99110102 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY —I —1 I I 0—I b L
CITY OF CUPERTINO BUILDG-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBINRiG.MECHANICAL
BUILDING PROJELTIDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMI'17M,DATE
ii 3 o ( r,_,�wcoA -
WNF. 'S NAM -� f � 2,53_93ro CONTRACTORS NAME: �_ -y Ll�y°o4i
Q. C.LTh!C N/C CONTROI.p
ARCHITECT IiNG INFER: LIC NO: ADDRESS: ❑
N I VA-Vir-o Old S 1
CONTACT PHONE � BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) B,LEi ELECT PLUMB MECH
L ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby nlrrm that lam licensed under previsions of chapter 9 mammencing JOB DESCRIPTION
aF Z with Section 7000)of Division 3 ofthe Business and Professions COdd,nmd my license is RESIDENTIAL:
WOO
PERMIT ISSUANCE.
[-w,4 in full force and effect. G"rb q1 ' ❑SFDWL ❑KITCHEN REMODEL
4ZW Licensetss �1J Lic.p� gppL1ANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
,:L W Ume Contin Yor
why ❑MULTI-UNIT ❑STRUCTURAL
ARCH(FACTS DECLARATION
F D wy PANELS MODIFICATION
Z O y❑ I undersmnd my plans shill he u.uJ as,uMic records
=z„0 UP T02W AMPS ❑INTERIOR 1-1 CHIMNEY REPAIR
F[?,,W Licensed Probe ssiooal 201-1003AMPS IMPROVEMENT LJ SWIMMING POOLS
G S`] OWNER BUILDER DECLARATION
OG yr a' OVER IOW AMPS It
REMODRL/R AIR ❑DEMOLITION
yy 1 hereby affirm that 11. exempt from the Cessions O License Law for the
C.O following reason.[Section]113 L5,Ensinesa and Pm[eaelons Codc Any city or county SIGNS ELECTRICAL E
E"k'0W a y iv`� which requires a permit to common,alter,improve,demallsh,or repair any structure oc'o ;CA oczli 04-C
6 priorto its issuance,also reyuims theapplicant for such,ermine files signed smmmvnt SPECIAL CIRCUIT/MISC.
IcL�yi that he is licensed pursuant to the provisions ofthe Courtrooms License Lw(Chapler9
Wald CO (commencing with Section 7000)nf Division 3oOhe Business and Pmr adores Code)nr TEMP.METER OR POLE INS'E MM R I
Tee o ee that he it exempt tMmfrom and the basis for mo alleged exemption Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
IWC..y Sect ion 7031.5 by amyapplicanr for a permit subjects dicapplikenl to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
oat more than five hundred dollars($500) - IMPROVEMENT
Q ❑1,as owner Or the property,or my employees with wages as their sole campcosation. SWIMMING POOL ELECTRIC
Es will do the work,and the structure is not intended or offered for sale(Sec.9044,Business El OTHER
and Prol.. Curd:Th Contractors,License Law dads not apply t f OPERMITISSUANCE
SWITCHES-FIXTURES
property M1 b ld p Ih n red who does such w k h neIf
his ow employees,provided that h improvements am not in t ended E .
sale If I thebuilding improvements sold within nue y m [ p SQ.FL FLUOR AREA S15Q.PT.
nenbn(der will have the harden of,raving that he did not hal Id or impm
pme of.le.). TAL:
1,as owner of the property,am exclusively ray wo.bud with licensed contracts msruct the psect(Seo.7fk4,Bas nss and Professions C(de)The Cenvnaor'cense Law tlom not apply to an ownerof,mpeny who builds or imPrnves thereon, d QIF PEE
whouehow.for such pmcet withaconnnctor(s)licensed pursmmto the GmwLicense exe UANCE mow embeI am exempt under Sec. .B&P C f.RMWT
IN 1VALUATION
DineCOMPENSATION DECLARATIONICI herebyoff ai underpenaltyOeor Ce aneofthefollowingdodon'SCs:❑(have and will for by Se Certificate of the Lahto rCode,foreforWokera Compen- LOOR.BOOP.AREA.GOND. STORIB.S 'TYPE CONSTRUCTiOhwork t as provided for by Section 3]00 of the Labor Codc,far ilia performance of thework lin which this permit is issuJ. PER TRAP❑1 have and will maintain Worker's Compensation Insunmce,as required by Section3700oftheLaborCode,for the performance of the work for which this permit iv issued YSTEM-1 INC.4 ORTLETS (ICC.GROUP �My Worker's Compensation Insurance carrier and Policy number are:Carrion Policy No.: YSTEM-OVCR 4(EA) 2—
CERTIFICATE OF EXEMPTION FROM WORKERS' OREASFJINDUSTRh WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING 61VISION FEES _
(Thissectien need not be completed lfthe permit is home hundred dollars($100) GREASETRAP
nr less) PLANCHECK FEE
I verify that in the,comrmancdoffie work for which this permit is issuad,[shall SEWER-SANITARY-STORM EA.200 FE
not employ any person in any manner sin as to became subject to the Workers Compen- ENERGY FEE
salon Laws Cal' ilii Data� WATER HEATER W/VENF,LECIR
O Applicant T/ GRADING PBB
tr NOTICE O APPACANT:If,after making this CertificldExemh Id
(~ NNp become xuhjecuo the Worker's Compenxat un,mvisions o Labort Code,yen must WATER SYSTEMITREATING SOLS FEE
Fy fOMwith comply witb,vuch provisions or this permit shall be deemedrevoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NF.W RESNENTIAL PLMB. SQ.Pr.
PAID
V0 k frewyaBimis pa there issued(See 30 lending agency for the performance of me cetPt#
the Laddwk for which this pemht is issued(Sec 3097,Cm.C)
L>ti U Lcndce' Name TOTAL:
� Lenders Aallyt TOTAL:
1 eenify that 1 have toad(his application and state that the above infiortnxtion is BUILD( F aE
I� vl correct.I age to comply with all city and county oninances and some laws relating to QTY. MECHANICAL PERMIT FEE SEISM( E
building consmmrion,and hereby authorize repre9enmtives of this citymenter.,..,he
above-mentioned pmperty for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep ham loW the Cay of Cupertino against ELECT'R PEP.
Iirhilitics,ridgments,cost and expenses which may in any way same against said City ALTER OR ADD TO MECH. PLUMB
is consequence of the granting of this permit. [
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL FEE
SOURCE RE ATIONS. `
� AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
Si 'treed AppliechiRondictor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSU n
Will the applarinor future building occupant store or ndlc hazardous material HEATING UNIT GO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12, red me Health and Safety
Gadd,Section 25532(x)^ HEATING UNIT(OVER 100,10()BTU)
❑Yea E]No PAID
VENTILATION FAN(SINGLE RESIU) Dom Receipt#
Will the applicant or future buildir,oOmpanl use equipment or devices which BOILER-COMP(3HP OR 100,(0(HO U)
mit hazardous air contaminants as defined by the Buy Arca Air Quality Management TOTAL:
District? BOILER-COMP(OVER 100,0[0 BTU)
F]Yea F-1 No
I have reed die h erdomommnin,requitementunder Chapter 6,95 of to Call- AIRCONDI'DONER ISSUANCE DATE
forma Health&Smmy Code,Sections 25505,25533 and 25534.1 understand Iha lithe NEW RESIDENTIAL MECH. SQ.FE
building esnatcmtvntly huveolenanb th. tlsmyreaponsibilily mi notify the occupant 2--3
��LLLi
of the re mems which n ba mu p e.isavnna of n CcABcamof O cuPanc.
er or ahmme,ed agent ''//.•``---- �I Date TOTAL: ISSUED BY:
OFFICE