99120148 ,APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY1, O
CITY OF CUPFRTIN0 BUILDING-ELECTRICAL PGR f IT N
APPLICATIONIPF.RMIT PIAIMRINC MECHANICAL
BUILDING DIVISION BUILDING PROJEC'PIDEN'I IFICATION '
SANITARY NO, APPLICATION SUBMITTAL.DAI
BUILDING ADDRESS:
10124 malNLAL U4l� eT
OWNER'S NAME: I-HONH: [ CON'1'RAC'FOR$NAlsl T�^1 LIC NO,
O - —69 etf DVJCI _t 0 /'p 1 NIC CUN'1'ROLp
2HITECfIENGI EL LIC NO, IAC VO g^ -1 Jhk bWo 111 lOG ❑
CONTACT: 1'HON : tlk� L la-u BUILDING PGRMI'I'INPO
❑ Consultant Fces Paid by Applicant(Initial) BLDG El CT / PLU❑MB MECCH
El
LICENSED CONT'RACTOR'S DECLARATION QTY ELECTRICPERMIT FEE JOB I!
)I E/SCRIPTION
I hereby affirm that I.,it IicenzeJ under provisions of Chafer 9(commencing
Q=Z with Sechion](gXDof Do, Sof the Business and Qrof�o C pdplY lipenx is R NID-NTIAI,
FOO in Bill force and t (/J_ ryry Y / PERMIT ISSUANCIi
'/� Vn (p ❑SLOWI. C1 KITCHEN RIiMODFa.
<UU LiccnwCes N APPLIANCES-BESIDIiSI AL ❑ADUI'11ION ❑PLUMBING BE PIPE
h¢i Dotes ^�� �onwtor
ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑MODIFI STRUCTURAL'
Z O H Z 1 understand my plans shall be used as public records h10DIFIGCI'ION
OZ=M UP To 200AMPS ❑INTERIOR [I CHIMNEY REPAIR
F via l-„W Lirenccd Professional 2111-II00AMPS IMPROVVMEN9E]SWIMMING POOLS
�•CE� OWNER-BUILDER DFCLARAFION El BATH REMODHL/RliP IR ❑DHMOL.I'LION
C C Q I hereby affirm that 1 am exemp from the Computer's License Law for the OVER IfX1UAMES
10a.0 following reason (Setion7031.5.Business and Pmfessions Cade:Any city or county SIGNS ELECTRICAL ❑OTIILR
a ILh whim re,mme,11 perrouts Int llr, mprooc,domolish.or repair any.l cture
prior to it, l.e remine,dirapplcomI hpc in 31
a l 'C C l .. r
f,'�y— marl licensed p rsua a 'hep ns filo C r f AI. Ph COMMERCIAL:
I+I�CC teem B 'tnS ni ]Wlll fU -sits J fIM1 D a Q^'f .nI.. CM r 1 i .
C.A.o a that h pr therefrom I men. f the II g J en f ❑NEW BLDG/ADDI'T'ION ❑DEMOLITION
ScNoo]11315 by any apphcn ft for a Lotus ubcus the appl cenno t civil penalty I 1 E ❑Tf.NANI' ❑FOOD SERVICE
ani more man Eve hundred dollars(85(10. IMPROVEM['N'F
Q 1,as owner of the pmpvny,or mY empinyws with wages uz Iheirsnl nmpen t 1
p. will dothework,andlheclrumue isnot Innermostor offered for.de(Se Mal.B ❑OTHER
Lc n.,i f Code Th Contractor,L I J not apply
3� .,,city who h l l or mr,osll tl n,-,III who does suchnett or rhmt An W n.rN ..TI SQ ItT.
work h h
his temployeespn 'd I that h imp r:tat.not ihfor SQ.PF.FLOOR AREA 95Q.FT.
sale.If,n the building improvement ld 'th n r
owne,4builder will have the burden f pourvingthth did nor p
pec of sale.), 'AL:
❑1,ac no,of in,pmpmril ant excln.ively amVaeting wit IC�•�,1 eemnclor.ser
msuuct the Project(Sec.]IMP.Buuiness and Profession,G 8h5 Contactor'.,hi.
se law dao ern apply man owner nfpmpcnY who build, pr�jsyp,_thara
mJ Q •,`. •�I L(�v1B FEE
who contracts for such project.,with a comracmr(s)licensed pursuant to the Comrnmor'n
I.icen.e Law. PERMIT ISSUANCE
❑ I nal exempt ander Sec. ,B di P C I'nr This reason
AUIER-DRAIN N VENT-WN'ER(IiAI A'1'1ON
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 fortifyxlf
on,
under pemJly of perjury one of the following the Interior.:
I havcundwill main a Comm,aeof Consent to.elf-offfor Worker.Camper' DRAINS-FLOOR,ROOF,ARIiA.CDN[. STORIES 'TYPE Cf1NS'I'RUCI'I('
sattion,as provided for by Section 3700 of the Labor Cade,for the Performance of the
work for which This permit is issued. Il%TURFS-PER TRAP
I have and will nmintain Worker'.Compensation Insurance,as required by Section GAS-EA.SYS'TGM-I INCAOUTLETS WTLGTS
37(y)(If the LaIsr Coda for,he penomrwecol'the work ku which mi ,onail i,hmeJ. OCC.GROUP AP �
My Worked(' Pem tion ;nncepInie and Policy
n14n n�R GAS-EA SYSTEM OVERJ(G)
Carrier. Ff1F d Y
CERTIFICATE OF EXEMPTION FROM WORKERS' GRHASMNDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thi,.coft ncedna hecompleed it thepotalM.Ila.mchunmadddIa,(81(X11 GREASE'LRAP
PLANCIIIiCK PEE
or lcss.l
Loy any Person
in the any mrnnerof as tohe Is
for wubjectch 10 Perthe Wo rker"Mmosco' SGN'GR-SANITARY-STORhf EA.200 FT ENERGY PRE
' ern employ any person in any manner so u,mnecome subject the Workcn'Compcm
Z ,ation Law,el California.Daic WATER HEATER WNENTITILECTR GRADING T12F
O Appucam
z = NOTICE TO APPLICANT..IL after making Ibis Cenificae of Exemption.you should WATER SYSFEM/fRFAT1NG _ SOILS PEE
F beorm%object to the Werkce%Compensation provisions of the Labor Code.You must
d+? forfssion mMIy with such prov.cmr—,,bis permn,hall he deemed revoked. WATER SERVICE /rte
GONS'FRUCTION LENDING AGENCY NEW RF_ti1DIiN'I'IAL PLMB, SQ.pT. 1f'•IIAI) 1
,U Z 'Dare Receipt p ,
C.7 0 IM10 whichby his
fermihat is issuedconstruc
30 .Cil agcncY fonhc perfofhancc of IL
'L,
the work for whim mise permit i.,iwoed(Seo.3B9].Civ.CJ T T(AL
O U bender'.Name 'TOTAL: 1
W Isndee Add max BUILDING PEE
G 1 cendy that 1 have read this application and slate that the aMrvc nomination i. )I
N coned.l agree on comply with all city and county ordinance.and state laws mining to QTY. MECHANICAL PERMIT FEI m SEISMIC FEE V
U Z huildingerosvuction.and hereby authunic representatives of this city to enter upon the uy
above-mentioned progeny for inspection purposes. PERMIT ISSUANCE ELIZO OGFEE��_ f
(We)agree m...I,indemnify and keep harmless the City of Cupertino against
Iiobilitiec.judgment.s.costs and expenses which may in my way accrue againslsaid City AI,T'ERORADDTOMECH. PLUMBING FEE
in consequence of the grafin,winds pmmil.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IROOBCFM) 111HANICAL FEE
SOURCE REG U LAHONS. AIR HANDLING UNIT(OV LIR IPON)CPM)
CONS'I'NUCTION'IA%
tg atum of Applicant/Commotor Uac EXHAUST HOOD(W/DUCO HOUSING MITIGATION FEF.
HAZARDOUS MAT P.RIALS DISCLOSURE
Will Ihutp,d.mnr Btutrc nuilding nttnpum.elnre or handle huenMno.nnncrial HLATING UNIT'Cf0 INLIHXI BTU)
as defined!by the Cupertino Municipal Oslo,Chapter 9.12,and the Health and Safely HEATING UNI'I'IOVGR IIM),IXM)BTU)
Coda.Section 25532h)?
E]yes, ❑No VI?NTILATION PAN[SINGLE RESIU) PAID
Date Receipt N
Will lhcapplicanl or future building occupant use coleducnl or dmicc,which BOILER-CoMP(3HPO111(m,(Xq IfIU)
at hrvnNom air comanhinetn,as defined by the]tiny Arca Air Quality Maregemetn TOTAL:
)btdcC BOILER-COMP(OVER Iffiff"BTU)
❑Vc, ❑No .92
AIN CONIN TION ER ISSUANCE PATE
1 hove end IM1C huunlous mdond,requircmcm..under Chapter 6.95 of the C'ai'n / '
fomia Health As Safety Ode,Sections 255115.25533 and 25534.1 understand that if the NEW RESIDENTIAL MICH. SQ.I'll 7
building dees not currently have a tenant.thus it is my responsibility to notify the accupom
,it t qm
uirecres which must hi,met prior to issuance of a Certificate of OscuPmcY.
weer or authorteed agent Date TOTAL: ISSUED BY: Y
OFFICE