99120033APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING. EL.ECTI
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECIA
BUILDING PROJECT MEN
BUILDING ADDRESS: (
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OFFICE
ARC411TF.CT/ENGINIiiiR: LICK DRESS:19-
CONfAC. rBDNE;
BUILDING PERMIT INFO
BLDG ELECT PLUMB MBCA
❑ Consultant Ekes Paid by Applicant (Initial)
❑ ❑ ❑
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LICENSED CONTRACTOR'S DECLARATION Q'FY. ELECTRIC PERMIT' FEE
I hereby of irm thin I am licensed miner protusion. of Chapter 9 (inntmenc 9
with Secdon]tXX)l ob Div6innJof the Business and('rain„innsCMe, ane my liansc is
PERM111'I' ISSUANCE
in buil farce aadc 1 )fi
Lae is Cls - p APPLIANCES - RESIDENTIAL.
nam C....
JOU DESCRIPTION
RESIDENTIAL.:
❑SFDWL ❑KITCHE REMODEL
[]ADDITION 4EY.G�ING RI:PIPE
❑MULTI -UNIT ❑STRUCTURAL
MOHII9CATION
❑INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT C] SWIMMING POOLS
El BATH REMODIihlltl?I'NR ❑DEMGLff1ON
❑ OTHER
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A CHITEC'S DECLAR PION PANELS
I understand my plans shall heated as public reads
UPT0200AMPS
,E]W Liccnsed Prefc,xitnal 201-1000AMPS
OWNER-HUILDER DECIARA'1'ION OVER 1000AMPS
Q I hereby affnn that I am exempt from the Cnnvnmar's License haw for the
=U following reason. (Senior ](IJLS, Businos and 1'nul'evainn, Cale: Any city nr mm�lY SIGNS ELECIRICAL
O y which requires a permit to concoct, alter, improve, demolish, or repair any uwemre
P,air t.it,isuvance,al,o occurs, the.pplicial haunch p[,art to file. signed slme:nem SPECIAL CIRCUIT'/MISC.
} that W is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
;0C (commencing with Section ](XX))of Divis+on 3ofthe Husinessand Prueisions Code)or TEMP. METIiR OR POLE INST.
yy that he is exempt therefrom and the basis for the alleged exemption. Anyrof .�a1�
inLL Section 7031.5 by any applicant for apceme subjects the applicant to a cin I�XvsBKI) I
more than fvc htmdreA dollars ($5110). . -.. ' L
La. owner of lM1e n I lh con thea- ee con.�p prole y. or my corp area col gcx ax
N will do the work.andthe.wcom ix not intended or offered lir sale(Sec.),sc
13 and Professions Crde:'ILe Contractors License law docs not apply n+an aw of OUTIJUS-SWITCHES-Il%TIIRGS
property %he builds or improves thereon, and who docs such work himself or IM1 IS
his own employees• provided that such impressment, are not intended or n@EW 1
side. IL however. the building or improvement is sold within one year or cominetio
m Nor
COMMERCIAL
❑ NEW BLDG/ADDITION ❑ DEMO[d RON
❑TENANT ❑FOOD SIiRVICIiun
IMPROVEMENT
❑OTHER
SQ. FT. FLOOR AREA
ASQ.14.
owner Wilder will have the burden of proving that he did not build or improve for pur-
frt,f )
Fl I. as ounor of th lro,try. mr, excl-ect, conoraor, 1h I' e d -
,t nh p yet (S ]W411 dP t a Code) C
sense I J t apply 1 f p p ny h 'Id. . p E I FEE
whoeonlmcisfLrsmhpryeasw'Ihavontranotts)bcsatdpa- a th mwc or.
License law. PERMIT ISSUANCE
1 an exempt under Sec. . H & P C for this recon
VALUATION
•r'J // ��WORKER'S
(F
Dwner Dafe
COMPENSATION DECLARATION PROTECT DEVIC :I
5ALTER-DRAIN&VENT-WATIN&VENT-WAT
herebyaffirmuvder penally to perjuryencofthefnllowlnr Worker' Cour, as and will lot by oCi.... 3 am of the La or soflox... far crl m ncelth- 00R. R F:A D.
us Pmvidad for by Scotian J]IX) of the Lnbnr Code, for 1M1c peHomwnceof thek lin which this pcnnit is flood. PER "TRAPIhaveand will ode. for Workehefa,d s Come of the n rkfor ce,whi h recanhisper by Scclion
- lobthe Lahr Codc, for lM1e performaan?ce�of the word for whichystXhis permit is ruined. STEM -I INC.JOCI'hITS
S'rORIEs TYI'I? CONti CRUCI'10mion,
OCC.GMyW1
` JnPcq gI ryloom aaWPolity Noyn 'JJ�IS'fEM-OVER 4I EA)
Cartier. -- Yi F{
CERTIFICATIi O_ FE%EMI�fION FROM WORKERS' GREASUINDUSTRL WASTE INTERCEPTOR COMPENSATION INSURANCE
.S
BUILDING DIVISION FRITS
Qhis,ectien nevil not ccom,Icted ifth.,rount is fornnehundreddn11ms 1S11XB GRF,ASETRAI'
I ccnilythul inthc pcdonaancc ufthcwnrk fin Which this pmmit ix i11nad,lah°11 NEW]:R-SANITARY-STORM HA. 200 FE
nm employ any person in any manner to ac to became seetm (,,be Wnrlots' Conifer.
1'LANCIIIiCK Iq[li
IiNF.RGY Ila:
GRADING FEE
Z union law, of Califtment Dam WATER HEATER WNENT/ELI:mR
OO Applicant
Z N NOTICETO APPLICANT. IL after making this Cenificmc of Exemption. ynr should WATER SYSTIiMTREATING
a ; bemnne subject to the Worker's Compensation pmvixions of the Labor Qdc. You most
forthwith comply with such previsions or this pvoodshallM deemed revoked. WATER S17RVICE
y OPAID
O z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ. IT
I hereby all o..lhn there is a construction lending agency for the perfimmance or
he work hu which this pmaud is i...cd N,,1. AN7, Civ. C) \\�'�Int
Name 'IDEAIit\I
IsnJcr,Addmxs
SOILS FEE
Dom Receipt p
TOTAL:ULcuder's
�LLO
tot
y
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I certify that 1 have read this application.ad slam that the above information is iI !
conal l agree to comply withal( eity and county ordi...ces and sure laws relating to QTY. MECHANICAL PERMIT
building construction. and hereby aohodae representatives of this city to enter upon rheuMrve-metinned
RITE
properly for inspection poupoW . FERMI T ISSUANCE (We) agree m nave, inJenmify and keep harmless the City of Cupertino againstIiahiline,,judmenitn+su and expenses whch may in any way accrue against said City ALTER OR ADD TO MECH.
vn.u4ucnccofNa g,; ingot' this pcnnit. ALIN '1' UNI S'I' NDS AND WILh CU 'LY 1'I'H AL1, NON-PUBN'1' qpt DANDLING UNIT('m 111,1%X1CM) YPE;
REGI31 /
AIR HANDLING UNIT (OVER 10,001 CIM)
CONSTRUCTION 9A%
o A t Contmcom Date E TIAUST HOOD ONMUC)
HKLARDOUS MATERIALS DISCLOSURE
Willthc... (warn nr forme holding -title' store or handle haurdnus material HEATING UNIT (10100.0X) RTU)
its defued by the Cupenlno Municipal Cade. Chapter 9.12, tied the Health soil Solely IIBATING UNIT(OVER 100,000 If I'U)
Cala Section 25512001
HOUSING MITIGATION FEE
❑Yes ❑No VEN'I'I I.ATION PAN (SING LE RES I U)
PAID
Dam Rcecipt p
bUraner'
Will the applicant or future building recursion use equipment nr device. which BOILER -COMP (3HP OR 100.000 BTU)
mit hauNaus air contaminants as defined by the Bay Arca Air Quality Managenmm
TOI'Ah:
a Q,
BOILER - COMP (OVER 101.000 if Fur
❑Yes Fl No
ISSUANCE DATE Q
/ Z — 3
AIR CONDIIONER
I have reed the h ode S s materials 5, 25533 an under Chaplin rda of the Cali.
farm Hcallh & Cldc, cations 255(19, and ]5534.1 ut d that Hire NIiW RIiSI)IiM'IAL M[CII. SQ. FT.
is try Polly
M11flibe gInasnotn�mmdy hocamoan(, that it i,myve o1 ablBfymnotifythea-rtlum
l comm
nl'@c rcyuiramm�tx wldch must he met prinnu lsuuanm nl'n Ccnilic.te ol'(kenpuncy.
OFFICE