99120130 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL- PERMITNO.
BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFIL'ATION
OW
BUILDING ADDRESS: �f/� ANI'TARY NO. APPLICATION,UBMITTALT TU
ATE
o ee}sep ij I3 . -42 qq /pCl//,� '
O ER'SN ME: c4 P NE: COME RACfOR'S NAME: LIC NO: 2- z �^fIr
• L O
NIC C��0N'rRnLe/
�R ITEC(/F:NGINEBN: LIC NO: ADDRESS: ❑ / 2 (O
G 12 F7 F. inns r ak /
oNL'nLT. PHONE.: BUILDING PERMIT INFO
T'� '� ❑ Consultant Fees Paid by Applicant(Initial) 1{hr)c F v B MECH
LICENSED CONTRACTOR ❑
'S DECIARATION QTY. ELECTRIC PERMIT fEh: e�•�y _
1 herchy m0irm that I nm lirvnsed under provisions of Chnpar 9(cmnmenciny JOB DESCRIPTION
y,D00 with S11ion9o( pnf Division 3.Ohe Bearasanl Professions Cale, it mylwcuoa is
.Win full fnrceand eB' PERMIT ISSUANCE RESIDENTIAL:
yUU license Class Lick Al I I ❑SFDWL ❑KITCHEN REMODEL
F'yZW Date Cont.Oor • APPLIANCES-RESIUENTIAI.
y6d []ADDITION 11 PLUMBING RE-PIPE
ARCHITECTS DIiCLARATION PANELS ❑MULTI-UNIT El STRUCTURAL
z O rn 3 1 undersand my plans shall be used es public records s
OZ-C UP'H>2f(1AMPS MODIFCHIMNEY
HIMN YREPA
ATION
F.'�..F,W LmenseJ ltnfesnonal El INTERIOR ❑S IMMING P00N
r -1 VAMPS IMPROVEMENT
OWNER-BUILDER DECLARATION ❑FINITEREMODFUREPAIR El DEMOLITION
I herchy nl'fimt that I am exempt from the Camnnnr'S License haw far the OVER Ifl(111 AMPS
x d U following reason(Section]1131.5,Business and Povessinms Code:Any city a County ❑OfFHER
4- SIGNS 131.ECI RICAI.
F O ma which requires a permit m uiconstruct,thealter,improve,demolish,or repair any structure
qqvs to.] that heor
its censeepunuue,also requites the sa Brz Contrasuch rm3t ai,u,nle i Law
SPECIAL CIHCUI'f/MISC.
24!<E that he Ls licensed pursuam le the provisions of the Cnmmcmr'x License Low(Chapter
66WC pO (commencing with Sectian9fp0)nf Divicinn3 nfthe BusinasenJ Pmfesninm Cvdehm TEMR b1E1'ER OR POLE INST R
iC m LL that he is exempt therefrom and the basis for the alleged exemption.Any violation of 0"" GIADDITION ❑DEMOLITION
cull ,� SmBnn 9031.5 by any applicant fora permit subjects Bas appliaonl In a civil penalty nl' POWI3N DEVICHS
1„z} not more than five hundred dollars($500). ANT ❑FOOD SERVICE
F< ❑1,as owner ofthe propcny,or my cot 1 with wages pcnsa PROVEMI,
W poyeeswr gesasthci(See.B94 tion, SWIMMING OF"ER otM- F-f
wlildmhewools and the betrafeisnutl Lndal or owdofieod forsaltpply to
an sruness
a}v and Professions Cts orimewes(hereo License law Jcesmmapplysamownerof OUTLETS-SWITCHES-FIX'1'URE.S
pmpeny who builAs or improves thereon,and who does such work himulf or through
his own enpinyecs,provided that such impnwemenks me not intended or offered for NEW RESIDENTIAL EI.ECTR SQ FT.
sale.If.however,the building arimpmvenmm is sold within one ywrofcnntpletionrtb, SQ.IT.Iq.00R ARCA $/SQ.Ff.
owner-builder will have the burden of proving that he did not build or improve for Pur
pose of sated.
❑L Its owner at thepropen,am rxulusively,ommeting will,licensed cumrucuns to 'I(TI'AIL
common the pmjrcl(Sec.7814,Business and Professions Cale:)To,Cnmuneme,Li-
c setrwdtcsnotapplymen with
ofprapeny who
ceawddsor3mproves Contra and QTY. PLUMBING PERMIT pgg 31t,^� �
whocontractsl.w.farmch pmjmla withoronnonngs)licntxvd pursmmllothe Contractor's `d I
License I,aw. PERMIT ISSUANCE
❑ lam exempt under Sec. ,B&PCfor this rennin
OwnerALTER-DRAIN&VENT-WATI3R(IiA)
Dmc VALUATION
WORKER'S COM PENSATION DECLARATION BACK FLOW PNOT[CT.DEVICE
1 hereby effirm under penalty of perjury one of the following declarations:
Ih:rvv and will muinminaCcrific:ec of Cnnsem lr sell'-insure for Workers Cnmryn- DRAINS-FLOOR,ROOEAREA,COND.
lion,az provided for by Sectio 3900 of the Labor Cale,for the perfomunu,of the STORIES 'TYPE CONSTRUCTION
ask for which this permit is issued. FIXTURES-PER TRAP
❑I have and will mainutm Workers Compensation Inunnu.,as ,,irW by SpOwn
3900uf the lsRm Cod,for theperformano,.fluework for which this permit is issued. GAS-IA.SYSTEM-I INC.i OUTLETS OCC.GROUP nPN
My Work Coou pc ation Insurance ca nd Policy
Cpmer: e--/'-'I'!"TM�'Policy No.: GAS-EA.SYSTEM-OVER 4(FA) p
FiAllf—CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRFASEINDIISTRL WASTE INTHI CEPTOR
(This section need mot be completed Bob,permit is(iron,humdreddollars($100) NUILUING DIVISION FEES
in Icss.) GRI7ASE TRAP
I'LANCHECK AIL E
Ic,abythat inthe perfomenceaf,the��'wfo�rl.n., ir)t Nis RermitiIwoc wupm,- SEWER-SANITARY-STORM EA,200 FT.
nor employ any parson in any mannerso12!2.3w7 Pte Workers'Comµn" ENERGY FEE
z-I saunas laws of Cnl�'fo�r^r�ysn Data
�:/ 4•?
z Ap ICH vAM WATER BEAT 17R WIVIiNI'/ELEC'1'R GRADING FEE
f0
became
TO APndle Workers
AMP,If,afarnm..li this Cenificete of Exemptin�,you should
WATI3R SYSTEMITREATING
a hecome suhjen vs the Wnrkcr's Conlpcnsation pnrviniom of the L:Ihor Calc,you most
f SOILS ITE
nnovith comply with such provisions Unhis permit shall he deemed revoked WATER SERVICE.
c.
LST. z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
1..)Q IM1arnby uBirm tum lhercieacrnsWelinn lvndhtgugenay for lM1e performance of Dam Receipt#
D. F the work far which this permit is issued(Sec.3097,Cie C)
Lenders Name
O L) Lender's Address B'O'1'A[, TOTAL:
H0. I c,ttify that 1 have read this n1ow.licn and sate net the shave infnortrah m is BUILDING FEE
tm correct.I agree comply with all city and county onlinances and state laws relating to QTY, MECHANICAL PERMIT FEE
70
f,a building amsatnclum.and hereby aathmi7e apmanatives oflhiscity(center upon the SEISMIC IEE
above-mentioned pmpery,for Inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep l amless the City of Calsu ire.,.Inst FLECTRIC FEE
liabilities.judgments,costs unit expenses which may in any way accree aguinstsaid City ALTI7H OR ADD TO MECR
nseyucnce at the grantin"COMPLY
PLUMBING I>Eli
APPLICANT UNDERSTANDN-POINT AIR fEANDLING UNIT(TO IO,t1f1U CFMI
SOURCE REGULATION. MECHANICALPEE
AIR HANDLING UNIT(OVER 10.000 CPM) CONT RUCTION TAX
Signature ofApplican a EXHAUST HOOD(W/DUCI HOUSING MITIGNI'IOM1'fTE
A.ARDOUS MATERIALS DISCIASURR
Will the applicant or future building occupant store or handle h=-dous material IIEKDNG UNIT(TO I(1,000131'U)
as definM by the Cupertino Municipal Code,Chapter 9.13,and the Health and Safety
Cole,Scnioo 25532(x)' _� HEATING UNIT(OVER 00,000 BTU)
❑Yes bNo
VENTILATION FAN(SINGLE RESIDE PAID -
W311 Ne.pplicamor Tamm Fuilding cecupam useeyuipmem or Jevics which Date Receipt 4
hasuNnus air comom ants,as dduen!by the B.y Arva Nr Quality Mun.gcmvnl HOILI3R-COMP(3HPOR 100.001 BTU)
.ret •L TOTAL:
Cl Yea �INo BOILER-COMP(OVER 1(10.000 BTU)
I have read the hamldous Ivduls reyuiremems under Chupmr 6.95nf the Culi- AIR CONDI'T'I)NER ISSUANCE DATE
forma Health&Safety Cal aios 25505.25533 and 8531.1 unJentald that if the NEW RESIDENTIAL h1ECH. SQ.FT.
building Jces not cuu,nd tanant,that it is my anImusibilhymnnifyt •asap:
oflhereyuirements h' st be mm prior to issuance nfo Cenlllrute of capons
2
Owner onatho-. agent Dat TOTAL: ISSUED BY:
OFFICE