99080225 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 9y o 8 002„2�
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
r
BUILDING.DIVISION APPIACATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENI' APIF'ICATION
BUILDING ADDN�i55: � SANITARY NO, APPLICATION SUBMITTAL UATI
Lu r d -3J 49
OOWNERI,,N ME: PfION@ CONTRACTORS NAN; LIC NO:
5 -O`6 3 Nrc coN ftoL.
RUTHIECTALNGINIZER A LIC NO. ADDRESS: ❑
CONTACT. �I('PHONE: BUILDING PERMIT INFO
ty�,
``S Yn� ` 1 / I 1 �O ❑ Consultant Fecs Paid by Applicant(Initial) BLDG EL1iCT PLUMB MHCII
a ❑ ❑ ❑
LICENSUD CONTRACTOR DECLARATION QTY ELEIZ RIC PERMIT FGE
1 hereby affirm that I am rtcenxed order provisions of chapter 9 commencing JOB DESCRIPTION
DOZ
W OO with Section 700(Di Uivis 3ose
.fthe Businend Prfessiuns Code,and mylicenx PERMIT ISSUANCE is RESIDENTIAL:
g-i- in full Tinos and effect. ❑SPUWL ❑KITCHEN REMODEL
<nu License Class Lie.IT
1-4W
Dam Conomort, APPLIANCES-RESIULNTIAL EDAUUITION El PLUMBING HhPIPE
6
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
Z O on Z 1 understand an,plans shall he used as public m<oNx PANELS MODIFICATION
UPT02M AMP5 I ❑INTERIOR ❑CHIMNEY REPAIR
F.N..f..W Licensed Pro.aionrl 201-IOIx)AMPS IMPROVEMENT' E]SWIMMING POOLS
Eow< OWNIam BUILDERm The ComIION OVER I(xX)AMYS ❑BATA REMODEUREPAIR ❑DEMOLITION
C C Q 1 hereby affirm that 1 em exempt from the Comrecmrs License Law for the —�fl_ Q �_—
X
Eo
a F- following no mn.(Section]OJ I.S,Business and Professions Cate:Any city m county SIGNS ELECTRICAL ❑OTHER
R: u,y which requires a permit to construct,alter,improve,demolish,or repair any srrnure O
r�0
pr oat t I: y the f such Permit fl signedstatement SPECIAL CIHCUIT/Is115C.
9 ,>
that he Ip -i II the p : I'th C t t 1' L (CI picr9
Wa0C (commmovingwth Savion]IXXOufDrvii on 3 of the Buivas end Professions Cade).1 TEMP.M C'll?R OR POLE I NST. COMMERCIAL:
a ty o y 'hat he is exempt Inercfrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
�H
Section]U31.5 by any applicant fora pcnniwubjm¢the epplicannuacivil penalty of POWER DEVICES JNEI
FOODSERVICE
F Z} not more than five hundred dollars 18500). VMPROVEMENT
=M ❑La,avomnsfthepropeny,of my employees with wages as their sole composition, SWIMMING POOLELF.CTRIC
FSG will do mho work.and the-otmboreio not inlendeder offered ba,cle(See 7044.IIminess C1 OTHER
a3 and Professions Code:The Combecter't License Law does not apply to an owner of OUTLETS-SWI'1'CHFS-FI ORES
progeny who builds or iinprves thereon,and who does such work himself or through
Ms own employees.Provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELF. R ,
sale.If,however,the building or improvement issold within one year ofcompleion.the .� SQ.FT.FLOOR AREA $/SQ.FT
ovac,ladderiH have the burden of proving thin he did not build or, improve for par-
pe c ol'alc.).
Las owner of the property,inn exclusively contracting with Iicensedla amrecom m
construct the prject(Sec.70W,Business and Prfessio r,Coded The Conewhor's Li- Y
m law does not apply to an owner of progeny who builds or improves theater,and QTY UMB PF.RM1IIT FEE
whoastnfactsforsu chits that lora rnr(s)IicenseJ pursrnuu Ne Camnemr's
.��'�L]i$$kFF�a aw. E�(� I'BR ISS
1 -am excmptu S y11 dcPClin this remr
1 - �1 :R-SRA VENT-WAl13R(r-) VALUATION
Owner te Q, Q
WORKER'SCOMPENSATIONDECLARATION B ROTEC..DEVICE
To
1 hereM1y affirm under penalty of perjury one of the following declarations:
I hove nttdwillmuinminaCenifcut¢OfL'nnsenno,wlGiirsurc iia Wnrker'.e Compen- DRAI -FLOOR,ROOF,ARBA,COND. STORKS '1'YPECONSTRUCI'ION
sxtion,as provided for by Section 3700 of Labor Code,lathe perforrowee of the
work for which this permit is issued. FIXTURES-PER TRAP
1] 1 have and x'ill maintain Workers Compensation Insumnas,as required by Section
4700 of the lana Cede,for the pedormoneeof the work for which this permit is issued. GAS-PA.SYSTEM-I INC.J OUTLETS CGOUN
My Worker's Compensation Insurance carrier and Policy number are: J✓ W
Carrier: Policy No.. GAS-EA.SYSTEM-OVER 4(EA) Ol�
CERTIFICATE OF EX EM VI ION FROM WORKERS' s
COMPENSATION INSURANCE WASTE INTERCEPTORNUILDING DIVISION FEES
(This section need not be completed it permit is forone hundred dollars(SIM) GREASETRAP
nr
less.)(This
FE6
I certify that in the performance of the work for which this permit is iv,med,l shall SEWER-SANITARY-ST ORM EA.20U ITT.
not employ any persa any n nerve as to become subject to the Workers'Compen f?NFRGY FEE
zZ onion Lawsof California,Ume un WATER HEATER W/VENT/ELECTRf
O Applicant RAIDING FEE"A\
h NOTICETO APPLICANT':If,tfier making this Cenificam of Exemption,you should WATER SYSTEMITREATING
u
F' besets object m the Worker's Com nsatiun f the labor Cade,you most $OIf K FEE
fa' emiisionan Aft n )I.
Q funhwith tangly with such provisinno onHiv pemait shop he Accred revoked. WATER SERVICE
1AP AUC A 1 1ggq I,
CONSTRUCTION LENDING AGENCY NEW RESIDPWIAL PLMB. SQ.CC j
5 z IID Dam RecciplM '7
V k(or whaf6rm ohm fiber isamnstruc.30 len ding agency fgr Ne perfnrmartce of 11 /
F the work bar which this permit is issued(sin.J09J,civ.C.) I ..
U's Lender's Name TOTAL:
Landers Address TOTAL: _
G 1 ocrody that 1 have read this application and state that the above information is BUILDING,.
to correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U building conxuuction.and hereby aitnorim representatives of this City to enter upon the SCISMICFEE
is
above nenomad prepeny for inspection purposes, PERMIT ISSUANCE
'(Wc)cEmm it,save,indemnify and keep harmless Ore City of Cupertino against ELECTRIC FEE
liabilities,jmlginens,coos and cxpemes which may nany way uceme against avid City ALT ER OR ADDTO MECH
to nsvnce of the gow owing of this pern.it. PLl1st Plili
yue
APPLICANI UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,00i 1t) MECHANICAL IT
CPR ' [CATIONS. s
AIR HANDLING UNIT(OVFR TO."CFF) CONSTRUCTION T X
Sigoalum of App isms Cnn at IAttc LXHAUS'I'll(lOD(WIUUCIl HOUSING MITIGANN FEE
HAZARDOUS MAE HRIALS DISCLOSURE
Will the applicamor future building occupant store or handle hamNous nuredal HEATING UNIT(10 1(0,)(10 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cala Sotto 25532(a1T HEATING UNIT(OVER 100,000 BTU)
[]Yes ❑Nu VENTILATION FAN(SINGLI?R[SIDI PAID
Date Receipt p
Will the applicant isfuturea it fir d occupant use .Air ear it devleeo which
ithuallous air conmminanrs as it fired by the Bay Arta Air Quality Monagemenr ROILCR-COMP(3HP OR IOB.WO BTU) Al.
carie'? HOTTER-COMP(OVER 100.000 BTU)
❑Yes E]No
I hove Tend the hanudous materielsrc to under Chapter 6 95o the Cali- AIR CON HIT IONER ISSUANCE DAM,DAM,yulrnnen
fomia Health k Safety Cede,sections 255115,25533 and 25534.1 undersmnd that if the NEW RESIDENTIAL MECH. SQ.FT p G
/
be ra
ntly have a ten r,that if' my atagmsibili,to unify the receptor
,c(hlmusr k mq poor AM
n nouS of a Ceri ram;(sopa'>. 3Owns mn�ng�� 9 Doone C� TOTAL'. ISSUED BY:
OFFICE �_