99120080 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
' CITY OF CUPE RTINO BUILDING"ELECTRICAL PE MIT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDE.NT'IFICAT]ON
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BUILDING ADDRESS: - 1 L(. Q�MSANITARY NO. APPLICATION SUBMITTAL DATE
" 1 9 2 i PI
S64T1A
OWNER'S NAME PHONE: CpNTRACOR.S AMP: ' � Q
�� ILtLagl L N/C C.NTROLN
ARCOITECT/ENGAlk INEER: LIC NO: ADDRESS: ❑
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CONTACT PHONE: BUILDING PERMIT INFO
• - ,�t-t"1 \,UILp1YlA.eJ11 ;A—I It L ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT Pi UMMBB MECH
- t /hC/� ❑ lK ❑
LICENSED CONTRACIOR:S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I ten licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
GCZ with Sectio FN1f11otDivision Sof the Businessand Prufesslons Cnde.marty license is. - RESIDENTIAL:
W O FERMI I'ISSUANCE
g,1z0 in full force ani eB t. - ❑SFDWL ❑KITCHEN REMODEL
�VU License �Lic.N APPLIANCES-ItN.51D1iNTIAI. ❑ADDITION ❑PLUMBING NE-PIPE
HZ W Dale TS DE m
H6d ❑MUL'1'1-UNIT ❑STRUCNRAI.
FDy AR shollb an DECLARAT N PANELS _
OZ4zcu�- lundcrstand my plain shallM used ux puM1lic mcoMn MODIFICATION
OZr'30 UI'To]1111 AMT'S I El INTERIOR ❑CHIMNEY REPAIR
F h.FW Licensed Professional 201-1000AMPS IM EmENT C]SWIMMING POOLS
s OWNER-BUILDER DECLARATION
O C a1 hereby aflinn that 1 am exempt from the Contractors License Law for the OVER 1000AMPS ATH REMODIEIJREPAIR ❑DEMOLITION
sD.06V following rema.(Section703 L5.Businessland Professions ClNe:Any city car SIGNS ELECTRICAL � �OTH[:R
a13 W Fm¢' which
�`rOisJ pihnol..0anu pe,rmit m cnnnnlct,aper,intpmve,demmhlinh,or repair any s...couenret -
SI'ICCIAI.CIRCUIT/MISC.
ls��. that he is licensed punuanuothe provisinnsofine Commmea, License Lawn zh l)r9 COMMERCIAL:
�2 Q (commencing ,t thedion 9 wri f basis
far
r oOhe aged also and l n.Ze l P R
d Ii eG ma he is 31.5 b therefrom and or basin fns me alleged exemption.An ❑NEW BLDG/ADDITION ❑DEMOLITION
LLX7 4• Sectinn'/BlL56y any epplicum fora patelli subject the npplicam mact ITEMPROV ANT ❑FOOD SERVICE
46 aim
nm mare than five hundred dmlars(551)(1).
O C] POIMPROVEMT:NT
SI,as owner of the properly lir my employees with wagesaz Meir sale compe...no... SWIMMING OL ELE [I OTHER
wit do me work,and fa muenno knot maradedor offered fm sale(See.7w4,1as
and Professions Code The Cartel License Law does not apply to an U 1
L ...pony who builds or improves,thereon,and who does inch we himself a h
his own employees,provided that such improvements are mol i tell c lir n I: T.
sale.If.however,the building or improvement is sold wihin one yarn n.the SQ.II'.FLOOR AREA 5/SQ.FT.
war,larlder,will hme the burden n(proving that he did not buil)all
poxco(sale.)
❑Las owner of the property,am<nd ova
and chntmcting with Iicen m L'
ow,hoot the pejeW(Sec.?Iw4.Business and Profession,COJe:)The w o. -
se Law Anes not apply to an owner of property who builds or improves thcremn,and QTY. PLUMBING P FEE
mmm
who contracts for such projects with a c.ntmetw(s)licensed pursuant o the Contractors
License Law. PERMIT ISSUANCE
1 that exempt under Sec. .B&P C for this mason
AIfrER-DRAIN IsVFW-WATER(RA) VALUATION -
Owner Date
WORKER'S COM PENSATION DECLARATION BACK FLOW PROTEGE DEVICE
1 hereby will
under Cnahy le of Cononeofthefnsure for Baker's Cs:
FI (have anivid, far bynaloon 37000
7ateofCn labrCod.far for Worker's Ce of the DRAINS-FLOOR,ROOF,AREA,COND." 5ORILS 'TYPE CONSTRUCTION
,melon, r pmvt this
for by Section lTW o(dhe Iskm Cak,forme performance.(the
work for which this permit is issued FIXTURES-PERTRAP
1 have undo will maintain Workers Compensation Insurance,ca required by Section
l?ql of melabor Coda Tonle performance ofthe work for which this permit isissued GAS-EA.SYSTEM-IINCAOUTLETS OCC.GROUP ZAPNJejo
My Worker's Compensation Insurance carrier slid Policy trundler arc:
Carrier. Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' 2- 2
OItBASIIINDUSTItL'WASTE IM'[RC[PTOR
COMPENSATION INSURANCE tlUILDING DIVISION FEES
(Thissation need not be completed if the Permit is for me hundred collars Oulso GREASETRAP
or lcxsJ PLANCIiF.CK PEE
I clarify thmoheperfnmtanceofthessork forwWh�icph thispennitis issued,ishall SEWER-SANITARY-STORM F.A.21X1 FT.
not employ any pemsn in any manner ro all 1`I the Worm'Cooper- ENERGY PEE
z ration Inws n G�il t `I-1 WATER IWA'TER W/VENT/F"LFCTR
z Applicant h�'�t .LC l7Yl o GRADING PEE
p.1 y NO]ICE TO APPLICANT:If.after meningitis Cenifcnte of Exemption, no should WATER SYSTEM/I BEATING
become suhjwd lir the Whdeh Cmnpensaoon provisions nl the Labor Crude,you
� .. Tonhwim oonnply with such provisions or this permit shell le Jamal revoked WATER SERVICE JFE
CONSTRUCTION LENDING AG17NCY NBWRESIDEiIA1.('LMB. SQ,IIT, i)!g1L)Q Ihcmly affirm dhanhere iso mnswctihn knJing agency bx theperfnrmanttof
the work far which hispermit Is issued(See,309],Civ.C.)O V lender's Name Lenders Address TOTAL:I cosily that I have read this application undo store thin the above itrhmmminn isBUILDING hiliN correct.I aged.to comply with all city and county ordinances mad nate laws relating to QTY. MECHANICALPI?RMIT building conshuction,and hereby authorize representatives ofthis city theater upon the '3,61,SM�6.1"1,,L- —
ndwe"mentioned property for inspection Purposes. PERMIT ISSUANCE
(Wes)agree m leve,indemnify and keep hamtless the City of Caputo.against ELECfRIC FEE
liabilities.judgments.cre,mind expenses which may in any way ncenmagunto said City ALTER OR ADD TO MECH. '
in consequence of the granting of his permit. PLUMBING TEF.
APPLICANT NDERSTANDS AND WILT. MPLYWITH ALLNON-POINT AIR HANDLING IINIT(TO 10.000CFM)
SOURCE U S. MECIIANICAI.fTIi
q C 1^IN fig AIR HANDLING UNIT(OVER 10.000 CPM) CONSTRUCTION TAX
Signal/e of Alllpppli�a ammeter -(e Idol Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE
Will thoapoxam or future building occupant entre lir handl.ImzerJons mnelt-1 HEATING IINITO'O toms)B 1'U)
as defied by the Cupertino Municipal Code.Chapter 9.12,and the Heath and Safcty
Gale,Section 25532(a)? I(RATING UNIT(OVER 110,000 BTU)
❑Yes )(No PAID
VENTILATION PAN(SINGLE RESfD) Date Receipt Is
Will the applicant or future building a'cepant use equipment or devices which .,, BDILF.R=COMP(3HP OR IOf1.01N)BTII)
call hazaNaus air comearee is as defined by the 13,Amu Air Quality Management TOTAL
Distract? 11011 ER-COMP(OVER 100,00111 BTU)
Ely- o
I have and the humorous nateid,replibrams under Chapter 6.95 of the Celi- AIR CONDITIONER - ISSUANCE DATE
home Berth k Safety Cnlq Sealmn2551P5.25533 and 25594 I....kn lmnd thin if the NI?W RESIDENTIAL MECH. SQ.FT..
building requirements
hick must
met
is ua ce ofa Occupancy,
of the requiremeins which mu>t be met pranrmissuance ofeCrnifcnm nllXntpancy. C— ,
Owner or authorized agent Date TOTAL ISSUED BY:
OFFICE