99090156 'APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-P.LECTRICAI. Js /� PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. U
` BUII.DINGPROJECTIDENT'IFTOATION
BUILDING ADDRESS. L• 1 SANITARY NO. APPLICATION SUBMITTAL DATE
I S7 S cE.meSv�Wn Dr 9•�-a,�'-g9
O P 'S NAYIfi:o� PHONE: C kACI'OR'S NAME: LIC N0:
73--BG�7 8-n., P 1 a 9 NIC CONTROL p
KCIII'IECUENGINEEK: LIC NO: ADDRESS ❑
v 975,
CONTACT: PHONE: BUILDING PERh11T INFO
F1 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
ran c _ -; 53-0G,18 ❑ 1:1 i8-- El
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
hereby ararm that I ant licensed under provision of chimer)(commencing - JOB DESCRIPTION
FOQac, with Sectior7WO)of Dlvlaino3offie Bminessanlfrofession,Code,unda,license is RESIDENTIAL,
O in full l'nrcc and clfcn. FIiRMi'['ISSUANCE
y�n1F.J ❑SFDWL ❑KITCHEN REMODEL.
6UV License Clans hlc.0 APPLIANCES-RESIDENTIAL
y Z w Date Contractor ❑ADDITION B'PDDMBING RE-PIPE
C ARCHITECTS DECLARATION El MULTI-UNIT [D STRUCTURAL
F y PANELS
Z O- [undernnnJ Iny plans abaft he u.eJ as public records MODIFCHIMNEY
TION
REPAIR OZ-'0 UI"T02110 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F 4F" Licensed Profcssimaid 201-1000AMPS IMPROVEMENT [DSWIMMING POOLS
.,1 OWNER-BUILDER DECLARATION OVER I(N10AMPS [I BATH REMODEUREPAIR (]DEMOLITION
C 6 1 herchy am m
ffirtum 1 am exempt from the Contractor's Littnse Law far the
x Cii:LL FU- following remora(Section 7031.5,Business and Professions Code Any city or county SIGNS ELECTRICAL ❑OTHER
y which rcyuirca a pemtit m nmswa,ellen improve,demolish,or repair any strvnttrc
E-'LLOa prior to its issuance,also requires the applicanlfor such permit to file a signed statement SPECIAL CIRCUIT/MISC.
�. y 7 that he is licensed pursuant to the pmvisions of the Contractor's License law(shaper 9
ME00 (commencing with Section 7000)af Dienion 3oftbe Businessand Professions Codi TEMP.METER OR POLE INST. COMMERCIAL:
C.a o CC that he is exempt then ..end the Iasis fur me alleged exemption.Any violation of ❑NF.W BLDG/ADDITION ❑DEMOLITION
XmLL.
Section 7031.5hyanyapplwmfora permit subjems the applicamma civil penehyof POWER DEVICES
41^rn []TENANT ❑FOOD SERVICE
not more than five hundred rattans(S500). PROVEMENT
E-=6 wi Lo the work, the propcny. re myemployeeswiNwagesastlei(See c0W.Buss iess SWIMMING POOL ELECTRIC
'�F.O will do the andthe he Cam idn', ivem,Law
cal doz,nsale(dyto a, wde,of OTHER
W-' and property
whom QsJor imp Commaors License Law rices oat apply s an owner of OUTLETS-SWITCHES-FIXTURE$
his o ny who builds or tided th thereon,and who does such work himself m through
his own employeese provided the such improvements w are not amended ur offered for NEW RESIDENTIAL ELECTS SQ talk
sale,If,however,the building or intpnrvnnem is sold withinone ntand,ndtomplctinnnhe SQ.FT.FLOOR AREA SISQ.IT.
er-bander will have the burden of proving that he did nm huiW nr improve Inn pur-
e ee of sale..
❑ 1,as nwnmr,of the properly,nm exclusively curameti no with I cowd cnnb tots,b1 TOTAL:
tnstmet the project(Sec.7044,Business and Professions Code:)The Cnuoini-s LI- -
censc Law docs not apply to an owner ofpmpeoy who builds or hslproves thereon,and QTY. PLUMBINGPFRMIT i FEE
who comri cis for suclytmjoels with a contrucons)licensed pursuant a the Conloador's
License law. PERMIT ISSUANCE
❑ I am exempt under Sec. ,B&P C for this reason
Owner Doe
ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 herchy affirm under penalty of perjury,one of the following declarations:
�.�I have and will maintain a Certificate ofConscm to self-insure for Workers Cooper. DRAINS-FLOOR.ROOF AREA.CORD.
Noun.as provided for by Section 3]00 of the Labor Code,for the perfommnce of the ^ STORIES TYPE CONSTRUCTION
work far which mit this peris issued. fl/ FIXTURES-PER TRAP
1 have and will maintain Workers Compensation Insurance,as required by Section
3700afthe labor Code.for perorearceofrhe weak for which this permit is issued, GAS-EA.SYSTEM-I INC.40uTLETS OCC.GROUP 6AYN�'^
Mamey Wt Comp:nv t n nmmnce Tarnier unJ Policy numygT alc.'9S�IIS� GAS-F.A.SYSTEM-OVER 4(EA) VV
Cl rsuJrN ���--1 Policy No. 7GION
CfiN'I'IPICAOFEXEMPTIONFROM WORKERS'
COO MPENSATION INSURANCE GREASFIINDUSTRL WASTE INTF.RCF.I'IY)R
_ BUILDING DIVISION FI?liS
(lhls semimn aced urn be completed if thepertnit is farrow hundred dollars(311R1) GREASETRAP
or less.) PLANCHECK FEE
I cenily shat inthe patiormance fthe work farwhich this permit is issued,]shall SEWER-SANITARY-S'FORM EA.2B)FT.
not entplay any peons in any manner so ns to become subject m the Workces'Cnmpcm ENERGY FEE
Zz ambo.Laos,of Coitimtin.Date WATER I IIIATER W/VBNTMTCTR
O Applicant GRADING FEE
Vj NUI ICE 10 APITACAN'C[I',alter making this Certificate of Her"Ponn,yon Fhnuld WATT?R SYS'I'EMOREATING
ai became subject m the Workers Compensation provisions of the Lobar Cnde.you most SOILS FEE
I'onhwoh comply wilh,uchpm,toors on his permit shall he deemed revoked. WATERSERVICE
ow
0
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.IT. PAID
V O thereby affirm olio there iaeam.waiun lending agency fonhe performvnce of Dale Receipt#
LTr F the work for which this pomod is issued(See.3197,civ.C.)
Q Lenders Name T AL:
[U Lender's Address TOTAL:
y 1 cer ify that 1 have hear this application and one that the above information is t ... BUILDING FEE
kn comet.l agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT' FEE
U Z building construction,and hereby authorize representatives winds city to suer upon the I
f SEISMIC FEE
abwe vac mmand property for inspection purposes. PERMIT ISSUANCE
(We)agate to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments.casts mod expenses which may in any way raceme against said City ALTER OR ADD TO MECH.
in asequence ofthe dooming of Ni toil. PLUMBING FEE
APPLICANT UNOEH ANDS 1)WILL COMPLY WITH ALL NON.POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REO AT NS. MECHANICAL FEE
^ 7_97 AIR HANDLING UNIT(OVER10.000CFM) CONSTRUCTION TAX
Sign edl ApI ieuaUc ainr nae I7x11ADST I100D(W/DUCf)
IIAY.ARDOIIS MAI'F.RIALS DISCLOSURE HOUSING MITIGATION PED
Will the cppllcunt or knave building occupant rtn d or handle hnzmdnus nur,n,.I I[EATING IJ NIT TO IOQW0 It IT)
1s diumed by the Cupeninr Municipal Code,Chapter 9.12,and the Health and Safety
Gale,Section 25532110! HEATING UNIT(OVER 100,000 BIO)
-1 Yes ❑Nn
VENTILATION PAN(SINGLE KESIU) PAID .'
Dae Rescipe#
Will the air con m or furore building occupant use equipment or devices which BOILER-COMP(3HP OR IOR"BTU)
nit ItuzaNnus uirconmminants as defined by the Bay Area Air Quality Management r TOTAL:
vria?
❑Yes ❑Nn BOILER-COMP(OVF.R I()T000 BTU)
1 have mad the hr1.1
zard totems AIR CONDITIONER
rtquirements under Chapter of the Cali- ISS ANCE DATE
fomia Health&Sofa od.5 s ions 25505,25533 and 25534.1 understand that if the
Ijdmg Jcesy a nil 1 1,dutois my responsibility to notify the occupant NEW KESIDENI'IAL MECH. SQ.FT.
rQpuwle� i Phi s kmq'prianoissu ce ofa Cenifcate of Occupancy. -
Own or mithadfizedisigen Date I TOTAL: ISSUED BY:
OFFICE