99070054 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL PAINT PEN ONLY J" 4q Q0 S5
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT
BUIL DING.mVISION APPLICATION/PERMIT rl.umnmr.-ngecunwF SOOO]
BUILDING PROJECT iDENFEI 'C'ATION
BUILDING ADDRESS: SANI'I'ARYNO. APPLICATION SUBMrfI'AI-DATE
R'S N ME: PHONE: CONTRACTOR' CMF.: 1
V NIC CONTROL#
RCHIT[CT/ENGINEER: LIC NO:
ADDRESS: �. 1 ❑
CONTACT: - PHONE: •f0_ fCTLI`+ BU ILDING PERMIT INFO
❑ Cnnsultant Fees Paid by Applicant(InHtal) BLDG ELECT PLUIJB MECH
❑ ❑ ❑
LICENSED CONTRACT'OR'S DECLARATION QTY. ELECTRIC PERMIT FEE
QLL'z
1 hereby am.thatpnn
1 am licensed under mvisis of Chapter 9(commencing JOB DESCRIPTION
with Section 71N3 or Divi sion 3 or the Business and Pn tions Code, mylicemnis RESIDENTIAL:
1�'100 PERMI'1'ISSUANCE' - '
F [[ in full farce.nJe '❑SFDWL C1 KITCHEN REMODEf.
�FUt) License Clas` Lic.p %1.ANCES ❑ADDITION [I PLUMBING BE PIPE
NQS ontrecm
F.7 to ARCHITECTS DECLARATIONi'ANEIS ❑MULTLUNIT El STRUCTURAL
z p v2 un
Z I dersmnd my plans shall he used es public records; MODIFICATION
Ioz-, UPT02WXMPS [I INTERIOR El CHIMNEY REPAIR
(-.4�IY Licensed Professional 201-Iq)AMPS IMPROVEMENT E]SWIMMING POOLS
16 Cy'r � OWNER-BUILDER DECLARATION OVER IINI(IAMPS ❑BAfI1 RIiM0 EVREPAIR DEMOLITION
I herchy affirm m
that I am exempt from the Coreet a's License Law r the
O following maim(Section]031.5,Business and Professions Code:Any cityor county SIGNS ELECTRICAL. ❑(/p�HFiR .a �� e
LL which requires a permit to contact,alar,improve,demolish,or repair anyy,structure Q
14.J'l�F _W
N��0.j print to its issuance,also requires the applicant for such permit m rile a signed statement SPECIAL CIRCUIT/MISC.
F. y that he is licensed pursuanuo the pmvisinns nfthe Cmnractues License Law(Chapter 9
(commencing with Scene.700B.1 Divisimn 3afthe Fominessand Pmfessiore Code)., THMP.METER OR POLE INST. COMMERCIAL'
G q e a that he is exempt therefrom and the basis for the alleged exemption.Any violmion of ❑NEW BLDG/ADDITION ❑DPMOLI9'ION
iC 4. Section 7031.5 by any applicant far a permit subjects the applicant to a civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
YFIZNY
of mare Nun Five hundred dollars($500). IMPROVEMENT
< I,as owner of the propcny,or my empinyeea with wages as their sale ennpemntion, SWIMMING POOL ELECTRIC
O will dome work.and the structure is not intended monitored forsale(Sm.7014.Business 171 OTHER
and Professions CodToe e Calamines Lima.law does not apply to as owner of OUTLETS-SWITCHES-FIXTURES
�' property who huilds or improves thereon,and who docs such work himself or through
his own empliVecs,provided thin such improvements menm amended or offered for NNW RESIDENTIAL ELECTR SQ E'."
sale,IL however,the building(it improvement is sold within one year ofcnmpletirn,the SQ.F..FLOOR AREA WSQ.per
owner-builder will have the burden of proving that he did not build or improve for pur-
pose of ado.).
❑1,m owner of the proper,vin contracting exclusively concting with licensed enumerates'. TOTAL:
consumer he pmject(Sec.701al.Business and Prrfbsslon Code:)The Cuntmetnan a I.,
cense Law does not apply in an owner palproperty who bui ids or improves thereon,and QTY, PLUMBING PERMIT FEF, do
who contracts for such projects with it eontruaoKa)licensed parsoant to the Gmtmemes
License Law. PERMIT ISSUANCE
1 am exempt under Sec. .B&P C for this rcuwn
ALTER-DRAIN&VENT-WATER IEA) VALUATION
Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE O R� QO
1 hereby.ITrm under penalty of perjury one of the following declarations:
❑ I have and wil l minimum a Cerifiedeof Consenu.self-inure for Worker's Compel- DRAINS-FLOOR,ROOK AREA,GOND, STORIES TYPE CONSTRUCTION
nation,es provided for by Section 3710 of the Lahor Cade,for the performance of the
work for which this permit is issued. PI XTU RES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
J]fl0of th Later Csdgfor the perfnrmnnc of the work for which Nis pcntdt is iuu J. GAS-EA.SYSTEM-I INC.J OUTLETS 04::C.GROUP APN
My War Co a iq 1{qc rPoldY NiayAu.IMd k3a KyyO GAS-EA.SYSTEM"OVER4(EA)
Cartier:
CF.RTIP CATS OFT.
COMPENSATON AI IONIINN INSINSURANCEWORKERS' GREASPJINDUSTRL WASTE INTERCHPTDR
BUILDING DIVISION PEES
(This section need no[he completed ifihe permit is for one hundred dollars 1$100) GREASE TRAP
or less) - PLANCHECK FEE
Icenifythm in the performanceofthe wort forwhichthispermit i.mind.lshall SEWER-SANITARY-STORM EA.2W FT.
part employany person many manner ennt rte./: LeritlrtYe Worriers'Cornice- ENERGY FEC
O z s him Law=..(Cela Dm,. �LLllaa. 7777 WATER HEATER WNHNTMLECIR J-� a hTK/QS -99 U GRADING FEE
2 Applicata
h NOTICE TAP
O PLICANT.If,after making Otis CerliGcum of Exemption,you should WATER SYSTBM/TRBAI'INC,
a a become stiddon[n the Worker's Cmbpetnmirn provision of the Labor Code,you most SOILS ITE
LJ forthwith comply with such provisions or this permit shall lte deemed revoked. WATER SERVICE
or Q
.7z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL YLMB. SQ,17. PAID Uta¢ Rttciptp
L) 0 k foreb hath thi that there is.
..edl( et.30 len ding agency forthe perfnrtnnnce of
the work for which this permit is iasuW(Set.J09],Ci,C.)
QU Lender's Name TOTAL:
04 1 Lender' AIDEALes IDEAL
Ty 1 certify that I have read This application and tame that the shove information is BUILDING FEE
r rA mon,a. egreemcnmply with all city vnd crumy onfinunus end sate laws rclmingm QTY. MECHANICAL PERMIT FEE
U building construction,andhereby authorize representatives ofthiscity menterupnnthe SEISMIC FIDE
above-memmned property for inspection pudic.. PERMIT ISSUANCE
(We)agree to save,indemnify and keep ml
haress the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way aceme against said City ALTER OR ADD TO MECII.
msequence oft 6th n ofthls at
PLUMBING FEC
APPLICANT' JE r )SAND VILL t )MPLY WITH ALL NON-POINT AIR HANDLING UNIT LTO 10,M)CFM)
SOUR .L f> MECHANICAL.PEE
1 7-CZ'� AIR HANDLING UNIT(OVER In."CFM) CONSTRUCTION TAX
sii Duro EXHAUSTHOOD OMMUCD I HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store par handle hazardous muarad I HINTING UNIT 00 IN),000 BTU) -
us defined by the Cupertino Municipal Coale,Chapter 9.12,and the Health and Safety
Cade,Section 25532m)7 1 H13A'I'ING UNIT(OVER 100,000 BTU)
.❑Ycs )on VENTILATION FAN(SINGLE RESID) PAID Date Receiptp
Will the applicant or future Mali ing occupant use equipment Or deVICCS WhiCh
emit hazardous it Omaminantsm defined by the Be,Are.Air Quality Management BOILER-COME(31111 OR 100.)))BTU)
TOFAW.
e
District? BOILER-COMI'(OVER I00,000 BTU)
❑Yc: �Nn
� Ihave read the materials rtgm mems aider Chapmr695 of the Cali- AIR CONDITIONCR ISSUANCE DATE/'
foredo Health C ons 25505,.s 533 an 25534.IuMemaml that if die NEW RESIDENTIAL MECH. SQ.ET. — ,S v 9
Wilding a ave warm t y suitably a nmily the neupant G
of the t Ix mu t pri d u Ceniftcateof Ore.papacy
7-41?
Owner or authorized agent Date TOTAL: ISSUED BY: '(
OFFICE