with woes as Weir sole atmsnvati.n, SWIMMING POOLE OTHERVF:MENI'
��� ❑ prose a my in Y 6 1
_ will du the work.and the he mreis nar,License Law dos sale I pa.] rni olsoc,of ❑OTFIER
Law and Professions Code The Contme.,, Licence Law does not apply m an owner of OUTLITS-SWITCIIGS- IX' li
progeny who builds or improves Werehn,and who does.ouch work intended
or or through
his own owe eyeea provided that such imptvvemrnw ere not iyearm or offered!for NEW RESIDENTIAL ELIiLTR SQ F1'.
sale.ILhowevcgllbothe ve ding.rimpmveotent is.,hedid ma bidder
hiompletfoa,IM SQ.FT.RWRARIiA 5/SQ.FT.
owrrcr-huildcr will have the HUNcn of proving that he did not build or itnprme for pur-
pascof role.). -
❑L n a owner of the property,am exclusively contracting with licensed commeturs to I OPAL:
i,drict the project(Sce,]xLL Business and Professions Code:)The Cantracmr's Li-
cense law does not apply it)an owner of progeny who builds or improves thereon,end QTY PLUMBING PERMIT FEE
who contracts for such projects with a contractor(s)licensed pursuunuo the Contractors
License Law. PERMIT ISSUANCE
Lamexemptunder Sec. ,B&PCmrthisreaon
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Dam
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby a1Brm under penalty of pedury one of the fallowing decimations:
I have and will muinui it a Certificate of Consent to self insure fin Worker's Cum,crr DRAINS-FLOOR.ROOF,AREA,GOND. $TORTE TYL':CONSTRUCI'ION
ration,as provided for by Section 3]00 of the labra Code,for the performance of the
work for whish this pctmit I,issued FIXTURES-PER'I'RAP
❑ 1 have and will maintain Workers Compensation Insurance,as required by Section
3110 of the wile r rformancc ofthc workfnrwhichthis lonamd, GAS-EA.SYSTEM-IINC.4OUTLIi I'S OCCLGROUP 2APpptk
My Worker's o pen o ranee Gamer and Poli e)
Currier. Policy Nt: r GAS-FA.SYSTEM-OVER 4([A) /� Op
CGR'FIFIC (1F TION I N FRAMVOM E RS/
'RATIO N INSURANCE GREASFJINUUSTRh WASTE INTERCEPIY)R
�a� ./� BUILDING DIVISION IELg
seaion n ,Idedlithe permit is fnrot�i hut( du un(o GREASETRAP
or less.) PLANCHECK ITE
Icenitiy Wa antic perfomctncmd the work for which this permit is issued,l shall SIiWER-SANIIANY-S'FORM EA.20)FI'.
not employ any provers in any manner so m m become subject to the Workers'Compcn- ENERGY FEE
ZZ smion laws.(California.Date WATER HEAT ER WOVEN VELECTR
O Applicant ( GRADING FEE
!n NOTICE TO APPLICANT:If,after making this Cenificmc of Escmmion,you should WATER SYSTEMO READING
a {'^ become subject to the W.rkees Compensation provisions of the Labor Code.you must SOILS FEE
I]a forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
d n
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FI'. PALO
U O I far which nn tproant i is sued govt 30 lcnCngcnry for 0c per(onnanco of „I)am-----•Nam'suM'��
F" the work for which this permit is issued ISec.l W].Co.iv.CJ
C) U Lenders Name
DU Lender's Address l'OTAL: -
1 certify that 1 have read this a,plicmion and emm that We.have information is BUILDING FEG
ycorrect.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMITFEE nr
V Zbuilding construction.and hereby auNorice representatives of this city to enter upon the REISellEP€E 1 i/
above-mentioned Property lire inspection purposes. PERMIT'ISSUANCE
(We)agree to vvn.indemnify and keep harmless the City of Cupertino against ELECTRIC FEIi
Iiuhiliics.judgm �rs,
mcostsand expenses whichmaYmany wayac...c ai,madnld City ALTER OR ADD I'O MECH.
in consequence of the gonfiing of this permit R MBING TEE
APPLICANT U' STANDS AND WILL COMPLY WITH AL1,NON-POINT A1µHANDLING UNI'1'('I'O IB.(xX)CFM)
URCE REGU 4'II . 'EE
V.. _ AIR HANDLING UNIT(OVER 1I,000 CFM) CONSTRUCTION'FAX
,V\
Sl gnatumofApplicant/Comrecter Dam EXHAUST HOOD(W/DUCI HOUSING MITIGATION FEE
HAZARDOUS MAFERI )SURE
Will thcapplicturm forum building cernpuntemreor handle hazudoosnmtedal BEATING UNIT(10100.1X0 BTU)
On defined by the Cupcnino Municipal Code,Chapter 9.12,and the Health and Satiety
Code.Section 25532(x)? HEATING UNIT(OVER 1I0,I00 BTU)
0 Yes ❑Nn
VLNTILATION PAN(SINGLE R151U) PAID Dom Boccei
WII the applicant or fvwm building oceupam use equipment or dmices which
emit hazardous air contaminants a defined by the Buy Arca Air Quality Management
BOILER-COMP(3Hr OR IIXI,gO B"1'U7
8 District?
❑Yes � ❑No BOILER-COMPfGVER IW.OINI HTUI
AIR CONDITIONER
I have mud the h.vtrJoos materials regnarnalits under Chapter 6.95 of the Cali ISSUA CE ATE
him.Health&Safety Calc,Sections 25505,25533 and 2553..I understand that if the NEW RESIDENTIAL MECH. SQ.FT L./ ,
vildingdoesnotcu - ly have o mount @m it is my reaponaihility to notify ticnecupant
C requireme ail 1 nor to iss an ofa Ccrtificat of Qcuparrc
Owner or authodxd ligem TOTAL: ISSUED BY:
OFFICE