99080127 1,.APPLICQNTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY �'j qOg o 124
CITY UP CUPRRTIN0 BUILDING-ELECTRICAL � NO.
ROILDING DIVISION APPLICATION/PERMIT 1'I,UMnINGMF.CHANICAI, .50001
IIUILDINC PROJECT IDF,NTIF'ICATION
HUILNG ADDRGSS'. SANITARY NO. APPLICATION SUBMITTAL.DATE
lieA� zCl6 e - 17 -9
OWNER:SNAME: FII( 1,.- COM' IUR:SN E' 1,1 NO:
OOe NIC CONTROLN
CHITEC`f/ENGINEER: LIC NO: AI It1iS.: EJ
I
CONTACM PHONE: BUILDING PERMIT INFO
8'3l 3�Y's-/�3 ❑ Consultant Fecs Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
❑ ❑ �Y ❑
LICENSED CONTRACTORS DECLARATIONQTY EI,ECTRIC PERMIT FEE
I hereby effort that 1 am licensed under provisions of chapter 9(commencing JOB DESCRIPTION
M=z with Section70Nkof Division Jofrhe Business and Professions dmy1werwis RESIDENTIAL'
W O 0 In PERMIT ISSUANCE
F ty_ fulIfarce and eIT �1 f ❑SFDWI. ❑KITCHEN REMODEL
FatUil patrnse Class Con once—/ APPLIANCES-RESIDENTIAL. ❑ADDITION El PLUMBING RE-PIPE
ARCHITECTS DECLAR G []MULTI-UNIT ❑STRUCTURAL
p..D n PANELS MODIFICATION
z O y z 1 understand my plain shall be used as public records
Oz�� UI'T0211(1AMPS El INTERIOR LI CHIMNEY REPAIR
1-•�FW Licensed Professional 201-100MAMPS IMPROVEMENT F]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
C Q 1 hereby affirm thin 1 am exempt from the Commerce's License Law for the
XO6 V following reason.(Section]031.5,Business and Professions Cale:Any city m County SIGNS HLECTRICAL ❑OTHER
W 3 LL H which requires a permit to construct,alter improve,demolish,or repair any suuctua
1��'O�
prior o is issuance.also requires the applicant(orsuch perminn rile u nignedsmtement SPECIAL CIRCUFUMISC.
f�} that he is licensed pursuant to the provisions of Ne Contrast License Few(Chapter 9
�WCpo (commencing with Section 7")of Division J.1 he Business and Pmficaons Coast or THMR MIIR OR POLE INET COMMERCIAL:
6 a o C that he is exempt therefrom and the basis for Ne alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Iy t Section 7031.5 by any applicnmforapermir subjects the applicant to cravat Penalty of POWER DEVICGS (]TENANT ❑FOODSERVICE
mo
f-Z P a Nan five hundred dollars(SSW). IMPROVEMENT
_< wiLmownerk,the property,oemyemployeeswithwrgcauth (Sm.c0dL Buri ien, SWIMMING POOL ELECTRIC
F�0 will do the work,and the stmaum isnot in¢ndcdaraffed forcalc(Ecc.711W,Business ❑OTHER
!Wil m add Professions Cede:The Cmdraemrs License Law does nut apply it,or owner M OUTLETS-SWITCHES-IIXTURF
a 3^ property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements art not intended or offered for NEW RISIDENTIAL ELECI'R SQ FT.
sale.IL however,the building or improvement issold withinom yearofcompletiod,the SQ.FE FLOOR AREA $/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pur-
pose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed can,melon to
construct the project(See.]t W.Business and Professions Code.)The Contractor's Li.
nu Law does nor apply u,an owner of property who builds or improves thereon,end QTY. PLUMBING PERMIT FE
who contracts far such projects with a commmor(s)licensed pmauonnn the Comfacun's
License Law. PERMIT ISSUANCE O
❑1 am exempt under Sm. .B&P C for this masam
ALTER-DRAIN&VENT-WATER(FA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hand w ll mai under penalty perjury one of the fallowing detheWorkee.s Co.
400[have prividl for
maintainCertificate7ofCousent
LukrCod,for the Worker'sce it th- DRAINS-FLOOR.BOOK AREA,COND. STORIES TYPE CONSTRUCTION
is on for
provided for na Section 3]01 of the Luker Cada,for the perfarmance tel the
work far which this permit is issued. 17IXTl1Rfi5-PLR TRAP
I have and will maintain Worker's Compensation Insurance,whi h required by Section
J7Wofthe Labor W,forthe performanccwnrklnrwhich Nisptrmir iaiaaued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC,GROUP APN
My Wo r r flim a'a s n a I Folic r GAS' EA.SYSTEM-OVER 4(EA) ,
u
Came r ley FROM
CERTIFICATE OFIS R ONINSpRAN WORKIikS GREASIYINDUSTRLWASTL IN'I-ERCEPTOR -_— l � Q
COMPF.NSAf10N INSURANCIi � glll UI DIVISION PEES
(This section ted nm ba compleaAlf the punch Isfonmo LunJrcA J011ars ISI IgB
or leay.)
GREASE TRAP I PLANCHECK P[E
I certify[her in theperforounce orthe worklar which In,permit is issued,lehall SLiWlik-SANITARY-STORM EA.211111T. I
not emi any pre,on in wrynmmersousm bmunmsubjan ser the Woken Com,". tt� EN�GpI (J L{
,7.a eidion Laws of Cnlnt `forri Dam WATERIIENIERWIVENT'/ELEC]'R �-:
O GRADING FEE
z NOTIAppliCE
t•N r�i NOTICE 9Y)APPLICANT:If,atter ranking thin visivacntc the Labor C d you should WATER SYS'1IiM/TREATING
forthwith come omply itthuche Workers Compensation thixermitdrismthemedr Cade,You orae ,OIL LE
(31 comply with Pnrvi,tim Fermi +hull he deemed revnkuL WAI'IiR SERVICE ----^--- -- _
.�ti. z CONS'1'Rt1C'I'ION LENDING AGENCY NEW R17S JOENTIAL PLMB. SQ.ET. PAID Dale ReceiprN
elluvnx
t.)0L hereby affrzm that is a construction lending agency for the performance of
H the work for such his permit is issued(Sce.3097,Cie C.)
Lender's Name TOTAL:
G Lender's Address TOTAL:
�•n 6iBUILDING FEE
1 certify that 1 have read this application and state thin the atone infmnwinn is
NF-a y correct.I agree In comply with all city and county obliterates and state laws relating to QTY. MECHANICAL PERMIT FEE
C.) Z building construction,and hereby authorize represcnwriva of this city m enter upon the
SEISMIC FEE
above-mentioned property for inspection porpoises.
(We)agree to xam.indemnify and keep marmleas the City of Cupertino ugai nsr PERMIT ISSUANCE ELECTRIC FEE
Imbilitimpedgarms,costs an xpcoseswhicb may in anyway accrue against said City ALTERORADDTOMECH.
inconst seance a Ne gmmin frM1is permit PLUMBING TLE
APPLI AN' N RSTA 1 AND WILL COMPLY WI'T'H ALL NON POINT AIR HANDLING UNIT(TO IU.0W CFM)
MECHANICAL FEE
SOUR:E 11 ONS.
g / AIR HANDLING UNIT(OVER LO,BW CFM) CONSTRUCTION TAX
Signature ofApplicanITC011tridetor I Dat EXHAUSTHOOD(W/DUCI HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building mention smrc rehandle hazdnus material HEATING UNIT LTO IW,BW BTU)
as defined by he Cupenim Municipal Calc,Chapter 9.12,and the Health and Safety
Cade,Section 25532(+)'! HEATING ON]P(OVER IW.0W BTU)
C]YesPJNn PAID
VENTILATION FAN(SINGLE RESID) Dare Receipt N
Will the applicant or future building reeupmt use equipment or devices which
emit havrdeus air communicators ad reed by the Buy Area Air Quality Management BOILER-COME(314P OR IW.fIW BTU) TOTAL:
' District^ BOILER-COME(OVER 100.01!1 BTU)
El Yes n
I have mind the harardnus materials mems under Chapter afthe Cali- AIR CONDITIONER ISSUANCE DATE
Squire
forma Healmc
,Secri a 25505.25533 aa1255J4.1 understand that if Ne NEW RESIDENTIAL MLCII. SQ.Pr'. ppp O
building doeseats m,their is my mapnnaduliy to notify Ne reopen A r D
of rhe mlui st et prior toissuanceofaCern a cy.w Jate TOTAL ISSUED BY:
OFFICE