99100132 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMI
BUILDING DIVISION APPLICATIONIPERMIT 1'LUMIIING-MRCIIAT.CAU
BUILDING PROJECT IDF.NT'IFICATION
BUIIpING "-S S: : NITARY NO. APPLICATIGNSUBMITFAL DA
H`fbC AIX CUKIM90 _`17
OWNS 'S NAM PHONE: CONTRACT'OR'S NAM : LIC NO:
O NIC CONTROL#
7CON
CHI'I EC'UENGINEER: LIC NO: ADDRESS: ❑
TACT: PHONE. BUILDING PERMIT INFO
❑ Consultant Fees Paid By Applicant(Initial) BLDG ELECT PLUME{ MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under Provisions of Chapter 9(commencing JOB DESCRIPTION
bS.idn700EofD:v"xlan Sollhelhuimss and Pmfe,,ionsCWe,andmyEecnseis RESIDENTIAL:PERMIT ISSUANCE
full tomo and cRcct. SFDWL OKITCHEN REMODE
ense Class Lic.# APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RIPIPI
vite Contractor `
ARCH F,CI"S DECLARATION ❑MULTLUNIT ❑STRUCTURAL.
F7h PANELS
Z O N 3 I understood my Plans shall be used as public rcuu:Ls MODIFICATION
ZLC Up TO 2118 AMPS El INTERIOR El CHIMNEY REPAIRP4F"ty Licensed Professional 201-1010AMPS IMPROVEMENT [I SWIMMING POOLS
I�d,J OWNER-BUILDER DECLARATION OVER 1000 AMPS 0 BATH RF.MODEUREPAIR 0 DEMOLITION
C Q I hereby uRan Thal I u;n exampl Poon the Commam,License Law Scribe X 3 d O following mason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑(7fHER
W o y which requires a permit to ronsoum,alter,improve,demolish,or repair any structure
f"LLQ
prior it)its issuance,also requires the applicant lar such permit file a signed statement
Penn6 SPECIAL CIRCIII'1'/h11SC.
wwy-
'not be"mmg,aJ pursuant ction7the pnwmionsof the Contractor s License Law ssma((Chapter 9
Wa:0 (commencing with Semion]INXI)af Divisinn3ufthe Busincxs nnJ PnFlessions CnJel or TEMP.SIFTER OR POLE INST. R AI' f"',
a a e m that he is exempt Iherefmm and the basis for the alleged exemption,Any violation of 0 N'W BLDGIA N LIF,MDIaTION
x LL
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil Penalty of POWER DEVICESu1�N N FOOII SERVICE
nal come aIban f vc hundred dollars($SINII- O JQf.'4T
aSC 01,°,owner of the properlynr my employees with wages as heir sole emn'tr mmi. SWIMMING POOR.ELECTRIC
wm
will do the work,and thescre is not intended or offered for sale(Sce.70,14,Business 00 L
W 3 m and Professions CWe:The Contractor'r License Law docs not apply to an owner of OUTI.EIS-SW'ITCHF_S-FIXTLIR
ma wrty who builds or improves thereon,and who docs such work himself or through �P
his awn employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTS SQ
sale.If,hrmxver,the building or improvement is sold withi it one year of completion.the — SQ,FT FLUOR AREA SISQ.EL
nerbuilder will have the burden of proving that he did not build or improve for per 10
-
p rte n- . Ie.).
as owner of the property,am a Chssivdy conlmeting with Licensed contractors to TOTAL:
umstmm the project(See71F4,Bus and Prefcs nsCalm)TneContracmi
screwshl-
lawdoesnotapplyloanownerofpropenywhobuildsofimmrovestheteon.and QTY. PLUMBING PERMIT FEE
whocontracts fortechpmjemswithacomractarbd licensed pursuantmthe Con memiss
License La n PERMIT ISSUANCE
01 ant no an�. _�.B&PCfar thi,mason
Owner
Date ALTER-DRAIN&VENT-WATER(EA) VALUATION
WOR IkER:S COMPENSATION DECTARATION BACK FLOW PROTECT.DEVICE
L hereby affmt,under Penalty of cUuty one of the hollowing declarations: // lJ
❑I leavened will nummaina Cenlficamof Canwnnowif-insurcf..Worker's Comfort,- DRAINS-FLOOR.ROOF.AREA.COND.
ration,az provided for by Section 370 of the Lather Code.for the performance of the SIO IES TYP CONSTRUC'TI
work for which this permit is issued. FIXTURES-E'ER TRAP
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labour Code,for he ry:,fnrmanccof the work for which this Permit is issued. GAS-EA.SYSTEM-I INC.Y OUTLETS OCC.GROUP AP,
My Workers Cumpetnatbn Insurance canner and Policy rembennre:
Carrier: Policy No.: GAS-G.SYSTEM-OVER 4(17A)
CLIO IFICA'1'li OF EXEMPTION FROM WORKERS'
to Alo?
COMPENSATION INSURANCE GREASELNDUST IL WASTE INTERCEPTOR
(This section need nnl becomplenl ifthe Komi)is for one hundred dollar,($ISP BUILDING DIVISION FE S
ar leas) GREASE TRAP PLANCIIECK FEE
I.edify lhrl in the pe,formovoinflc work for which this pencil is issued I JdII SEWER-SANITARY-STORM EA.200 TT.
nm employ any formon in any mm�ncr ro us m became subject to the Workers'Compete ENI!RGY FEEZ ration laws of Califomia.Dec WATER HIiAIER WNLNT?LeCfR
O Applicant t GRADING FEE
YNOTICE'D)APPLICANT.IL after making this Cenifi,me of Exemption,you should WATER SYSTEMTREAJ ING
hcomcmbject to he Worker's Compensalionprawkiuns of the labor CWe,you must SOILS FIR
forthwith comply wish such provisions or this permit,he]]be donnictim,oked, WATER SERVICE
7 Z CONSTRUCTION LENDINGAGENCY NEW'R13SIDENTIAL PLMB. SQ.Irf. PAID
L� k far wicby honth permit i isaronseuni30 lending agency for the performanceof U;nc RaeiPl#
W F the work far which this permit is Lsnunl(Sm.109],Civ.G)
O L) lender's Name TOTAL:
Usnder's Address TOTAL:
I certify that 1 have read this application and state deal the above information is BUILDING FEE
V) emoccl.I."memmmpIy with all city and county ordinances and slate Laws relating to QTY MECHANICAL PERMIT FEE
LIZ bufldingcommuction,andherchyatifferiac represemntivex of this city menter upon the I SLL-S`MICFl]?��
alnve-memiotted progeny for inspection purposes. /
(we)same m save,Indemnify and keep handless the City of Cupertino agxPERMIT ISSUANCEinsl I;'If.ECTRfGFLE�
Iiabilitics,judgments,costs and expenses which may in any way rescue against said City ALTERORADDTOMECH.
m
in Laer of the gamong ofshin'nuil. I 'PLUMBINGFEE
APP IC NT i 'DF STANDS AND WILL COMPLY WITH ALJ.NON-POINT AIR HANDLING UNIT(TO 10.000CI I
S I E E.0 A'I NS. ML � CA '
AIR HANDLING ONI'1'(OVBR I(I,gNI CIM) CONSTRUCTION TAX
.tgnatC of ApplicanVCammetor Date EXHAUST HOOD WIDUCT) 'HOUSUGMITIGATIONFEE
HAZARDOUS MATERIALS DISCLOSURE
Will theappllearam fmum builiir,occe,ruoireo lmendle haanrdotumatedal HEATING UNITG'O 100.000 BTU)
as deiced IFy the Cupertino Mmucipal Code,Chapter 9.12,and the Health and Safely
Code.Secfion 25532(x)? HEATING UND(OVER 100,000 BTU)
C]Yes C]No
VENTILATION PAN(SINGLE RESID) PAID
Will thea Ikanl or fnture huildin I use•ui mens or devices which Date Receipt#
PP gby then sq P BOILER-COMEOR 100.0013TU
emit hazanlons air contaminants as defined by the Buy Area Air Quality Management )
DiatieC TOG1h:
E3 Yes ONo BOILER-COME(OVF.R IfXI,IKKl BTI11 -
moardomounivials requirements under Chapter 695 of the Cali- AIR CONDH'IONEK ISS ANC• Dfnim"r
h fn oda,Swtinns 2.5505.25533 and 25914,1 undcmrnd Nal ih theNEWRESLDF.NTIAI.M[CH, SQ.Fr.bunn m n a ly have aletlaraded its my resPunnihitirymnmifythe«engemm nt.w It h e of a Cenificam of Occupancy.
roto I've.genl Dale TOTAL: ISSUED BY:
OFFICE