99110039 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OP CUPERTINO BUILDING-ELECTRICAL ERMIT NO.
RUILD[NG DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
,p BUILDING PROJECTIDENTIFICATION
HUILD?NG ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
8/29 �- i ,e, v 9s o� / .
OWNERS PH NE01:17 AO ` :!/Q /CON A OR'S ML: � LIC/�O .
J 7 7 L/i N/C CONTROL#�
CHITECT/ENGINEER: LIC NO: - ADDRE S: ❑
CONTACT: PHONE: 9y p _ BUILDING PERM[T INFO
^1_/7/'14_ , ,^ /�� 5 q5 /Jq p� ❑ Consultant Foes Paid by Applicant(Initial) BLDG ELECT PLUMB MF.CH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under poo cons of Chapter 9(commencing JOE DESCRIPTION
OCy with Section7000)of Drvlsom 3 ofthe Business and Professions Coe,and my license is
F�� w;full force and eRect. PERMIT ISSUANCE FDWL ❑KITCHEN REMODEL
W F in /
�UU License/C�lvs�s Q/q/_r��'�C//�Lia# APPLIANCES-RESIDENTIAL ADDITION El PLUMBING RE-PIPE
Z Z W Date-l•r=-r— -/�--Conoccur,
"Ilfr_lyea It
oo ARCHITECT'S DECLARATION DI"r,- [I MULTI-UNIT ❑STRUCTURAL
ZFON,z I understand my plans shall be used as public records PANELS MODIFICATION
QZ.N.,O UP TO 200 AMPS El INTERIOR ❑CHIMNEY REPAIR
EL)-F. Licensed Professional 201-IWOAMPS IMPROVEMENT []SWIMMING POOLS
C w9, OWNER-BUILDER DECLARATION OVER 1000AMPS ❑BATH REM DEUREPAIR ❑DEMOLI ION
C Q 1 hereby offnn that 1 am exempt from the Cnnlmc/A1y'Tco`,ifth(y
w lar the
tY U following reason(Section 9!1.315,Business vnd Professionsorcounty SIGNS ELEGTRIDAI.I- which requires a permit to construct,site.,improve,demoliatmance <iO�0priortoiu issuance,also requires the applicant for such permismmmem SPECIAL GIRGDD'Ihil$G. �thatheislicensedpursuanttotheprovisionsofteContractor (Chapter9
CO (commencing with fiecdon]OfMpof pivisionJ ofthe Bmsi and Professions Code)or TEMP.ME"fBk OR POLE ST. COMMERCIAL:
tY a that he is exempt Iherefmm and the basis for the alley exemption.Any violation of El NEW BLDG/ADDITION ❑DEMOLITION
Section]03 LS by any applicant fora Pamir s"M1jec the nppliwnimacivil penalty of P(1WER DEVICES ❑TENANT ❑FOOD SERVICE
FSCnot more than five hundred dollars($500). IMPROVEMENT
❑ 1,as owner of the propny,onny employ with wages as theirsnle cnmpensaliun, SWIMMINGPO ELECTRIC
wtldmha work,and the stntmm"'is not in dedorotYeredfor sole(Sec,7044,Business ❑OTHER
w
and Pm wooea Code.The Centome' License Law does not apply to on owner of OUTLETS/WITCHES-FIXTU S
3 property who builds or""proves I do,and who docs such work himself or through
his awn employees,provided in such impoevemcno are not intended or offered for NEW .IDENTIAL EL SQ Up.
sole.IL however,Nebuilding improvement is'old wiNin one year of completionthe SQ.FT.FLOOR AREA $/SQ.Fr.
er-builder coil l have U nrdenofpmvmgthathediJnalhuildnrimproveforpur-
pose of sale).
❑I,as owner of the apiary,ora exclusively contracting with licensed mntmgmrs to L'
onstru2 the proje (Sac.]044,Business and Professions Cn l,)The Contractor's LI-
censeLowdoes I apply to an owner ofproperty who builds or improves thereon,and QTY PLUMBING PER FEE
wh000ntracts r such projects with o centractor(s)lic sed pursuant m the Cognomen's
License La . PERMIT ISSUANCE
❑ Ione mel under Sec. ,B&P C for this mtam,
ALTER-DRAIN&VENT-WATER NA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under Penalty of perjury oneof the following dedaraimm: / /-#
l have and will monism a Ceriticam of Come..self-i.sem for Worker's Camden- DRAINS-FLOOR,ROOF,AREA,GOND. STORIES TYPE CONSTRUCTION
sntlon,m provided for by Section 3700 of Ne Labor Code,for the pardro ncro of the
If..which this Detroit is issued. FIXTURES-PER TRAPa
g1 have and will maintain Worker's Compensation Insurance,as required by Section
3900ofthe Lahr Cade,forlheperrmarrmonce ofthe work forypwhictithlspermit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCCGG�ROOUPP �]! APN 7
Caner cY % U-_Poli"Noy dPolicnR=Ta=% 7 GAS-EA.SYSTEM OVER 4(EA) p
C `(ERTIFICATEOFEXEMPTION FROM WORKERS' "`aler •••^^^"'"'DDD
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR
BUIL DING DI VISIONFEHS
(This.nctlon need not be complemenThe permit is manna hundred dollars(900)
or less.) GREASE TRAP PLANCHECK FEE
Icarry that in the perfcoanccofthe work forwhichnds,crmit is iaweA,Ishad SEWER-SANITARY-STORM EA 200 FT.
not employ any person in any manner so as to became subject m the Workers'Compen- ENERGY FEE
0 whine Laws of California.Date WATER HEATER W/VENT/ELECTR GRADING FEE
,7. Applicant h '
h NOTICE TO APPLICANT.if,after making Via Certificate of Exemption,you should WATER SYSTEM/TREATING
become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS PEE
forthwith comply with such provisions or this permit shall be deemed meeker. WATER SERVICE -
Q
� CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL.PLMB. SQ.FT. PAID 7" iherehy nl'firm that there isnconstruction lending agency for the performance of Dam Receipt#
V 0eworkforwhumthispermiti is 1(Sec.30it Co.C.)
Q V LenderTOTAL.
Name (a.
Lender's Add as TOTAL:
Y �1 —
BUILDING FEE
[.r 1 certify that 1 have read this application and state that the above information is
tr u!, correct.lagreem comply with all any end county ordinanmsvnd sone I....dom,to QTY. MECHANICAL PERMIT FEE
UZ building construction,and hereby authorize represemmtivec of this city to color uponthe SEISMIC FEE
above-mentioned propeny,for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE EL �
IC FEE \ t7
Ilvbilities,judgments,ants and expenses which may in any way accrue againAund City ALTER OR ADD TO MF.CH, PIL I
in mequence of the gaming citing ,,air
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) M HANI .
SO CEREGUL "IONS. C AM
d AIR HANDLING UNIT(OVER 14000CF&U C TRUCTIONTAX
Sigvomm ofpelican .m m r em EXHAUST HOOD(W/DUCT) H SING MITIGATION FEB
HAZ DOUS MATERIALS DI CLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100,010 BTU) By _
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)^ / HEA'L'ING UNIT(OVER 100. BTU)
E]Yea TQNo VENTILA9'ION FAN(5 .LE RESIO) PAID Data Receipt Will the applicant or future building occupant use equipment or devices which
kit hazalloes'kir contaminants as defined by the Bay Arco Air Quality Management BOILER-COMP P OR 100,000 BTU) TOTAL:
,i)isnicfl El Yes )J m tH10 BOILER-C . P(OVER Ir BTU)
p N
1 have read the hazardous m;nerinle regniremcnts under Chapter fi 95 of the Cali- AIR C -ITIONER ISSUANCE DATE
^
fomin Health&Safety Core,Sections 25505,25533 and 25534.1 undersand that done N RESIDENTIAL SUCH. SQ.FT. y O
Into does not on only have a tenant,that It is my responsibility to notify the nccupann / / a .�
of mem whi� ual men prior no'ssuan ofo Ce Iticme of Occupant. ( r
w out
e age Dole TOTAL ISSUED BY
OFFICE