99110001 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONL ONLY
/ / 0Ov III
BUILDING
CITY OF CUPERTINO ELEC
PERMIT
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL
11111 LDING PROJECT IBBN"1'I F'ICATION
SANI'I'ARYNO. APPLICAI'IONSURMI'19AI.INI
BUILDING ADDRESS: 9
�.
OWNS ' NAME: , t _ 1'NO _ CONTRACT'OR'SN Mli: `.1C NO: / CONTROL#
Oak
'
CIR ECT/EINTER: �6✓�/k'•�-I-.IC�I(l�.x ADDRE:
CONTACT: PHONE: BUILDING PIERMIT INIYI
❑ Cansullanl Fcce Paid by Applicant(Initial) HLry ea-- IO
PLUMP_ 1l
LJ
LICENSED CON IRACE ON S DECLARATION QTY. ELI: 'TRIC PERMIT FETE JOBDDESCRIP•I'ION
I hereby affirm that 1 am licensed under mvixions of Chapter 9(commencing
061 Ili'h Scctiun]INNq nI- rl cup;ne.v ape Pmfe.corns sects.aha myliatu'c is RF,AIDENTIAL:
W 0C) Wfull force vnd pl'Imt 4 I'IiRMIT ISSUANCE ElsErtwi CIIIiN REMODFa,
QUU License Cas Lica APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING BE PIPE
Z trocar ❑MULrl-UNIT ❑STRUMURAI.
ARCHITECTS DECLARATION _11ta PANELS MODIFICATION
ZQy'Z IunecmanJ my plum sh�llbeums ae public records U UI'T021NIAMPS
OZ4— ❑INTE:RIOR ❑CIIININ17Y REPAIR
FO, .nLicensed Yrufes,ianal 201-100AMPS IMPROVEMENT' SWIMMING POOLS
Q :F_1 OWNER-BUILDER DECLARATION OVER IINX)AMPS ❑BATT(RCMODEIIRF.PAIR (]DEMOLITION
z L hereby ammo mw l at exempt Bom me Colnracmrx License Law for he
XC,wu following reason.(Section]031.5,Business and Pmfeccions Calc:Any cilynr county SIGNS ELECTRICAL ❑OTHER
m 3 w H which requires a pemtit to construct.alter,improve,demwi,h,or repair any, Ins
H 0sc prior min issuance.alsorcyuirca the apPltcant for such permit at rile a signed statcou,el S I'ECIA I,CIRCA I'1'/M ISC.
y�yyNjY that he is licensed pu analto the provnionam'the Cmuncmh License L.aw(Chapter 9 OMMMERCIAL
wl�'00 (coourencing with section 7000)of lh,Woo 3 of the R.sins and lhofcxsinas CIA.)or 'TEMP.M ETER OR POLE INS]'.
L 400: that he is exempt therefrom and the basis for due alleged exemption.Any violmiun Of NIEW 1,) I DrTION ❑DEMOLITION
X�m Section 0031.5 by any applicant fit aPmuit mbjoets the applicant m a civil Penalty of POWER DEVICES NT Ell-OODSERVICE,
nnnnre than Eve It dmsdullarx(A51N)). 1 P EMENT
SOLas owner of the PropcnY or mY employees with wages as their sole nvnpensatinn, SWIMMING POOL ELECTRIC
will do the work,and the struchum is not intended or offered for sale(Sec.V(H4,Business ❑O(TIER
O:F' OUTLETS-SWITCHES-FI%TORES
3 and property
,W b pose:me cnntmemrx License Law does
not apply ort alt manor
his Own who bails,or improves t such improvements ane who fires such ante deed or m Through NIiW RESIUEMr1AL IiLLCTR SQ IT.
his own employees,pmvidcd ohm such ensisoldw me not intended m OBeme far $Q,f4.FLOORAREA 5/SV.IrI'.
sale.Ifwilder ithebuildingor improvement provinl Is soldwithinone yearnr improve
me
her-lwildcr will have th<harden of paving That he did nen Wild or impmvc for pur-
lxtscnrwlc.). TOTAL:
❑has owner of the pee.70, .Business
exclusively amuonins with Ecto,:)The C contractors i-
conswnmepmjee(Sec.l(W.Bmincesand
lly lee,hai Code:)The Contractors cid
wotaeDlw sax nmapply maeithite fpropetywecowld orlmpmvvs Wucmeand QTY. PLUMBING PERMIT PCE
o camnas roe such Pntiects wins a comracmrls)IicenscJ pursuum m the Cmnvunor's
License Law. ,B k P C lin this reason PBRMIT ISSUANCE
❑ lam cxentpnmdcr Scc.
ALTER-DRAIN A VENT-WATER(lia) VALUATION
Is cr Date
WORKER'S C(1ysi SNFION DF.CLA RATION HACK PLOW PROTIiCI'.DEVICE
I hereby umrm under peachy of Perjury one of the following declare irce
I have and wi 11 mainuti n a Ccnificam of Consent mmlbinsure for Workers Compen- DRAINS-FLOOR.ROOF,AREA.CONED. NTORIES TYPE CONSTR UCTR
,shoat as pmvidcd for by Section 370)Of me lahnr Coda for the p,I mance 0 the
Is for which this permit is issocal. FIXTURES-PER TRAP
and will rainlain Worker's Contlwn.xatiun Insurance,as required by Section
wtT/Epof the lame QvJe.for the performanre of the work for which this Permit i.is.med.. GAS-Eh SYSTEM-I INC,40UTLIi 1:S OCC.GROAT' �APN� j
v Wnrk� sCOm tion nen camI r akIPOlicY nJ�be GAS-IiA.SYSTEM-OVER4(IiAI (b L I
chrder: 3`iGA r nVIs tyNl'��O (¢
CERTIITCATEOI E%IiM ION FROM WORKERS' GREASEANIIUSTRI.WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
("is coon needna the annpletcd It the pernnt is licOna hmWrWdnlla,(511X)) GREASE TRAP PLANCHECK P[li
or less.l
1oyanythat
,anin anya,..11nl 1tobehe klin subjectch hispermitoser,C.Ima11 SEWIiR-SANITARY-STORM EA.200 Ff. ENERGY PEii
nmI employ any ppnon in any manner so ux In become xv�'aY lee the Waders'Cnntpen-
Z xmion lawsof Culifomia.Date WATER HEATER W/VENTIELECTIR
Z O Applicant 1
ZN NOTICE TO APPLICANT:If, ni
after making this Ceticam of Hlvarl tions M/I
You should WATER SYS SOI.:
P:
? become subject m the W'oderu Compensation provision,of the hoer Code,you moa
I2]
hard,ith comply wish inch Posi ins,or this pemtit shall W deanmd revoked. WATER SERVICE RFt��
CONSTRUCTION[.ENDING AGENCY NEW RESIDENTIAL]'LMR, SQ.ET.
IYOci
r JZ D
I Hanby wfirm mm mem is a amxm,mimt Icmeitts as.,tpy for me perh,nmtace of
s [UJr 0 the work fm which this pemtit is I...ed(See.3097.Ci,C) I L:
O Lenders Name TOTAL:
r � L.endor,Address BUILDING ITIc
1 certify that have rcaJ this application ahs state that the.hove momentum is
F. rap t man.l agree btntmply with all eity:md enurtymdinunces ane state laws relating Or QTY. ME CHANICAL PERMIT PT: SEISMIC I9Hi
UZ huRdiagconxtrncron.and hereby nomnria rcpmeentm'nmonbis city mcntcripon the
above-mentioned poepctY for inspection Purfew% PERMIT ISSUANCE ELECTRIC FEE
(We)agree In save,lndenmify and keep hmmlcxs the Cllr of Capetian against
Iiabilitics.judgtnctns.custs andexpensexwhich mayinany way accrue against said City ALTER OR At)[)IG MECH PLUMBING FEE
in nmqucnce orthe granting of permB.
APPLICA IT U N DERSI AN US AN O W I LL COM PLY W II i A 1.1,NOMPO[NT' A IR I]ANGLING ON IT(TO 10,fNNICFM) MSCIIAN ICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNH'(OVIiR)B,IX)LEND CONSTRUCTION L\%
Signomm of AltplicanUCuntrcmr Date EX14AUST HOOD(WMUCI) HOUSING MITIGATION FEE
I IAZARDOUS MAI ER1ALS DISCLOSURE
Will the applicant or future building(ceupunt store to handle harardous material HEAPING UNIT(10 IINI.(N)d BTU)
us defined by the Cupenino Municipal C c.Chapter 9.12,and the Health and Safety HEAPING UNIT(OVER 100,000 BTU)
Coda,Section 25532(x)'!
❑Yes o VENTILATION PAN(SINGLE RE51 D) PAID
Date Receipt a
Wtll trip applicant or mare btdmmg occupant use Waipamot nr dwicea which BOB.ER-Coll(311P OR 1.).10X)Iransa
mit bamNous air comatniwnts as defined by me Bay Area Air Quality Management 'I(YIA..
11Gxicaror
onal? t_ / BOILFR-COME(OVER 1(10.001[11 U)
pYes VY
AIR CONDITIONER ISSUANCE DATE
1
have rate me ltwardoe tie-materials rcyaimmetnx o2da chapter rami of me Cali e /
ealth K Sa&tyCode.e amo s25505,25533 ahs 25534. Ondenand trot ifthe NEW RESIDIiNT1Al.MECiI. SV.1'1'.0mngdmino¢utrently have amnanLmm it is my,cof 0C,rafiRt anilythe a'cupam te l'cyu mnwhionamt M!ntd pnonFl ixnuanuofoCcnificamts11Oce p�,uy�Xy0L � 11 1 � r / TOTAL:authnriuJ agent
Due ISSUED 13Y:
OFFICE