99100128 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF,RTINO BUILDING PL MI N).
RUII,DING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S0001 um
BUILDING PROJECT IDRNTIFICATIIIN
SANI'1'AItY NO. AI'i'LICAI'ION SUBMI TIAL.Dn'll
BUII.DIN IgoSS: 6,ckiree_ ^ r
liNAMEra C qH I C CONTRA( O N 1-IC NO: NIC CUNTRULM
Id .J h/J- r 6
7COWACM
CI'IENGINCER: LIC NO: DRI+S". So �� � .—n ❑
. PHONE: „i HUILDING PERNUT INFO
❑ Consultant Fees Paid by Applicant(Initial) DOUG ELECT PLUUh/}H MECH
❑ ❑ YJ ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
reby:,mm,mal I an,licensed Order provhlmrs of chapter 9 commaininglOH DESCRIPTION
n11X0)ol Division3ofthe Business and Pmfcssions Crde.many liceawis RESIDENTIALry I'IiRMIT ISSUANCEassd ellen O ❑SFUWL ❑KITCHEN REMODEL
a, APPLIANCES-RILSIDENI'IAI, ❑ADDIIIUN ❑PLUMBING RF."PIPIT
6aAz AConuannr []MULTI-UNI'1 ❑STRUCTURAL
A CHrTECCS DECLARATION PANELS MODIFICATION
z b I undersmnd my plans shall be axed m public nand, UP TO 200 AMPS
❑INTERIOR El CHIMNEY REPAIR
O Z-b
P 4F yl Licensed Pr..fico incl 201-1000AMPS IMPROVEMENT 0SW IMM ING POOLS
� �'.j OWNIIR-BUILDER DECLARATION ❑BATH REMODEIl11EPAM ❑DEMOLH'[ON
� OVER ISM AMPS
C C Q I herehy vffinn that I am excmpl from the Commnnr's License Low lin the ❑OTHER
XNU following reason.(Section]8.11.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL
W 31L y whin+reclaims a patina n,to a,,.At,bnpmve.detmai.b,Of eapm,:,ay mmllaro
F poor to its issuance.elm requites the applicant for such peril to file a signed statement SPECIAL CIRCUITIMISC.
� y IhmhcisliccnwJpursmnnntMpmvisinnsofthe Cnmrmno/sLicenuLaw(CTapar9 COMMERCIAL:
�jCLOp (comn,cntingwith lection llNNnof Uivisinn9 nl the Dnsinusvnd Pndcssinns Cndc)or TSMC MITTCR OR POLI?INST.
a a catY that he is excmpl therefrom and the basis for the alleged exemption.Any violation of ❑NEW B DGIADDII'ION ❑DEmoLIIION
Section 7031.5 by any applicant for u permitsubjects the applicant to a civil penally of POWER DEVICES ❑'TENANT ❑FOOD SERVICE
nut store man live hundred dollars($5m). IMPROVEMENT
ESO QLas rnver of the pmpenY,ter mY anploytts with wages aUheirwle rnmpcnsmiw, SWIMMING Pi ELECT RIC
will do the work.and the structure is not intended orolfemd for sale(Sec.1DW.Business ❑OTHER
C,.m and IPrnfessions Code:The Contructnrs License Law dims nal apply m ata owner of OUTLETS-SWIICI ES-FDOORES
W
3 property who build or improves thereon.and who does,such work hnnslf or through
his own employees,provided that such improvements am not intended or offered for NEW RESIDENTIAL ELECTR SQ IT.
salc.D.hosse,aenc huilde,or improvement is sold within one Year of mnalition,the SQ.FT.Il.00RARISA 5/SO Fr.
ref-Wilder will have the burden of proving that he did not build or improve for par
pow of sale.). TOTAL
0 1,as owner of Ihc ampoly.am exclusively eonnuning wins licensed cordon,ors m
onstmctthe project(Sea 704,1.Business and Professions Case)The Comracmh Li-
cnaLow d(es nm apply to an owner of pmperty who build or improves thereon,and QTY, PLUMBING PERMIT FEE
who rout.',fill .,It projects with o co manr(a)linmwl pu,and in he Commctnfs
License Law. PERMIT ISSUANCE
I am exnlmt under See. ,B&PC fonhis reams
AI:rER-DRAIN&VENT-WA'1p (lin) /1 VALIJnI'ItIN!�
r Dam {7/ 35-c7 V
net WORKEN;S COMPT;NSATION DECLARATION BACK PLOW PR(ITECf.DEVICE
1 nearby ambo under penalty ofpmjuy nate of the fIIIII gdaelamhm,s
�Ihave and will maime,na CertiEczmofConsento elf-inmm far Worker's Compen- DRAINS-FLOOR.ROOK.AREA.CON D. STOR5 '1Y1%CON l'I'RI1CI Ed
snti:m as provided Is
by Section 318(1 of the Labor Code,for the pertimmaoce of the
work for which this pvnnn is issued Iq)(TUkIS-PIiR TRAP
I have and will mninmin Workers Compensation Insurance.as required by Section GAS-IIA.SYSTEM-I INC.1 OOrLETS
STEP of the Laser de for the p rhmmance of the work forwhich this permit is issued. OCC GROUP
My Work's Com cm non,lass ncaearrlcramd Policy rypLllI ly�rlrv�
Cartier�t -III No.:IS ersn7°'7? GAS-IIA.SYS TEM-OVE'RC(HA)
CERTIFiCNI'17 OI'EXEMPTION FROM WORKERS' GREASC(INDUSTRI,WASTE EN'1'ERCEPTOR
COMPENSATION INSURANCE BUILDING DIV1510 PIiF.S
(D,issectionnecdnothecompleted ifthepem,it isfofanchundreddollum(SIM) GREASETRAP PLANCHECK FEE
or less.)
le,any lhalimhepey...a, of thework
been which this the W i ker,'C.iahsll SEWER-SANITARY-STORM f:fs.21x)IT ENERGY IEE
Orn employ any penin in any manner w as m become subject m the Waders Compen-
Z cation Lnwx of Cnllfurnia.One WAT17H IIEAT17R WNEWELF.CTR ORADING FEE
O Applicant )
pz. y
NOTICE TO APPLICANT.If.after making this Ccnifcam of Exemption,you should WATER SYSIEMOTREAI ING SOILS FLE
L Mtnme snhjcal Is the Wnrare,Coon,...unn provisions of Ihe Lahr Cade,you must
I IYss forthwith comply with sO,hpfivioon,or this permit hall be deemed m,almd. WATER SERVICE
y
CONSTRUCTION LENDING AGENCY NEW'kC51DEW1AL PIMR. SQ.14. PAID
�S O Data Receipt It
J Thar sihi lion lhannere comencion(So,.3097.
landing agency for the perfonnance of
W (~
Be work for which his psnnil is issue)(Sec..1891.Civ.CI I Cl Ah:
O U I,aI Nana
ds Address TOIAI.
>. Isrd1 crniy that I have mad this application and state that the above information is DU 4)ING FEE' Is
g comply w. y and y nr , QTY. MECHANICAL PF.RMI'I' FEC
cnrmt.I a rcc m nm, I with all cit J crnmt Amanccs send sem laws relmin u' SG,}tom F � T �
U z huildin6 cnnswninn.and herchy m,mnrire mpmsenmtives nl tris city to enter upon the v v mJ
ahwomcrtioned property for inspection putpmes. PERMIT ISSUANCE III 'r RIC FEE
(We)agree m save,indemnify and keep harmless'he Ciy of Cupertino apiarist
Iiabilities,juJgmevls,eost,..dcxperses which may in any way accmcagainnl said City ACTT7R OR ADD'10 MECH. i'1 MBINGFld;1
i,conxyuarea of the ming of this permit _
A I'i'LICA " IND tSl'ANUS WILT,COMPLY WIfH ALh NON"POIN'T AIR IIANULING UNIT(TO II,(00 CFM( MECIFIANIC-AIAll
SG'Li( 's�N IONS.
��r /If ^/s AIR HANDLINOUNIT(OVER 10,(X0 CIM) CONSTRUCTION TAX
Si ,maren[Appli<vnJConitamir 6' [e,/�Dvtm EXHAUST IIOOD fWIDUCp HOUSING M,IGAI ION PPE
HAZARDOUS MA N DISCLOSURE,
Will the npplicvm ar fuwrc huildingo upnotsmrenrhandlchwardmo,material ((EATING UNIT 001(X1.801)BTU)
as defined by the Cupertino Municipal Crile.Chapter 9.12,end the Health and Safety HEATING UNIT(OVER 1 W.(XX)BTU)
Cde.Section 2.553201?
❑Yes' Wm VMRESIDE�ALMECH.
'I[Al ION PAN(SINGLE RISS I D) PAID 19
Date Recclptk
Will the applicant or future building mcupmrt use cyuipment m devices which11'OR IIx1.IXX1 H"fU)
+it A:reardous air eonvmlnatns us defined by Ihc Ito,Arun Air Quality liC crucialTOTA.:
Distal? VER 110,(X0 BTU)
C3 YO, IeNo
ISSUANCE DAhli
1 have mad the haeamous ntatemods myuiremcnts under Chapter(+95 of the Cali-
fnmia health Sof Cook.Sections 25505,25533 and 25531.1 understand that if theL.MECH. SQ.FE uildngdoe' Pte endyhnvetOb which mail Inst nee of a Craft' fqctD e rieda8enlD ` T(TAL: ISSUPU RY:
OFFICE