99120131 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -1 { lab (�
CITY OF CUPERTINO BUILDING-ELF.CTRICAI, PERMIT NO.
111/I4DING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJF,CT IDENTIF'ICA'TION
BDILDINGADURBSS: ;ANOTARY NO. APPLICATION SUBMITTAL DAH:
OW NIiR'S fJ0 1•... ✓ 406S PAT - Tptp MII�OLry.N�f. 1 LICONU�
I, k,•" N/C CONTR(lhH
)HIT[Cf/EIJGINEER: LIC NO: ADDRESS: �S
G I"123? b9 E ,,L_5 - %,VD Since Ilio G
CONT'ACP. I'110NG: BUILDINGPER IT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
to
LICENSED CONTRAC'TOR'S DECLARATION QTY ELECTRIC PERMIT FEE
Z
1 hereby afford that 1 um licensed under pow sinus of Chapter 9(commencing JOB DESCRIPTION
wpwith Section 7000)of Division Jnfibe Business and Professions Code,and license is
IW- at If and cficc G� /aa PERMIT ISSUANCE RESIDENTIAL:
aWUU License Class Lic.is ' • �O`� I ❑SFDWL ❑KITCHENRF.MODEL
yah Date 12�Contractor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE PIPE
I 'ns shallARCHIW used IECLA ovoids PANELS ❑MULTI-UNIT' ❑STRUCTURAL
O Z y I undemmd my plans shall be used as public retterds MODIFICATION
UPT020DAMPS
F, W Lmenacd Prolc.,l.na1 11 INTERIOR El CHIMNEY REPAIR
¢� 2111-1000 AMI'S IMPROVEMENT
y�Y ,,j that
OWNFR-BUILDER DECe RAI[ONContractor's
❑SWIMMDEMOLITION POOLS
I hereby,(Sero that 1 1. exempt from the C.nw,Clot License Law for the OVER I(NXI AMPS ❑BATH REMODF.IIREPAIR D DEMOLITION
fn ill,for mono..(Section)011.5.Business and Professions Cade:Any city oreoumy
aI 3 a F which re SIGNS ELF:CfRICAL ❑OTHER
F O m Ol is a a permit comma roa he aIle,improve,demolish,lir repair any stmcuvu
�y�' 'but hor oslicenadPorstrrill. Orthe thempplior,fdreear,to,mchractot I.....Law smtemem SI'F:CIAI.CII(CUIT/A11SC.
that he is licensed pursuant Or the provimona of he C.ntmnnh License law(Chaple9
WX00 (eomnarncing with Sectio 7000)of Division J of Be Bminess and Professions Cde)ar TEMP.ill=R OR POLE INST COMMERCIAL
6 6 to al: that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 70311 by any applicant(..u permit suhjeccadic applicant to n civil pemdty,,f POWER D17VICEg
FZY not prom Nan Eve hundred dollars S500). yvy'ENANT ❑TOO[)SERVICE
E C
01,as owner nfthe property.or my empinyus wire wages heirmle compensation, SWIMMINGP00LEl.FCI'RIC IMPROVEMENT
c, will do he work.and the structure is not intended oroRemd fesale(Sec.7044,BusinessOTHER 11�
and Professions Cale:The Cnmmdor's License Law does not apply to an owner of OUTLETS-SWITCHES-TEXTURES S�SAr�/ 6hwr-
property who hullds lir improve,thereon,lint]who does ouch work himself lir(tonight
his"Wit employees,provided that such improvement,am not intended ar offered for NEW RESIDENTIAL ELECTS SQ PT.
sale.If,houevice the building or improvement is.mld within line year ofcompleti.n,dre SQ.FI'.FLUOR AREA VSQ.EL
ner-huilder will have the burden of proving that he did not(wild or improve for pun
pow of sale.).
❑ I,as owner of the PreSee 704,,B excessively nnmallivag with 1111m:)The Ccnnaactnzv m TOTAL: Y�I / /��
comaum,d es nPoliet apply
(pec.TBS.),Rushes and Pmfeho Wi Carkd,-1 im o es neer,Li- y �O
c se tawdtslotIcpplytoan ith- ofpmpenywhosedpuuant to the Conmacand QTY. PLUMBING PF.RM11IT FEE 1.�1
who nolle¢for Inch projems with a conwmogs)licensed pursuant to the Commemrx
License Law. .Y
El Iamexemptmade,Sec. ,B&PC!..thisreason PERMIT ISSUANCE
r Dam ALTER-GRAIN&VENT-WATER(11A) VALUATION
WORKER'S COMPENSATION DECLARATION
there by it Hun under penalty of pe Jury nnenf the fid lowin,dellooinnr
IWh , HACK FLOW PROTECT.DEVICE
uve and will maintain,Ceeifirm,of Consent sell-insure for Workers Compen- DRAINS-FLUOR.RODE,AREA.COND.
` trillion,so I xvidel for by Scetion 37M of the Labor Cale,our me performance of the ST( IF TYPE CONSTRUCDON
work her which his permit is issued FIXTURES-PER TRAP
1 have and will maimmin Worker's Compensation Insurance,as required by Section
1701 of the Labor Cddc..for the peeflormmaancee-of the work for which this permit is issued, GAS-EA.SYS'1'EM-I INC.40UT'I.171SMyW OCC.GROUP ANN
G merrPk'es Ci� LII S!'I I TYf land y N my n�u QbeJ gV 3i� e 7 a
9'71 1. • GAS-EA,SYSTEM OVER 4(G)
/ ��ZXERTIRCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTR,WASTE INTERC-EMOR
IT,h s seelion need not bo completed ifthe pemdt is rnrnnehundred dollars(S100) BUILDING DIVISION FEI?S
lir less.) GREASE TRAP PLANCHECK FEE
Loy any thm in he peffoanyprmanceo a,;I �ro .which this the W rkersu Commit.
not employ any polon in any manner cost boco,�e yjed to the Workers Commit. SEWER-SANITARY-S'fURM EA.2tkt FT.
z salion laws.11 dIllyr�m�esDo�- pen FNIiRGY IEE
O O A tical to Q-4—..5 WATER HEATER W/VENT/ELECTR
Z .+ I Irk�n 1 GRADING FEC
.�. NOTICE TO APPv,1. he Wallwe.Compenking sation
s CeABo of of Labor io da,yen ouldam,, WATER SYS'IEh1/fREATING
a , become subject m he Workers Compens:hnn varitshal of the Labor Code you man SOILS FEE
0. Q forthwith comply with such pnrvuions onbi,permit shell he JeemeA rewked.
WAFER SIiRVICIi
7z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMN. SQ.FT. PAID
L) 0 Iherehy alarm that here isaconmmnion lending agency for the performance lir Date Receipt as
12w (~ the work for which'I'll Permit is issued Nov.30Y7,Cis.C.)
Lender's Name
Lenders Address TOTAL: TOTAL:
y 1 verify hat 1 have rend this ap,lica,i.a and state his me above information is BUILDING FEE
h7 ,
correct agree it) with all city and county ordinances and state laws rtWin,t. QTy, MECHANICAL PERMIT FTE
U Z bnildiag construction.and hereby authorize repreventutives of this city u, ,, , m the SEISMIC FEE
abnvomentin led pr.peny for inpedion purposes. PERMIT ISSUANCE
(We)agree it)save.indemnify and keep harmless the City of Cupertino against PERMIT FEC
liabilities,judgments.costs and expenses which may in any way zceme against said City ANTER OR ADD TO MECH.
consequence o(he gm ming or his emit. PLUMBING FEF.
APPLICANT UNDERSt'ANI DWELL COMI'hV WITH ALE,XON-POINT' AIR HANDLING UNI'I'CIO 10,000 CI'M)
SOURCE REGULATED MCCIIANICAI.19Ai
AIR HANDLING UNIT(OVER 10BOOCFM) CONSTRUCTION TAX
Signatum of Applica actor, Date EKHADST HOOD(W/DUCT)
H BOGGS MA I'BRIALS DISCLOSURE HOUSI NG MITIGATION ME
Will me applicant or future building occupant stoat lir handle hazardous material InixTING UNIT(TO I W.000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.)2,and the Health and Safety
Code,Sectio 25572(5)? HI7.ATING UNIT(OVER 100,000 BTU)
ElYes i(
No
V HNULAT(ON FAN(SING LE RES I D) PAID
Will he applicant or future building occupant use equipment or devices which Date Receipt p
nit hazardous air contaminants as defined by he Bay Area Air Quality Management BOILER-COME LINE OR 100.000 BTU)
7building
i,lria I - TOTAL:
❑Veto U/No HOILER-COME(OVER I Kodak)BTU)
I have read the heard as mamriab reyuiretmnta under Chat"116.95ofthe Cali- AIR CONDITIONER ISSUANCE DATE
ee,Oiuns 2i5(I5,11511 wt]255X.1 understand mat ifhe NIiW RESIDENTIAL MECH. SQ.EE
docs urn cu •amor,"a' ismyresrynlot requlmmu l' l tie mu pnonnissmanca of a Omtifelec"1Oc pun
I
Owner or au act]agent Da TOTAL:
ISSUED BY:
OFFICE