99090062 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. LT
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
i BUILDING PROJECT LDENTIFICATION. p
BUILDING SANITARY NO. APPLICATIONNSSUBMITIAL DATE
Jrlo PHONE
C; PIIf)NE. C N'RAC'In 'SN MIS LIC NO:
Lt,'Sl7otl/ '✓OP-a55- �F54 �t oar Tr.G 7434/a-- N'C CONTROL»
ITECT/ENGINEER: 1.1C NO36/ ADDRESS: �� „//as 0 El7G r aS3/ ire Cs
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CONTACT. PHONE NFO
BUILDING PERMIT INFO
(� ///�S / �j�lip('/. �' E:1Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
NT
C7 ❑ ❑ FL� ❑
LICENSED CONTRACTOR'S DECLARATION QTY EI.IiCTRIC PERMIT , 'FEL^
1 hereby amort that I am licensed under provisions of Chapter 9(cnmmeneing - r JOB DESCRIPTION
WOZ with Section 7")o'Division 3 ofthe Business and Professions Code,and my license is RESIDENTIAL:
FSO in full fore delle 9 PERMIT ISSUANCE
lu� scan '` 6 LIC.N ��� ❑ADII. ❑PLUMBIKITCHENREMODEL
Dae Cnnnvanr APPLIANCES-RESIDENTIAL. El ADDITION ❑PLUMBING RE-PIPE
ARCHI TE 'S DECLARATION ❑MULTI-UNIT ❑STRUCNRAI.
F D y PANELS
Zp 4— �ndcran-d tQy pl ssh us W_ ayJublic records MODIFICATION
OZ� /LSM /.L.Q�.CwI-�� UP tD 21UAM1'S
lOtj Licens Professional ❑INTERIOR ❑SWIMMING POOL
2111-I(NNIAMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER INX)AMPS El BATH REMODEUREPABI DEMOLITION
0 6 1 hereby of ina that 1 am exempt from the Commcmr's License Law for the
X1X O a U following reason.(Section 7031.5.Business amt Professions Gtde:Any city or county SIGNS ELECTRICAL ❑OTHER
W 3 LL H which Acquires a permit to construct,alter,improve,demolish,or repair any structure
print to its issuance,also requires the applicant for such Part to Ole a signed statement SPECIAL CIRCU117MISC.
yy that he is licensed pursuant to the provisions of the C'umrac..rs Limou Law(Chapter 9
uj�00y (commencing with Section 7")of Division 3 ofihe Business and Professions Code)or TEMP.METER OR POLE INSI,
a a c LL that he is exempt therefrom and the Wits for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
^ Section 703 L5 by any applicant for a permit suhjects me applicant to a civil penalty of POWER DEVICES
m El TENANT F1 FOOD SERVICE,
aQnot Anne than five hundred perty, rt yempl
❑ Las owner the c oemyempluyeeswith wageseredf as their
.compensation. SWIMMING POOL.ELECTRIC 0THERIMPROVEMENT
will d"the work,and the aW stare is not intended nr"ffemd fu...r apply to
owner of ❑OTHER
W end Professions Ctxlc:The Cmarach lis License Law docs not apply m un owner of OUTLETS-SWITCHES-FI%TUR
63^ propeny who builds or improves thereon,and who does such work himself or through
his nwn employees,provided that such improvements are not intended or"!feted for NEW RESIDEN LAI.EI.ECTR
snle.11:hnweveq the building or bnpntvemem is sold within nuc gent ofamidetion.the SQ.1'R FIAOR AREA $ISQ.FT.
ownenbuilder will have the burden of proving that he did not build or improve for pur-
,or nf.sale.).
❑ 1,as owner of the properly.tan exclusively contracting with licensed contractors to TOTAL
,monuo the project(Sec.70c.4,Bu,noss and Vmfessmns Coda)The Conlmount,U. --
ueLaw does nnt apply to ad(owner of property who builds or lmprovic thereon.said QTY, PLUMBING'PERMIT FEE
uh
rmarans forsuchprojects witheconowt...s)licensed pursuant..the Contractor's -
Liman Law. PERMIT ISSUANCE !?S
❑ I am exempt under Sec. ,B&P C for this reason
.Owner Date ALTAR-DRAIN A,VENT-WATHR(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE O I
I hereby affirm under penalty of perjury one of the f"Ibtwing melanomas:
Fl I have and will maintain a Certificate of Consent mxelbinsire for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND.
anion,us provided for by Section 7700 of the Lubar Code,for the pedornance of the STORIES TYPE GGNSTRGCI'IDN
workfn this permit is issued. FIXTURES-PER TRAP
and will maintain Workers Compensation Insurance.as required by Section
3700 ofthe Labor ICartel for me performance of the work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP 23 1,3 My Criernyl FlR-�m injdc c!2r still Policy no X38{� GAS-EA.SYSTEM-OVER4(I:A1 3�9e,e� Q�3
CEH TIFFIICATEE 01:EXE PTION):ROM WOR KERS'
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR
(Ous section nem nm be completed ifthe permit is foronc hundred dollars(5100) BUILDING DIVISION FEES
or le".) GREASE TRAP PLANCHECK FEE
I cenify that in theperflurnmae afthe work tinwhicb thi.sperrin is is.mad,I shall SEWER-SANITARY-STORM F:A.200 FT.
not employ any perm.in any manner so as to become subject to the WorkerF Cnmpen- ENERGY FEB.
Z scion Laws of Calimmia.Date l/
O Applicant WATER HEATER WNENT/ELECfR GRADING PEE;
Uj NOTICE TO APPLICANT.If,a0cr making this Cenifcem of Exemption,you should WATIiR SYSTEMO RFAUNG
a ; loma c subject to the Workers Cmnpemnium provisions of the Labor Cole, on must SOILS FEE
W forthwith comply with such provisions m This permit shall be deemNmvoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Ff. PAID
O IM1ureby n0inn mm morels twnnhwetinn landing agency Ort the lterfnmmace of - MAY Receipt
IL F the work for which this permit is issued(See.3047.Civ,C)
C) U Lenders Name f`'\ TOTAL:
� W Lenders Address TOTAL: `...' I cenify that 1 buns read this application onA nam that the above infnrmmion is BUILDINGFT: �
y curreeLlagreammntply with all city and conmy ordinances and Hale lows mlmingm 'QTY MECHANICALPERMIT FEE ( 1
U Z building construction,and hereby xuthonze representatives of this city to enter upon the SEISh ''ITE �� 1
above-mentioned property for inspection Imp"sec PERMITISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELE,C RIC FCEt.�
Iiabilhiex,judgments,casts and expenses which may in any way areme aguino said CityANTER OR ADD I r
in ennveanenceef the gnmtingaf this permit ALTER 9 y_
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) T1ECF/ANICAL FEE /x% n
SO/{,'�fyCE REGULATIONS.
J
•� I� - n/ S AIR HANDLING UNIT(OVER 10,000 CFM) CONSTt 612 Od TAX
Sigoaltur'il�mareannr 77—f Data/ EXHAUST HOGG W/UUC) HOUSING MITIGATIO
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant.or future Wilding occupant store of handle harallous material HEATING UNIT OO 100,MIO BTU)
As defined by the Cupcnino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(u)'! HEATING UNIT(OVER 10(),(11X)BTU)
E]Yes 4 VENT]LATION FAN(SINGLE RE.SID) PAID Data Receipt»
Whims air contaminacant or nts
a building by the nt use Bay
Air thong or evices whichManagement
BOILER-COMPCHPOR 1B0.(NXIBTU)
emit hazardous air comaminams us defined by the Buy Areu Air Quality Mnnagcmem TOTAL:
DisVicYl BOILER-COMP(OVER 100.0A)BTU)
❑Yes �QNo
I have real the haraNws materials requirtmena under Chapter 6.95.1 the Cnli- AIR CONDITIONER
IS ANCE DATE _
human Ilcalth&Safety Code,Sections 25505.25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.IT.
building Dues not cummmlyhave ategrn.mat it ismyresponsI If
upam /7
ofthereu4i;ai whist muse dpror is ora Cenilic ( cy.
Owwner/ser mirth Aced ago 4�D:lee— TOTAL: ISSUED BY:
OFFICE