99070042 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO IIUILDING-ELECTRICAL Pfi
BUILDING DIVISION APPI,ICATION/I'ERMIT PLUMB NG-MECHANICAL
BUILDING PROJBCI'IDENTIFICATION
HIJILDINGADDRIiS SANITARY NO APPLICAI'10 E
7- 19-1957
WNER'S/NAME: S ���ONE: / CONTRACTOR'SNAME: 7e_
�,0 x
F�
NIC CONTROLN
.G ilLECT/ENGINEER: LIC NO: ADDRESS: 907,4 r /�'/�/ rJ/, X�Qa) Q ❑
J f
CONTACT PHONE: BUILDING PERMIT INFO
❑ Consultant Facts Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONI RACTORIS DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under pmvislan.x of Chapter 9(commencing JOB DESCRIPTION
'xZ w{th$CCllnp]IXNI)ul Divi.xion Ldthe Husiness unJ ProfcssionsCWe.and my license is
O PERMIT'ISlUANCIi
L,0 in full fameandeffca, q _3/ 3 ./!/` 'FDWL ❑KITCHEN REMODEL
aULJ License Class Lica 7� APPLIANCES-RCSIDC:N1]AL ❑ DDITION C1 PLUMBING RE-PIPE
onZ ul Data : /'A F Contractor
ARCH[FECr'S DECL RAf10N El MULTI-UNIT El STRUCTURAL.
F.Z I and m h Il W used as public records PANELS MODIFICATION
ZOy- yprnxs a UP 1210 AM
'0PS
OZ�� ❑INTERIOR E3 CHIMNEY REPAIR
P4,E;W Lieclrxed Prnl'cssinnul 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
CCQ 0\VNER�II(]IhDIIR DECLARATION OVER 100m AMTS BATH REMODE:IJREPAIR [I DEMOLITION
by Il that I pt f tl C t ' L L f rite
3�F following (Section 71111 S B 1 f Care Any city county SIGNS ELECTRICAL
OTHER
a h witch ts P n I I p P J I,h r' Y,' tum
F�06 prml I uHo y %the uppfwn'fasuxM1 Ocrn lto fl usignul wm".mcnt SPECIAL CIRCLE I/ .C. GFJG:f/A'C-IdT
o'
'bat he is Iiccnscdpmuum to let provisions of the Commctora Llccnw Law(Chapter 9
NCO (commencing with Seclinn 70(X8 of Dlvisinn3ofthc Business and Professions Cody nr TEMP.MITfBR POLE INS'P.
Ci0,aC Ihm he is exentpuhcrefrom and the basis I,),she alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
x l N Section 7011.5 by any applicant fir a permit subjects the applicant to a civil penalty of POWER D/ ICP_l n ❑TENANT ❑FOOD SERVICE
SDnm more than five hundred delta.(E500). IMPROVEMENT
❑Las owner of the property.or my employees with wages as their sole compensation. SWIM NG POOL ELECTRIC OTHER
F will lathe work.and thestiulme knot imcnded.ombered forxalt(Scc.70Ll.Husines.
tailm and Professions Code: Me Contractor's License Law fres no'apply to an owner of O LI:-fS-SWI'CCHLS-FIXTURES
13-. prei eny who bunds or improves thereon and who does such work himself or through
his own employees,provided that such improverecmx are not intended or offered for NEW RESIDENTIAL ELECfR SQ pT.
gale.IL however.the building orimprnvemem iz mlJ wiNin one Yearnf completion.the SQ. OORAREA $/SQ.FE.
o.der-W ildcr will have the burden of proving Inas he did not Wild or improve for par- �a
Lw.of salt.). 7
TOTAL:
❑h as owner of the property,am exclusively contracting with licensed contractors to
conswn the project(Sec.70,l.Business and Professions Cedes The Conaactor's Li-
xmw Law does non apply to am owner of property whit builds or improve%therstan.and QTY PLUMBING PERMIT FEE
whocontracts fursuch projects with a conuactods)Iicensedpursuant a the Coouactors r -�a
License Law. PERMIT ISSUANCE aJa O(/
❑ l am exempt under Sec. ,B&P C for this mason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
ser
Data �WORKER'S COMPENSATION PECTIN RATION BACK FLOW PROTECT DEVICE 4NlW a
1 batch,atdrm under penalty of perjury one of the following declarations:
(have and will maintain a Cendicae of Consent o self insure for Worker's Compete- DRAINS-FLOOR,ROOF.AREA.COND. STORIES '1'YPIi CONS"[RUCTION
sa'ion,as provided for by Section 17(X1 cit the Labor Cada,for the performance of the
rk for which his permit Lwued. FIX l'URES-PER'ERAP SF2
I have and will muinwin Worker'a Conucnss ion Insurance,as required by Section
i Xlof it,Labor Code lin t he perl i,rnlanSent the work for which this pomlus saved, GAS-17A.SYS'I'EM-1 INC.af1U'1'I.ITPS OCC.GROUP APN
My Workcr'a G on IysmWrccFy[ricr and Policy n�IW-a1� �/J�
... hLUV is J/ 7 OAS-hA.SYS'CEM OVIik<l1?n)
came.: Policy RO
GI!RI'll'1GAIE01'1!XI[ONINPROM WORKERS' GREASE%INDUSI'RI.WASTE IN'ITRCEPCOk
CUM I'E completed
f INSURANCE BUILDING DIVISION FETsS
('Thiw Seclinn need nm he unnplmcJ iftne permit is for one hundred dollar l5l W) GREASE TRAP
in Tess.) PLANCHHCK FEE
Icertifytbm inthelwdonnanecofthe work forwhicnthi%permit nismrd,I%hall SEWER-SANITARY-STORM EA.20E)FT.
notemplay any person n ymanner so us
far of Workers'Compen- ENERGY FEE
QZ wain.Laws of California a /N'7o/ WRIER HEATER W/VEM'/F:LECTR /0.ov
Applicam GRADING FEE
Z N NOTICE TO APPLICAILT.if.after ter troking'his Certifies,of Exemption,you should WATER SYSTEM/CRF.ATING SOILS FEE
a 7 become subject to the Workers Compensation provisions of the Labor Code,you must
forthwith comply withsuch provisions.,,his permit shall be,deemed revoked. WATER SERVICE
0
7Z CONSTRUCTION LENDING AGENCY NEW RESIDHNI'IAL PLMH. SQ.FT PAID
C.)O l herebyaRm rthoutre iso construction lertalm, gency for the performance of Da, Receipts
the work for whm
which his petit is issued(Sec.109].Co,CJ
U. Lender's Name TOTAL:
WLender's Address TOTAL: q37O
y I certify that 1 have read this eirlica'ion and sure that the above information is BUILDING FEE
sF. h cones.I agree to comply with all city and county ordinances and hate laws relating to QTY. MECHANICAL PERMIT FEE
V Z building construction.anti hereby amhorim reprosemmivesofthis city menterupon the SEISMIC FEE
allovo-menrinned property for irtpa'ion purpows. PERMIT ISSUANCE
(Wt.)name in save,inde n lify and keep harmless the City of Cupertino againstin co
ELECTRIC FEE
habilitics.judgmcntx.cnhs and expenses which may in any way accmc againstmm City ALTER ORADD'rQ MECH.
asequence of the gunning of this permit. PLUMBING FBIi
APPLICANT UNDERS'T'ANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'1'(10111,0X0 CFM)
SOURCE REGULATIONS. y a MECHANICAL FEE
C" -- App /-/9,�/ 9� NIt HANDLING UNIT(OVER IUJ CFM) CONSTRUCTION'I'A%
Signuwre til APul Ap`P(hicJmL�'/e/onaunur ILCI�� Untc I.XHAUS'T I IOGD(W/DUC1) HOUSING MITIGNFION THE
HA'/.ARDOUS MATERIALS DISCLOSURF.
Will theapplicun'or brute building rscupml sto a handle haxalloas material HEATING UNIT TO 100 ISTU)
ax defined by the Cupeainn Maniequin Code,Chapter 9.12,and the Health and Sale,,
Cndc,Section 25512m)l' HEATING UNIT(0 " I(X),gX)BTU)
❑
Ya, '21<1PAID
VIENI'I LATIONI' (SINGLE RES]D) Data Rcscipta
Will the applicant nr fan bg re
faun use equipmem or devices which BOILER-C I'1311P ON IIO.INN1 BTU)
mi'lou wh as air commniwms as defined by the Bay Arca Air Quality Management TOTAL:
District!
0Yet ^ 1 ROILS -COMPIOVER 100.000 RTU)
y^•' Al 'UNDIII(lNlik
I have read the naardonw.,aerials rtyaimrtamw liner Chapter e.95 of the cae- ISSUANCE DATE
moria Health&Safety Cufc.Seetions 25505,25513 mall 25511 I understand that if the EW RESIDIiMIAL MECH. SQ.Ff. 7-2- -3 9
building drew not cmrently have a,nanWha it iw my rtsI«'mibiliry m notify the occupant /
anne req 1mema wmeh tnryQ met ErdyJm iwxaaree aracr/e9a y.
Own au�un oozed gent � �-Da'ey TOTAL ISSUED BY:
OFFICE