99080034 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY V Q
CITY OF CUPERTINO BUILDING-ELECTRICAL PE=TNO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION •y.
BUILDINGADDRESS. SANITARY NO. APPLICATION SUBMITTAL DATE
ro 2d+ LOWI,,9 LANs
OWNM2'S NAMpE: PHONE: COuA Y5�`fE ,L LIC N;®
�'l FE V 'xi NIC CONTROL#
)IIITECTIENGINEER: LIC NO: ADDRESS: ❑
o of Hn7nr A0
CONTACT: PHONE: tBUILDINGPERMIT INFO
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r1�ea QA0SEr✓ 127- 733-2, El Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
=1 5a ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY . + Sr ELECTRIC PERMIT, FEE
I hereby affirm that l licensed a p f Chapter 9(comma g - _ JOB DESCRIPTION
Q=Z with S C 9000)ofDveon 3 of the cosi and Professional Cale and my license is PERMIT IS O O - RESIDENTIAL:
C Wz r License ClesA-d�-ell��.F�t�L��a l is# C�7/4�O,.r�' ❑SFDWL ❑KITCHEN REMODEL
HQ Dmcin �Cnnlrecmr7ygJ tBLLG7M/L APPLIANCES-RESIDENTIAL El ADDITION [I PLUMBING RE-PIPE
ARCHITECTS DECLARATION PANELS [I MULTI-UNIT ❑STRUCTURAL
ZC.ZI understand my plans shall to used as public records MODIFICATION
__41- UP TO 200 AMPS
Licensed Professional ❑INTERIOR 11 CHIMNEY REPAIR
201-I000AMPS IMPROVEMENT []SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 1000AMPS [I BATH REMODEUREPAIR DDEMOLITI
I hereby affirm that i am exempt from the COmmemr's License Law for the
ipS.O L U following reoson.(Section 70315,Business and Pmfessloas Cuda Any dry tit wanly SIGNS ELECTRICAL ❑OTHER
W W 0.y which requires a peril to construct,alter,improve,demolish,or repair any structure -
�d print to itissoanee,also requites the applicant for such peril to file a signed statement SPECIAL CIRCUIT/MI r C 1 T
that he is licensed pursuant m the provisions of the Contrrartma License Law(Chapter9
0.'00 (commencing with Section 7000)of One...co3ofthe Businessaad Pmfessions Co de I I TEMP.METEBOB COMMERCIAL:
that he is exempt therefrom and the basic for the alleged exemption.Any violation of [I NEW BLDG/ADDITION El DEMOLITION
W y Section 703156yany applicamfors permit subjects theoppleemat m vdvllpenalty of POWER DEVICES
t more than five honored dollars(8500). ❑TENANT ❑FOOD SERVICE
FSQ ❑1.as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL EL IC IMPROVEMENT
F
Q will do the work,and the structure is not intended oroffered for sale(See.7044,Business ❑OTHER
and Professions Code The Oo s there's License Law docs not apply s if owner of OUTLETS-SWI'I'CHP,S-P U
property who builds or improves thereon,and who does such work
te himself or through
his own employees,Provided that improvement
improvements ere not intended or offered for NHW RESIDENTIAL HfPCI'R S _
sale.If,however,thehave the bun i rt of ro id issoldh within,build year vetfar the ' --3@g€ILELDQR AREA $ISQ.PT
own
sof alaer will have the burden of proving that he did not build or improve for pot- r�
pose a s manner
r
❑Iasownerofshe property, exclusively contracting gwith
mCd eC contractors l TOTAL:
unmet the project(Sec.to an B . d rt f.. milds N i pr C t t C ���
o se Law does not apply t I p perry h dp.the Core d QTY PLUMBING PERMIT FEE A
who contracts for suchproJectwthacommcmgs)Imnsed pursuant to the Contract. " Y 199
License Law, PERMIT ISSUANCE
❑lam exempt antler Sec. ,B&PCfor Nas
ie reon
ALTER-DRAIN&VENT-WATER HUG VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE.
1 hereby affirm antler penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's Compen- DRAINS-FLOOR ROOF,AREA,COND. STORIES 'TYPE CONSTRUCTION
action,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section
00 of the Labor Code,for the performance of the work for which this cern is issued. GAS-EA.SYSTEM-]INC.40UTLETS OCCGROUP J//-rYY�]]] APN
My Walk 'I Cnmpa tion Insuryry g$pntl Policy m�e
Cartiee(ALILO RATA, /MUNINrpnlicy No.: rj/�7��rOA GAS-EA.SYSTEM-OVER 4(EA) '44' 1 9
CERTIFICATE OF EXEMPTION FROM WORKERS' ¢/its
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR BUB, INGDIVISIONFEE x
(Thksmnan dead not be completed ifthe pmmit,x torose hundred dopers IS 100) GREASETRAP
or less) PLANCHECK TEF.
I certify that in the performance of the work for which this peril is issued,I shall SEWER-SANITARY-STORM EA.200 FE
er i
not employ any person in any mannas to became subject to the Workers'Compen- ENERGY FEE
Z satins Law.of Cali fnmia.Date WATER HEATER WNENT/ELECTR
Applicant GRADING FEE
y NOTICE TO APPLICANT:If,after making this Continence of Exemption,you should WATER SYSTEMiTREATING
a > become subject to the Workers Compensation previsions of the Labor Code,you music SOILS FEB
W fanhwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AG NEW RESIDENTIAL PCMB. SQ,FT PAID
L) p Thereby affirm that there isnconstruction lending agencyagency for peddrmvnce of Dore t#
LW � the work for which this permit is issued(Sec.3097,Civ.C)
0 U Lenders Name TOTAL:
LkI Lenders Address TOTAL:
HCa I certify that i have read this application and state that the above information is t ) BUILDING FEE
ti correct.I agree to comply with all city and county ordinances and state laws relating to QTY'; "MECHANICAL PERMIT , FEE ,
C.) Z building Conswction.and hereby authorize representatives of this city m enter upon the SEISMIC ME
above-mentioned property for inspersion nucleates. PERMIT ISSUANCE
(We)agree to save,Indemnify and keep helms the City of Cupertino against ELECTRIC FBE
livbilifies,judgments.costs and expenses which may in any way#cane againstaaid City ALTER OR ADD TO MECH.an
consequence of the granting of this permit PLUMBING ME
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,1100 CFM)
MECHANICAL FEE
SOU,R,,C�E�REGJJ'LATInONS.
%y p 6&40r
..__ ..� g/0" NR HANDLING UNIT(OVER IO,IXIO CFM) CONSTRUCTION TAX
Signature ofA,,da MConbacror�+ Date EXHAUST HOOD(WMUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant h
r future building occupant store or handle hazardous material HEATING UNIT(TO 100.000 BTU)
as defined by the Cuborr n Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(#)'! HEATING UNIT(OVER 100,000 BTU)
❑
Yea J1 No VENTILATION FAN(SINGLE RESID) PAID
Dem Racel #
hazardous
the applicant or infmure building occupant meequipment ordevicewhich BUTLER-COMP(3HPOR IOg000 BTU)
mit District' air contaminants as def sed by the Bay Area Air Quality Management TOTAL' t
D'svict^
E]Yes No BOILER-COMP(OVER 101,000 RTU)
I have read the hazardous materials requirement under Chapter 6.95 of the Cali- AIRCONDITIONF,R ISSUANCE DATE
fnmia Health A,Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL.MECH. SQ.Pf. �S
building does not currently have etenvm,that it is my responsibility m notify the occupant (7 LI/^ Y
ofd yul t atapiyrti met prior isseance of a Cooper,eof�(k�u�apey, l/Y
Owner or aautthhorizeeddaagent Date TOTAL: ISSUED BY: �' ��
OFFICE