99120101 .APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL E
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJFICTIDENI'IF'ICATION
HUILDINGADDRESS: SANITARY NO. APPLIG ION SUBMITTAL DATE
O Sir; dD.-�-0 I Cr h1 Sr b .moi ��
OWNER'S NAME: PHONE: K CONTRACTOR'S NnnAML: LIC NO', �i
aG.tgII'\ tp�11nj� IN', ({qV- bb A"TIGT� T'LVm81 'loalo_5 NIC CONTRII.p
RCIIITHUT/ENGINEER: LIC NO: DRESS ❑
ESS Qk'lM Q-1Q`9Y\ Q�
CONTACT: PHONE'. BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLL((ME MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm Nal I am licenud under provisions of Chapter 9 rconmerem, JOB DESCRIPTION
Dd'Z with Section]WO)of DivisinnJnf the Business mJ Professions Code.and my license is RESIDENTIAL:
FOO 'n full fo¢e and eReel PERMIT ISSUANCE
CSF t �� ❑SFDWL ❑KITCHEN REMODEL
QUU License Class tick APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
N Q W Dan. Con or
ARCHITECT' OF A TI N ❑MULTI-UNIT ❑STRUCIVRAL
Z
r-,n.NZ. 1 undcmtand my glare shall be u.ed as pu he PANELS MODIFICATION
CZ-� UPT02MAMPS ❑IN'I ERIOR [_1 CHIMNEY REPAIR
F�I"J WWWW Licensed Prom,,ioaal 201-1000AMPS IMPROVEMENT 0SWIMMING POOLS
�hdaOWNER-BIJILDI: tCIARATION OVER IWUAMPS BATH REMOUGL/REPAB ❑DIiMOLITION
CC I hereby affair that I am exempt haaia
t he Coat socs'.License Law far the
�xoq5t O y U following reason.(Section 7031.5,Business and Professions Code Any city or Arany SIGNS ELECTRICAL ❑OTHER
W'3 LL y which requires a permit to construct,alter.Improve,demolish,or repair any Stricture ���
F Oe prior,.its Patient,also requires thenpplicunt forsuch paranum Mentioned statement SPECIAL CIRCUIT/MISC.
Eby that he is licensed pursuaatto the previsions of the Contmmors License Law(Chapter 9
Wptp0 (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. L-
o.a o that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLOC/ADDITION ❑DEMOLITION
Wm.� Section 703 LS by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
oat mom than five hundred dollms(SSW). ❑TENANT ❑FOODSERVICE.
F Z Y IMPROVEMENT
SQ ❑ 1,ns owner of the property.ur my employees with wages as thei...lecnmpser.tion, SWIMMING Po0I.ELECTRIC
FI„G will do the work,and the structure is not intended or oriental for sale(See7044.Business ❑OTHER
3 and Profcssion.s Cale:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
properly who builds or improves thereon,i I who doe,such work himselfor Through
his own cra lnyces,provided Tlmt retch intpnecnems use not attended or ofersdi for NEW RESIDENI'[A],HLEC'Dt SQ FIL
sole.IL however,the timlJiialm-ntptovenum iv sod withinone yvarmf aarpled.a.the SQ.FT.FLOOR AREA $/SQ.FT
owner builder will have the burden of proving that he did not build or improve for per,
punt of sale.).
Fl h us owner of the property,am exclusively contracting with licensed contractors to TOTAL:
construct the Pmjxt(Sec.704,L Business and Professions Code:)The Contractors Li-
nselawdoesnotapplytovtownerofpropertywhobuildsorimprovesthemon,and QTY. PLUMBING PERMIT FEE
who cantreas for such projects with aconwonal)licensed pursuant,.Ne Contractors
License Law. PERMIT ISSUANCE
❑Tom exempt under Sec. ,B&P C for this..,on
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
e I hereby affirm under pcnultyof Iv:,juryone of be follUwing deelumtin ele C� d
1Iurve and will tnainmin aCerllf[ule nl Consent nt adl-insure Rn Worker's Cnnytoro DRAINS-FLOOR,R0017.ARI?A,CONDSTORIES 'I'YI'E CONST RUCTION
dial,e,Provided for by Section 3700 of the Labor Code,for the perfmimencc o1'The
work for which this permit is issued. FIXTURES-PER TRAP
I have and will maintain Workers Compenamion Instuder.as required by Section
370xufthe Lamar Code,made,perforeanceof the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC GROUP AP
My Work e((s pensJtion Ipsumtyc��t 5�gnA T NM
Curler. IL�� -lux' nGrYVa`ate"Tri .: I'Af{N L4001 GAS-EA.SYSTEM OVER 411iA)
CERTIFICATE.OF EXEMPTION FROM WORKERS' GREASF/INDUSTRL WASTE INTERCEPTORCOMPENSATION INSURANCE BUILDING DIVISION FEES
(This it..needram be completed ifthc permit is fa fon cmundreddollms($IW) GREASETRAP
ser less.) PLANCHECK FEE
1,arif,ded in theperfener.efthe work far which this permit is issued,Ishall V SEWER-SANITARY-STORM UA.2W FL
nat employ any person in any manner so as to became subject to the Worker,'Clausen. 1` E )FEE
Z2 xudon lawsof California.Dam WATER HEATER W/VEN'UELCCTR
APPllcrel 1 / RADINGFE,^`
NOTICC'1'0 APPLICANT.If,after cooking this Cenilicme of Exemption,you should WATER SYSTEMO HEATING /
hccomcsubjem to the Worker's Cmnrensadmi provi,earof be labor Cdr,you nest SOILS FFE�'
Wfnnhwith comply with such pnwislumor this permit ehallM deemed revoked. WATER SERVICE
5 z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLK1H. SQ,Flt PAID zy�—
V F Receipt k/
O I hembyalm Nm here iso conruction lending age
p
me wok rat wn.n this Permit i,issued(see.3097.cEc.) eomeoy
Li Leaders Name t0 rrL:
U Lender.,Address TOTAL: r/
W I ccnify that 1 have read this application and state Nat Ne above information is Bl G FEE
sFsy correct.l agree to comply with all city and esomyoninwces and state lawsrelating to QTY. MECHANICAL PERMIT FEE
U building construction,and herebyrmtherve representatives of this city,.enter area the S[I$MIC
olstve-nitntioned property for inspection purposes. PERMIT ISSUANCE
(We racer rise,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
Iiuhili' rju at. cs
s which may in anyway accrue against said City ALTERORADDTOMECH
insegvcncco • rantinthisit
perm . PLUMBING FEE
n gn
AM JCANT ON iRSTAN AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.0010 CFM)
MECHANICAL FEE
Sol CE RF.GU IONS.
' I'-1 AIR HANDLING UNIT(OVER IU.(XIO CFM) CONSTRUCTION TAX
.ignamre ofAppli a UContm Dat. EXHAUSTHOOD(W/DUC1) HOUSING MITIGATION FEC
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stem or handle hazmdous material HEATING UNI'r(10100,000 BTIH
as def nal by the Cupertino Municipal Code,Chapter 912,anti the Health and Safety
Code,Section 255320)? HEATING UNIT(OVER I00.00n BTU)
❑Yes Fl No PAID _ .
VENTILATION FAN SINGLERESIU) Date Receipt k
Will the applicant or fmum handing onvpnnt use agaipmem or devices which
at breallous air contaminants as defined by the Iluy Area Air Quality MonBOILER-COMP'(3111'OIt IINI,
ugmnenl 11(013'1 U)
scoot I Ye ON. BOILER-COMP(OVER I fluott0 BTU)
I hitt I materials mapencmenu under Chapter 6,95 of Nc Cali- AIR CONDITIONER ISSUANCE DATE
is Heal Six t Code enions 25505,25533 and 25534.I understand that if Nc NEW RESIDENTPAL MECH. SQ.Fr.
ildingdr•s atcur nil veatenant.thin it is my ranpansibiliry to malty the occupant i/ 7
for,my ire eau w must be met prior m issuance of a CenificatnYnoftQ uryncy.
or Y` em TOTAL ISSUED BY: , v
OFFICE