99080154 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 'Q
CITY� CU DIVISIONQ BUILDING.HI,MECHANICAL f. PF,RMIT�
BUILD%:IsiG DIVISION APPLICATION/PERMIT PLUMBING pIF.C1IANICAI.
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. AI'1'LICA'110N SUBMI'1'1'AL UA'1'li
1
WNER'SNAME: PIIUNE: CONI RACTOR'S NAME: LIC NO.
MT'�L J P -2 we CONTROL#
WrCHITECf/ENGINCER: LIC NO: ADDRESS: N l� a ❑
/70Y YS -s
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fits Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
El X ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
l hereby affirm that L atm licensed under provisions of ChrEw,9 train JOB DESCRIPTION
WOO PERhtI f ISSUANCE WOO with Section 7000).'Division 3ofthe Business and Pmfessions Cale,and my license is RESIDENTIAL
"
F LL n full form nnJ d t /! ❑SFDWL [I KITCHEN REMODEL
U F' liars lJ Lic a
r.zW Dem Comms S APYLIANCLS-RESIDENTIAL []ADDITION [J PLUMBING RE-PIPE:
07th ARCHITECTS DIiCLARAI'10N PANELS ❑MULTI-UNIT [I STRUCTURAL
MODIFICATION
Z p y Z 1 understand my plans shall he used as public record.
OZ�Q UP TO 200 AMPS [I INTERIOR [I CHIMNEY REPAIR
t:LL Lmen.wd Pone,nomul 201.IIp0AMFS IMPROVEMENT SWIMMING POOLS
�YfJ OWNER"BUILDER DECLARATIONOVER TWO AMPS ❑µATH REMOD.� R ❑/43 D AOLITIC
W=Q I hereby affirm mm I am exempt from me Contractor's License Law fur me
11 O 6 U following ne.wn.[Section 7131.5.Business and Prof r..ion,Code:Any city or annoy SIGNS ELL'CI'RICA], R A -'
u13 LL y which requites n permit re<'n'wm,alar,i applicant for
su demolish.or repair ed
� brheishesuamce.uls're(,,,he theoof,hetechPetors file.nignednatement SPECIAL CIRCUITIMISC.
2E mat hcaraing ithid Secuamn'meof Division hof commie's and
Professions
Law(Chapta9 COMMERCIAL:
�y�0 (commencing wim Section 7000)of Uivision3of the Business and PrnfesionsCMgor TEM1lMETER OR POLE INST.
6 c.cy that he is exempt therefrom and the basis for the alleged exemption Any violation of NEW BLDG/ADDITION (]DEMOLITION
XmN Section 7031.5 by any applicant fora peirtual ubin'Isom application'.civil penalty of POWER DEVICES 'HiNANT ❑FOOD SERVICE,
more man five hundred dollars IS500L IMPROVEMENT
=Q Q as owner'(the property.or my employees with wages as their sole compemmtion, SWIMMING POOL ELECTRIC
F• will do the work.and the suucwm is not intended or offered for sale(See.JOM.Business 01 HER
13 be and Professions Caste:'Me Contractor's License law does not apply to an owner of OUTLETS-SWITCHES-PIXNRIS
pruperty who builds',improves thereon,and who does such work himself or through
his awn employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECI'R SQ ET.
sale.IL however,the building or improvement issold within one year ofcompletion,me Q'VT.k100„?_AREA SISQ.F1'.
OWn
col aimer will have the burden of proving that hu ted nut build or inmpmve for par-
pox ofsalG). ) t+
TOTAL:
Fl I,as owner of the property,am exclusively contracting with licensed contractors to ('
umslmm the p,ojcn(Sc,.9044,Business and Professions Coda:)The Contractor's Li. AUG
c xe Law does not apply it)an owner of propeny who builds or improves thereon.and QTY. PLUMBING PERMIT FEE H 9 O
whocanmacts forsuch projects with a coeracnsr(s)licensed pursuant to the Commcmr'' /s 1999
License Law, PERMIT ISSUANCE
1 am exempt under Sec. .B&P C for this rmson p
ALTER-DRAIN&VENT-NATER TEA) B VALUATION
viner Data
WORKER'S COl,of Aryon DECLARATION BACK ROW PROI'ECI'.DEVICE
(hand wulRrmain a penahy n,Perjuryoneofineansure or decWorker ioor `.J
Ihave padwiefor bynetion 37am of the Labor
Code.forefer WrmprouBnmrym DRAINS-I LOOK.ROOF,AREA,COND. STORIES FZ:7
smirk,as provided far na Section 371p of the Lahr Cade,for the perfomunc<of thework fnswhidM1 this permit Ix orke, FXTURE.$-I'ER TRAP
❑ I has unJ will mainwin WorAers Compensation Insrance,as rcyuired by Section37M of the labor Calafor the performance of the work fm which this permit is iswed. GAS-EA.SYSTEM-I INC.4 OUTLETStKC.GROUP
My Worke�r'sQ'J�� T n{nyI(uIupicr and Puliey
Cnmcc l L 1 Policy No:QI h� GAS-EA,SYSTEM.OVER 4(EA)
CERTIEICATF.OF EXEMPTION FROM WORKERS' GREASMNDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION 435
(Mi%acaion need not he completed ifthe Permit is forone hundred dollars($100)) GREASE'TRAP
or Ics,.) PLANCHECK FEIi
I. Icenify that in The performance afthc work lm which this permit is issued,l shall SEWL'R-SAKI TARY-S'FORM EA.2W FIt
not employ any person in any manner sA� u' sent the Worker'Cooper- ENERGY PEE
O Z 'inion laws t Caa noorr ia.Dote O�02"",
�• • o T ! WATER HEATER WNEN MLECfR GRADING IEE
Z Q Appli,,,,w �7 '-
N NOTICE 10 APPLICANT:If,after making this Cenificme'If Exemption.you.should WATER SYSTEMUREATING
hccnme .hjmm the Worker's Comry'.ns.tiun pmvisiansaf the Labor Code.you nom SOILS FEF.
forthwith comply wim s.IM1 lovskinme,this permit shall Is,deemed revoked. WATER SERVICE
0. Q
CONS LENDING AGENCY NEW RESIDENTIAL.PLMB. SQ.FT. PAID
S
UO 1heathy affirmthldram I,.ecr,mcion lending agency f...he perliamance of -Date Receipt
W F The work fur which this permit is issued(See.3197,Ci,CJ
0 TOTAL:
U Landers Name
TOTAL.
1<ndds Address
>. y 1 sanity that 1 have read this application and state that thi information is BUILDING PEE.
FN m ...T.l ugrec tocanolly with all city and comd,ndlnamc,and swat lasv,ml.ongm QTY. MECHANICAL PERMIT FEE
U building construction.and hereby amM1a,im mprexnmmivesof This city mercer upon the SEISMIC THE
ahawc-ovenioned property far,.,Pecti.n puHamses. PERMIT ISSUANCE
(We)ebme I w c Indenwily and keep fa n ies,Thu City of Cupertino agmina ELECTRIC FEE
Iiabilitit,"pdgmems' wtsmd expenses which may in any way Beers against said City ALTER OR ADD TO MECII. PLUMBING FEE
in, n'emcnc<of grant "mispsao}l
APPLICANT It )E ND. AND WII .COM LY WITH ALL NON-POINT' AIR HANDLING UNIT fR)IU,Igp CFM) MliCfiANICAL IEE
SOURC RF Z,
I _ AIR HANDLING UNIT(OVER tO,(NIfI CFM) CONSTRUCTION TAX
Si sere'(ApplicanVCnmrac Dom EXHAUST HOOD(to'/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant ter home building occupant store',handle hazardous material IIENI 1N UNH(10 100.00t I BTU)
as def ned by the Column Municipal Code.Chapter 9.12.and the Health and Safety
Cock,Suction 25532(a)'I 1 HEATING UNIT(OVER 100.000 BTU)
❑Yes li6b V ENTILN'ION TAN(SINGLE RLIIM PAID Date Receipts
Wdkcha applicuo nr fawn 141dingoceupunt u.va a,ipmum.,devi,N which pUILHk-COMP(3HP Ok It)n,lN)11 BTUI
mit hazardous air contaminants as defined by The Bay Arcm
Area Air Quality IshummmiT TOTAL:
)iuric'? BOILER-COMP(OVER 10LOOB BTU)
❑Ye' k"a
I have read the h: ,:Nous n rials rc m under Chapter 6.95 ofthe Cali- AIR CONDITIONER CED li
qui men p
1'rnia Ilcahb&Suld' :dc, ton 255115, .11 and 255 J.I understand mm it the NEW RESIDENTIAL MECII, SQ,17E
M1uildingJ¢snmc rely amu nT.dmm itis Yas 1aythe aecupanT
'(the req.' n hi m bu t use. milieu¢of(keupuncy.
Owner uthoneeJ ager Uam TOTAL: ISSUED Y.
OFFICE