99090004 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 0 00044
CITY OFCUPFRTINO BUILDING.ELECTRICAL
BUILDING DI VISION APPLICATION/PERMITPLUMBING-MECHAn'IC,O.
BUILDING PROJECTIDENITFICATION
BUILDING ADDRESS: a SANITARY NO. APPLICATION SUBMITTAL DATE
C38 I o D -
OWN' AME: PHONE: N'I' AC'H 'S NAML: , 1 „ I.IC NO,
_ (AAV/NI• NIC CON'Doi.p
RCIII :Cl'/13NGINIiER: LIC NO
I tEs.` �l ❑
CONTACT: PHONE: BUILDING PIiRMI'1'INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
! ❑ ❑ ❑
LICENSED CON TRACTOR:S DECLARATION QTY ELECTRIC PERMIT' FEF:
1 hereby affirm that 1 am Reen,ed,ruder pmxkdnna nr cBafter 9 anmmencing JOB DESCRIPTION
X0'2 with Section'1B00pd'Division 30 the Basi nes,and Professions.Gide,andnty license is RESIDENTIAL;
F1_ in fall fixerand effel$i�n'1�-)���'±`k PERMIT ISSUANCT:
4 V U Licen.xe Cla c_LCL Lic.a ❑SI'DW I. ❑K11'CIIIiN REMODEL
r[F Qa Dale�—Q-}sem{. Cnmmnnr APPLIANCES-HISIDIiNTIAI. []ADDITION El PLUMBING RF:-PIPE
— ARCHITECTS I CLARA MN PANELS ❑MULTI-UNIT ❑STRULTURAI.
Z p to Z I understand my plans shall he used as public rccmdc ��,/J�fODII'ICATION
OZ—� UP To 200AMPS ❑INTERIOR d1HMNEY REPAIR
W Lierme,,Prof...road 201-1(MAMPS IMPROVEMENT 0SWIMMING POOLS
a SI2; OWNER"BUILDER DECLARATION OVER IOIN)AMI'S L3 BATH RF.MODEURIiPA1N DEMOLITION:tY 6 1 hereby affirm than I am exempt from the Commaar's License Law for the
❑,X13 Ac FU- following reason.(Sceinn]1131 5,puniness and Professions Code:Any city or county SIGNS ELECTRICAL El OTHER
which requires a permit to construct,alter,improve,demolish,or repair any structure
prions RI Issuance,also requires the applicant lot such permit to File a signed,mtentent SPECIAL CIRCUITIMISC.
�!!(} that he is Reamed pursuant m the provisions of the Calamities License W.(Couple,9
pal.^gip (commencing with Section 71)(Mof Division 3oflhe Bnxibcxxund Professions GMc)or 'TEMP.METER OR POLE?INST. COMMERCIAL:
a X e C that he is exempt therefrom and the bads for the alleged vaccinator Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
X
Section]831.5 by troyapplicant far a Permit subjects theapplicanl or artist penalty of POWER DEVICES
..y t meethan Five hundred delta,, PROV ❑FOODSERVICE
H Z i IMPROVEMENT
6
aid
I,as ownerk,the property,or is employees with wages as le(Sev.compensation, SWIMMING POOL F.LIiCfRIC
r� and dnihe work.and e The lrcisrour's all License
Law,,doered for at apply in an,Rusmere,If ❑OTHER
m and 1'rofessinns Axle:The CommcmLc Littnxc Law,does at apply In an owner of OVI'LE1:S-SWI'TC111iS-FIX'(UR r
Fitt 3.. Wnpeny wIt,,builds or improve,thereon,and who dues such work himself nr through
his own employees,provided that such improvements arm an rodeo,,.,,or offered for NEW RLSIDEN'I'IAl.ELECT R ti
sale.It.however,the building or improvement is sold within one ywr of completion,the SQ.FT FLOOR AREA $JSQ.FI'.
wnerhuildar will have the burden of pnrving that he did oat it,,nr Improve lir pur-
,we of ale.).
C] 1.as owner of the property,out exclusively continuing with licermd cantacmrs in TOTAL:
consumer the project(Sec.](D4 nosiness end Profcssinns Cxxde:)Bhe Cono-on s Li-
cmaLawdoesbill apply ,,anowne,atno,wrywho builds or improves thereon.and QTY. PLUMBING PERMIT FEE
who contracts for such,a jests with a,.raced,)licensed pursuant m the Conbacmrs
L.icelxe Law. PERMIT ISSUANCE
Fear exempt under Sec. ,B A,PC for this nabour
AUD711-DRAIN A,VENT-WATER(III VALUATION
Owner Dom
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE x\-
I herebyillmai under pamdty of e pct Jury one nl'the following Jwhmniom- [/`v
have and will for byneCion 37 cof Ce Labor self notice Worker's
orma Gompem DRAINS-FLOOR.RIII)P,AREA,COND. STORIES 'TYPE CONS'1'RUC'1'ION
sat n r provided for by Section 1]011 of the Labor Cale,brt me p'rfnnnana of me
r have
this permit i,arket. FI%'I'11R13S-i'13H TRAP
w I have anJ will main Wxnkefx Compe"IT Insurance ,s required by Section
of mel LJ�-'''�Iwi rlsyur nanca nl' c castor whicbdux amu GAS-EA.SYSq'I?M-I INC.JOf1T1.LTs OCC.GROUP APN
seat
�M1 Qa: tmflosur ecamer n olicy ��_Z t GAS-EA.Sys rEM"OVER 4(EA) f'O�7
Currier icy Nn,:
CER IF T OPEXEMPHONFROMWORKERS'
COMPENSATION INSURANCE ORGASFANDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FI'.PB
(Thisxalinn neW Ami beanmpinmtl ifthe pennil is fnrnnehnndruWnllurx 151011) GRI3ASE'1'RAE)
or leas.) PLANCHIiCK FEF,
Icertify that in the performance mfthe work for which this Pe it ix i...ell,(shill SHIVER-SANITARY-STORM P.A.2W Irv.
not ploy any Peon in any nDnnerso m to become subject 10 the Workccs Compen. ENERGY FEE
emrs
Z nation laws of Cd
iforria[)am WATER 1117ATER WNP.NTICLECTR
OO Applicant GRADING FEE
yNOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTF.MOHEATING SOILS FEE
herons solject to the Worker's Compensation provisions u1 the Labor Code,you must
W forthwith comply with such provisions or this permit shall the darned revoked WATER SERVICE
d 41
U Z CONSTRUCTIONLENDINGNGAGENCY NEW RPSIDCNI'IAL('LMR. SQ,PE PAID Date RaeipfIf
LJ I lot which
affirm that ad,the.I is a ed(See
len ding agency for the performance rf
U. E" the work lin which this permit is issue)(Sec.11N],Civ.C.)
Ixder'x Name TOTAL:
lenader's AJdress 'TOTAL
>. IJ.I :
C. 1 certify the I have mad this application and state Thal the above information is BUILDING PEE.
F-t rn coven.I agree at comply with all city tad rot y ord'oanc.x and sate law,relating to QTY. MF,CI IANICAL PERMIT FEE
VZ building construction,and herebyarhadu mpreavaltivesofthis city toemmT upon the SEISMIC PCE
shove.mentionell property for inspection proposes. PERMIT ISSUANCE
(Wc)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FIE
liabilities,judgments,cogs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in canseque the grarogof this perm it. PLUMBING FF.E
A PPLIC TUI. RST Ly WILL COMP LY WITH ALL NON.POINT AIR HANDLING UNIT(TO 10.000 CFM)
SOIJ .REG MECHANICAL FEE
�� AIR HANDLING UNIT(OVER 10,0110 CPM) CONSTRUCTION'TAX
Sig tum m(AHPllcam/C -CV
ac r Dam EXIIAUS'I'H(A1D(W/DUCT) HOUSING MI'I IGATION FIB,,
HAZARD SMATERIAISDISCLOSURE
Will 0teapplicantorfrombuilding'x'enpant sorenrhandlehuzardnux material HEATING UNITLTO 100.000 BTU)
a defined by the Cupertino Mumei 1 Cale,Chaple 9.12,and the Health and Safely
Code,Seen i25512fayt HEATING UNIT(OVI:R 1(10,0110BTU)
❑Yee VENTILATION FAN(SINGLE RISID) PAID
rnamd'efined
Date
Rc rpt p'
Will me applicantih ing nccupam use cyuipmenbntdeviccs which BOILER-COME OHPOR HX).01H)BTU)
tit hazardous air contain by the Bay Arca Air Quality Management TO
isiricl? BOTTLER-COMP(OVER 100,000 BTU)
Yes
AIIt CONDI'TIONElt
I have rtaJ the has nus numrials myuirements under Chapter M1.95 of in,Cali- /\ ISSUANCqE.IJATIi
feral, Safety Cn e,Sec'ons 25505,25511 and 255341 midentand that if the NCW RESIDENTIAL MECIL SQ,LT. Y'__� C 9
hu' mg disc I m 1 u enan6 at Ulf,my re,ponsibilityIn notify the wcupum
th m t uxl to met prion uabm of, iii ¢nf;1pan
or...Imaiz gc a TOTAL: ISSUED BY:
OFFICE