99080062 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 99 og V
F01TINO BUILDING-ELECTRICAL
ION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENICIFICATION
SANITARY NO. APPLICATION�t . OS NAM- NIC CONTROLX
+NYana& o ) a3 J 7Cps �s
C111TECT/ENGINEF.R: LIC NO; ADDRESS: ❑
Jen 5'Vale
CONTACT'. PHONE BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) 13LDG ELECf .0 B MrEECC(H
LICENSED CONTRACIOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under previsions of chapter 9(commencing JOB DESCRIPTION
Metz wins Smion]QYJ)of Division 3.flhe Buninesaand Professions Code.mal my license is RESIDENTIAL:
WOO /� PERMIT ISSUANCE35-
Fm Iofullforceandclic . O k4 tJ ❑SFDWI, ❑KITCHEN REMODEL
aUV I.icensc Class Lic.N APPLIANCES-RIiSIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
tFZW Date Crmntanr
oqflac --
'=,g, A HITECTS DECLARATION PANELS ❑MULTLUNIT []STRUCTURAL
L O d,Z 1 undersand my plans shall he used as public records MODIFICATION
7 Zrn-0 UPTO2WAMPS ❑INTERIOR [I CHIMNEY REPAIR
yHLL Licensed Professional 201-1010AMPS IMPROVEMENT SWIMMING POOLS
YX9; OWNER-BUILDER DECLARATION OVER laOAMPS ❑BATH REMODEL/REPAIR (:1 DEMOLITION
C C y' 1 hereby attain that 1 am exempt from the Ci ntmeor's License Law fur rhe
m O d U followin (Section]031.5.Baeirms and 1'rofestron,Codc:An t ❑OTHER
y 3 LL F g reason Y city o,county SIGNS EI,ECI'RICAh
prior
oi rM1 its isu'u penny to eunswd,alter,refer such
h permitdemolist ore a siif any ateemre
y4
Oat
he
lensed Pursuant
aovisio so lie mchpctors License aw(Chapt tet SPECIAL CIRCUIT/MISC.
E R�fY Nm he is licensed mrrsuam no the provisions of the Commaor'>Li<ense taw(Chapter
YCas (scramming is id,Section]000)rf Division 3ufthe Businessand l'mfadon.Code7 or. TEMP.METER OR POLE(NSI'. COMMERCIAL:
L 6 c C that he is exempt therefrom and the hsis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W Section 7031.5 by any applicant for a permit subjects me applicant to o civil penalty of POWER DEVICES _[]TENANT ❑FOOD SERVICE
ti y nm..",ban five hundred della,(S500).
.F+�6 D Las owner of the prnpeny.or my anployces with wages as their vole compensation. SWIMMING POOL ELECTRIC IMP�VFMF.TT�"-'
will de the work,and the structure is aminmoded or offered for sale(Site A(w4,Bnsiness ) r E /n\
W 3 ad and Professions Code:'ITe Contmcase,Liscme Law due,not apply to an owner of OUTLETS-SWITCHES-FI%TURKS I ��—
k-
propenywhohuiWaor improves thereon.and who does such work himself or through -�f
his own employees,provided that such imnmre
prments anot intended or offered for NEW RESIDENT ELECTR SQ FT. /
vac.IL however the building.,impmvcmcm issuld within me,ammcomplctim.the ++ ,�LAZTR 9 VsQ.F.
owner-builder will have the burden of proving that he did not build or improve for put- I I
pate of sole.).
0 1,as owner or the prnpeny,am exclusively contracting with licensed conttumors to TOTAL
instruct the project(See.AH4,Business and tire fessran,Code:The Commemr's Li- y �y
use taw does not apply m an owner of prnpeny who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
wbocomencis for such projects with a rmaractons)licensed pursuant to the Commences.
Liver.law. PERMIT ISSUANCE
unecS.
❑1 am exempt der S . .B Ar P C for this goon
ALTER-DRAIN h VENT-WATER(EA) VALUATION
Date
w WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE �-
1 hereby til Ilan order penalty of perjury one of the following dMam axon, _
I have and will maintain a Certificate of Cousenno sdf-insure tie Worker)Compin- DRAINS-FLOUR,ROOF.AREA,COND.v
wtl.n,as provided for by Section 3700 of the Labor Code,for the led..me of the STORIES TYPE CONSTRUCTION
w ark for which this permit is issued. FIXTURES-PER TRAP
1 have and will maintain Workers Compensation Insurance,as required by Section
3700 mile,latae Rode.for the performaneeorthe work for which this remit is ismnl. GAS-EA.SYSTEM-(INC.4 OUTLETS OCC.GROUP APN
My Worker s Compensation Insurance carrier and Policy number are:
Currier: Policy No.: GAS-EA.SYS'TEM.OVER 4(EA)
CERTIFICATE OF I:xl:mlrl'[ON FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUS"1'RL WASTE INRiRC,E1TOR
BUILDING UI VISION FEES
(Thissection need not be completed if the permit is for one hundred dollars OS 191) GREASETHAP
or le"') PLANCHECK FEE
I cenify that in Ox performancemthe work for which his pemrit is issued,[mall SEWER-SAN]TARY-STORM ITA.208 FL
not employ any person in any manner so as to become subject to the Workers'Cooper- I EN17RGY FTE
O Z .sailor Lowsal'Calilincona Ham WATER HEATER W/VENTIELECTR GRADING FEE
Z Q Applicant
F ? NOTICE TO APPLICAN'C If,after making this Certificate of Esempuen,you should WATER SYSTEM/TREATING
become.subject to the Worker's Compensation provisions of the Labor Code,you must SOI(S FEE
Ionhwith comply with such powerme,o,this peru ii,hall he deemed revoked. WATER SERVICE
Q
jZ CONSTRUCTION LENDING AGENCY NEN'RESIDENTIAL PLM.. SQ.FT. PAID Date Recalls al
U� Iherehy aftinn that isaamstmminn lending agency for performance of
I.L. F the wink for which this partnd is issued(Sce.3197.Civ.C.) 'TOTAL,
Q U Lcndcrss Net
} Lcndcrs Address TOTAL:
6. I cenify that].have read this application and state that the a eve information is BUILDING FEE
F N correct.I agree to comply withal]city andcounty ordinances and pate laws relating to QFY. MECHANICAL PERMIT FEE
U Z building construction.and hereby andarieerepresentatives of this city to enter upon the SEISMIC IEE
a1mve-ramo end property for inspection purtarses. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of C.'room against ELECTRIC FEE
I'idaIaice.jadgm ,t..costs.edcsNr,cs which any in any way accmeagura',adCity ALTER OR ADD TO MECH.
PLUMBING FEE'mf
svc,mvemnthe gruntingol hispenia,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT. AIR HANDLING ON]T(TO IBM)CFM)
MECHANICAL FEE
AIR HANDLING UNIT(OVER 10.001)CFM) CONSTRUCTION TAX
Signature m Appliedr/Cmaractnr I Data EXHAUST HOOD(WMUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DIS .(1SURE
Will the applinnuorfuture hiding uttvpant score or handle hueardous material HEATING IINI'1'(10 im,BIX)BTIO
as reined by the Cupertino Municipal Cala,Chapter 212,and the Health and Safety
Codc.Section 25532(x)] J/ HEATING UNIT(OVER 11(1,000()BTU)
((
❑Ye s /J,'u VEM1TIUxnoN PAN(SINGLE RESID) PAID
Dec Receipt X
Will the applicant or future building occupant eAint or devices which BOILER-COMP(3HP OR 100.910 BTU)
mit harmdous air conmminnms¢s or by the Bayy AArcaa Air r Quality bfanagenent TOTAL:
District^ BOILER-COMP(OVER 100,0(X)BTU)
[I Yes Nn
I have mad the It And..,materials resImmmu enunder Chapter 0.95 of the Cult. AIR CONDITIONER ISSUANCE DATE
forma Health A Safety Code,Sections] 505.25533 and 25534.1 understand Nat if the NEW RESIDENTIAL MECH. SQ.FT.
heking doe rot cu,m tly have a tenant that it is my responsibility to notify Ute occupant
of:hes hi m ten prim m i.ouatoe of a Ceniflcm of Ocsu
Ow i theri,xdagent vs TOT(''' ISS JED BY:
OFFICE