99100137APPLICANT TO FILL IN INFORMATION WITHIN RED L� BALL POINT PEN ONLY AR I (i 0-1 a-- .5�
CITY OF CUPERTINO BUILDwG- ELECRRICAI,
BUILDING DIVISION APPLICATION/PERMIT TING PRNG-MADENT[CAI.
NI111.DING PROJF.CI' IDY:NTIFICA'TION
re
BUILDING ADDRHSS: aS - 1� ��
Z2?3 1 11/1
7SANI N(.
APPLICATION SUHMI'I'1'AL �D%ATE
(0 ;2,6 - 9'/OWNER'$
TAm
ME: .a��.�'• PHONE
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CO gCfQR.S NAtyfr 1 LIC NO:
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CONTROLpRCtIIT1EC1'/IENGIN[Ek:.
LIC NO
ADURE
pWr
CONTACT PHONE.
BUILDING PERMIT INFO
BLDG / ELL❑�CI' PLUMB Alli❑CH
rL—_t/
�NI
y�j// �5b �12f _q�O
LI/YCENSIi1)CONI'RACTOR:SUBCLAARRAATION_1j
❑ Consultant Fees Paid by Applicant(Initial)
I harthy ardna mm into ecce s al under pruskinnx of Chante, 9 (summoning
with Scetion 7(XXb of Division3oflhe Business and l'mfcscirns Code, onA my licenwis
in full force amt cOe CJ�Q
Liccnu Clens Lic.M
Dae Cnntmcto Z
ARCHITECTS DEC ,AR ION
1 and..Band my plmw shell be used an public record.
Qry ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
❑SFDW'I. [I KITCHEN RIEMODEL
El ADDITION ❑PLUMBING RIE-P[PE
❑MUCI'1-UNIT ❑STRUCTURAL
HON
�MND[FEY REPAIR
❑INTIEItIOR CHIMNIeY kIiPA1R
IMPROVEMENT F]SWIMMING POOLS
REMODELfREPAIR ❑DEMOLITION
❑ OTHER �rS
tlJ Y'0a�fG
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
PANFIS
UP T0NX) AMPS
Licensed Professional
OWNER -BUILDER DECLARATION
teem the Cnownw, License Law fort the
I harth, alErm tea m I aexemptuo
hollowing noon. (Section 7031.5. Business and Professions Code: Any city or county
201-I0CNIAMI'S
OVER IM) AMPSElBATH
SIGNS ELECTRICAL
whim requires a Permit m construct, alter, improve, demolish. or repair any structure
prourn, it,:: ala y , ducallhunratl h ponarahn, tile a,i,anedouninumn
that lie is licensed pursuD The pumvisiona, oftheC t tor' License I' (Chapter9
(commencing with Section 7000) of Division 3 f he B. o, and Pr f:,bo Cedc)m
that he is ascots Inemfmm and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penally of
SPECIAL CIRCUIT/MISC,
TEMP. MISTIER OR POLE INST.
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TF.NANI❑FOOD SERVICE
POWER DEVICES
not more than live hundred dolWry (S500).
1, us owner nithe n
❑ Prop. %rte Tis mnpleymd withwred for their she (94. Business
T will Jn the work. and lM1eamcunc is nm intended or nlY•rcd for sale(Sec.Hostess
and Professions Cade: The Contractors License Law dues not apply In an owner of
O TER IEMENT
❑0"{IB
SWIMMING POOL F.LECI'RIC
OUTLC'1'S-SWITCHF_ti-h1%'ILRES
property who build, or improves doncon, and who does .ouch work himself or Ibmugh
his own employees. Provided that such improvements are firs intended fir offered for
sale. If. however, the building or improvement is sold within one year of completion the
NEW RESIDENTIAL ELECfR SQ '
Nss SQ. FT. FLOOR AREA
ESQ. FT.
tar -budder will have the buffen of proving that he did not build or improve for pur-
TOTAL:
po c oLsvkJ.
L m owner of the property,1 0 exdu,ivdy v u,nning with licensed contrncmn In
instant the proposal (Sec. 90,14,13mines, and Prnfessiom Cone:l'Ibta Cnmrecmfc Li-
ecow Law it,., not apply On an rwnerof pmpro, who build,., improve, marernnnd
QTY. PLUMBING PERMIT FEE
who contracts for such projects with a comraonort licensed pm,mm no the Contmemrs
Lorre 1 -ii..
PERMIT ISSUANCE
❑ I am exainpt rode, Sro. ,B&P C bar this mram
ALTER - DRAIN &VENT' -WATER (LAI
VAhIIAI'IUN
����----//gg9
/0D - �
///
Date
Owner
WORKER'S COMPENSATION DECLARATION
BACK FLOW PROTECT. DEVICE
I hereby offtmt under penalty of pequry, note of the following declaraions:
I] I have and will maintain a Cenificme of Consent to wlf-insure for Workers Compen-
satire, as provided for by Section 3000 of the Lothar Cada, for the performance of the
wart which this pcnnit is iswcd.
DRAINS- FLOOR, ROOF, ARTA. COND.
STrI IES
TYPE CONSTRUCTION
FD7U RES - PER TRAP
have and will maintain Worker's Cnmpenon i Iro mnee, as mapmred by Sectlan
37W n1 the Labon Laa,fnr the perhumieve rf the work for which this permit is issued.
GAS - PA. SYSTEM- I INC. 4 OU' I' LETS
OCCGROUP
,• ij AI� O
a/TC
GAS - EA. SYSTEM -OVER 4 (EA)
My Wmlor's�m-pcnsoti turves. wrier and Probe? rW4Cher �r G
Cartiee TIVtP Policy Nn.:T+ *Iie�`
GRGSIIINUUSTRL WASTIiINI'ERCEPNR
CEUIFICAT17 OLt EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
BUILDING DIVISION FEES
GREASE RAP
PLANCI{ECK 1'Ii1E
(Thi, section need not he completed lithe penult is- forma, hundred dollars (5100)
m,J
Iy lnnthc Pedancc oLbeworrk lmwbichthis Pc.l
nm employ any peon inany mannawacm bccnmezbjedm Ne W.kct,Coarsen.
SEWER - SANITARY -S'URM EA. 2M)IT.
ENERGY PEi
WATER HEATER W/VENT/FLEC R
GRADING IEE
e ion L.woof Cahmunio. Date
Applicant t
j N(THC1E TO APPLICANT It after making this Cmificatc of Exemption, you should
+ became .hjecl Ta the Wnrkur'x Cnmpenwmirn prnvi,in is of the LuMa Code, you n not
forthwith comply with wch Provisions or this pcnnif shall be deemed revoked
WATER SYS'TGM/IREATING
SOILS PEE
WATER SERVICE
CONSTRUCTION LENDING AGENCY
� Ihemhy affirm thauhem iso construction kmling agency for the terfmmmnce of
+ the work for which this permit is issued (Sec. 3097. Civ. Cj
P
Dat ace
in
NEW RESIDENTIAL PLMB, SQ. FT.
I
OTAL
Leadcr'n Name
Lcndcrx AJdrexs
TO'LAl.:
QT'V. MECHANICAL PERMIT FEE
DIN(( FLIT- 9 „
kY I
SMIC 1'lili
1 certify that I have read this application and state that the above infomattion is
curtca.l agree mcomply with all city and arumy ordinances and slue law, mining to
huildinR eon,tmmion, anJ bcrtby authorize rtprtwntativcs of thi, city mcnter upon the
aneve-mentioned properly for inspection Paul .
(We) agree m save, indemnify and keep haemlecs the City orf Cupertino against
Iiahilida'.jndgmenq costs and expenses which may in any way acerae against said City
PERMIT ISSUANCE
AIJER OR A DO TO MECH.
CTNIC FEE
PIsU FE;
in mv'cyucncc of the gom iag of Ihtx {Mrlail.
APPLI CA NERSTANI S A 11 .L C( FLY WITH ALL NON -POINT'
MECIIANICALPEE
AIR HANDLING UNIT G 01 OJXX) CFM)
SDDRCE RI 1 IONfs. /Vpq�
////// (/
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
Signature tsiiipplicanUCensmaar Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building oveupant store or handle hamfdous material
as defined by the Cupertino Municipal Cede, Chapter 9.12, and the 1lealth and Safety
Cao. Statham 25512fa)7
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION FEE
HEATING UNI 'I'(TO 100.000 BTU)
HEATING UNIT (OVER I(Xl.(XXI BTU)
VENTILArION FAN (S INGLE RESID)
❑Yes No
PAID Data NecciplX
tlOILIER-COMP(311P 012 I(N),(NX)BTII)
Will the oppl 'aims or future building oecupom we equipment or devices which
,.it hwinlnue air contaminants as darned by the Boy At. Air Quality Management
TO a
BOILER- COME (OVER I(XI,INXI BTU)
District? l
❑Yes z
AIR CONDITIONER
ISSUANCE DATE
l O 2 -
1 have read the h ode, Se mamriah 5 5551 an under4. 1 un r fl95 of Ne Cali-
h & Safety Code, Sections 25534. I andemafid that if the
2s
fermi�..ffion,
NEW RESIDENTIAL MECH. SQ. E°R
lay efid
Yy have ummmL sit very responsibility to nntiry the cectmant
militias . at
ntm oamttaerrC�c OeT o capaTYy.ant
TOTAI:
D �%—
ISSUED BY:
OFFICE