99110076 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY ID U
C
ITY, CUPERTINO BUILDING-ELECTRICAL PERMR NO.
LG1TiG DIVISION APPLICATIONIPERMIT PLUMIIING-MECHANICAL
IIUIIAINC.PROJECT IDENTIFICATION
ING ADDRESS: SANITARY NO. APPLICCATION SUBMITTAL OATI
llynAKqCu /I'S NAME: PHONE: ')NIIdS bi(�A).CO.CTIENGINEER: LIC NO. ADDRESS: ❑
S iJ �'o ST
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fecs Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm thin 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
G gZ with Section 9000)of Division 3 afar,Businessland ProfessionsGMe,andmy license is RESIDENTIAL'
l-0 0full PERMIT ISSUANCE
%- License
Class deflect. ❑'FOWL ❑KITCHEN REMODEL
QUU License Class LIf.N APPLIANCES-RESIDENTIAL. El ADDITION El PLUMBING RE-PIPE
yG L Dae Contractor
F,Om ARCHITECPS DECLARATION PnNCLS ❑MULTI-UNIT ❑STRUCTURAL
Z O H Z I understand my plws shall be,used as Public records MODIFICATION
OZ—Q UPTO200AMPS [I INTERIOR El CHIMNEY REPAIR
F-�Ful Licensed Professionvl 201-1000AMPS IMPROVEMENT (]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 1000AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
C Q 1 hereby aRrm that 1 am exempt from w the Contractors License lafor are _
K36V follow ing mason(Section 7031.5,Business and Professions Cade:Any city.,county SIGNS T:LECfRICAI. ❑OTHER
W a Nwhich requires a permit to construct.ally,improve,demolish,or repair any structure - �{-
FLL0.5 prior its also requires the applicant for such pert to file a signed statement SPECIAL CIRCUTUMISC. A ��
fN}e rtmi
that he is licensed pursuantto the Provisions.f the Comm
racrs License Law LChapmr9
��OQ (commencing with Section 7")of Division 3ofthe Business and Professions Cade)or TEMP.METER Ok POLE INST. COMMERCIAL•
a ti e Y¢ that he is exempt Therefrom and the basis for the alleged exemption.Any violation of NEW BLDG/ADDITION ❑DEMOLITION
Xmli Section 7031.5byuny applicant fora amcfsubjectsthelipplicunuo a civil penalty of POWER DEVICES laiD TENANT ❑FOOD SERVICE
not mom than five hundred dollars(5500).
IMPROVEMENT
E=n
❑I,as owner of the pr.peny.or my employees with wngn os their sole compcmefi.n, SWIMMING POOL ELECTRIC El OTHER
will dothe work,and the structures not intended or offered foradc XAc.]DOL Business
and Professions CNe:The Conualon,License law draw not apply to an owner.f OUTLETS-SWITCHES-FIXTURES
Property who builds or improves thereon,and who does such work himself or through
his on employees,provided that such improvements am not intended or offered for NEW RESIDENTIAL CLECfR SQ ET.
sale.If,traveler,the building or improvement is sold within one veer ofenmpletion.the SQ.FT.FLOOR AREA $ISQ.FT.
ne,builder will have the burden ofproving That he did nm build or improve for pur-
i pose le.).
r of The pmleny,am exclusively contra ling with licensed contractors to TOTAL:
construct the project(Sec.70LL Business and Pndassians Code:)The Conm,ctors Li.
ase law docs noaapply loan owner.( y.h.1milds nrimprovesthermal.md QTY, PLUMBING PERMIT FEE
whocontmcts forsuth pr.jau withac unit licensed pursuant to the Contractors
License La PERMIT ISSUANCE
❑ lame a rSe. PC for this mason
ALT13R-DRAIN&VENT-WATER(EA) VALUATION
as
OR C .A ION C ARATI N BACK FLAW PROTECT..DEVICE
1 ereby affirm
nvlty of Perjuryn the following declemtions:
❑I have and will main can.Cenificae of Cons o.elf-inmre In,WnrIke,a Catalan. DRAINS-FLOOR.BOOK A REA,COND. STORI TYPE CONSTRUCTION
scion,vs provided for by Section 370)of the Lobar Code,for Tho Pcnannanct,.I'the
work for which this permit is issued. FC(TURF.S-PER TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section
37M of the Labor Code,for the performance of the work for which this permit is issued, GAS-EA.SYSTHM-I INC.4 OUTLETS OCC.GROUP
My Workers Compensation lnsumnce carrier and Policy number ore:
Currier: Pnlie,No, GAS-RA..SY.S'MM-OVP.R 4(EA) 11
CERTIFICATE OF EXEMPTION 17ROM WORKERS'
COMPENSATION INSURANCE GREASUINDUS'I'RL.WASTE INTERCEPTOR BUILDING DIVISION FEES
Crtokseaion neednm becompundifd,permiala foranun
chdred dollars($10to GREASE'TRAI'
.r les'.) PLANCHECK ME
I evnify Om,in the Performancenflhewnrk fur wbluh ihiapermitlakss od,LshAl S(TWIIR-SANITARY-STORM I2A.200 FT.
not employ any pars nIn an,n an nerxnds¢,becamenurjen m the Wnrkon'Cmupun- ENERGY FEE
n
zz saimm Luwnaf Culdorniu.Dam WA1iR I II;AFER W/VIN VELECfR
0 Applicant I GRADING FEE
(n NOTICE TO APPLICAN'C IL after making this Certificate of Exnn'tit you should WATER SYSTEM/TREATING ITS FEE
w Lco
became
)ect to the Worker's C...i,nsmtlon provisions of the Labor Code,You mail
Q mply withsuch provisinnsor this moundiall be deemedrevoked. WATER S17RVICE /PAID�`\
� z CONSTRUCI]ON LENDING AGENCY NEW RESIDENI'IAl.PI.MB SQ.FT. 1 Dace eM
V Q l hereby affirm that here is a construction lending agency lin the performance of
W. the work for which this permit is issued(Sec.3007,Civ.CJ /
C Lender's Name OTAL.
LUST Lender's Address TOTAL. BUILDING FEE
1 certify that 1 have read,his application and Hate that the above information is
rF. Tom/) coact.lagreem comply with all city and rummy mmumm",vndsmm laws leasing ata QTY. MECHANICAL PERMIT' E
U Z buildingc.nsmuclum.and loom,aithorire represcand cs efahiscity memer upmflm SEISMICFE���—
above-mentioned pmpeny for inspection pt r,me,. PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City.1 Cupertino against ELECTRIC FEE
Iiabilifies.judgmen,s,costs and expenses which may in any way accmc it,mostond City ALTER OR ADD*10 MECH.
in onseyuence of the grunting oft rmia. PLUMBING FEE
APPLICA UNDERSTANDS, )WILL CO PL WITH ALL NOWPOINT AIR HANDLING UNIT(T010,IK)O CFM)
MECHANICAL FEE
SOUR F EGULATIONS.
AIR HANDLING UNTF(OVER 10.000CF1,U CONSTRUCTION TAX
Si am ppman ZAnes a Daae EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
RDOUS MAT AIS DISCLOSURE
Will The applicanamfmanclooldi g.ccupava store nr handle hulallous material HEATING UNIT(TO 100.000 BTU)
Il as defiZ by the Cupertino Municipal Calls.Chapter 9.12,and the Health and Safety
Cade,Section 95532(a)? HEATING UNIT(OVER 100.000 BTU)
Yes FIN. s
VENTILATION PAN(SINGLE RESID) PAID Date Receipt#
W011 The applicant in furore building by the Bt axe equipment Qu or devices which
emit M1aurdous air contaminants m Defined by the Bay Arca Air Quality Management BOILER-COMP(3HP OR I W,IXIO BTU) TOTAL
District? BOILER-COMP(OVER 100.000 BTU)
❑Yes ❑N.
Ihavereadthe haonall qrials tell all nb under Chapter 6.95 of the Cali AIR CONDITIONER ISSUANCE DATE
fomia H al Safety Cale, rasa 25NI5,255 3 and 8534.1 understand that if the NEW RESIDENTIAL MECH. SQ.Fr. // is
rutl I Ionicurmntlyh as
s 'responsibility to minify the.ecupam ^/� 7
of air
yu u 1ich� st e Iave of.Cenifiroteof Bceupmcy.
�p
O ne r autho a ge Date TOTAL: ISSUED BY:
OFFICE