99110084 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY UU )S
CITY OF CUPERTIINO BUILDING-ELECTRICAL VERMIT NO.
BUILDING DIVISION APPLICATIONMERMITPLUMPING-MECIIANICAL
IBLICBING PROJECT IDEN'I'IFICAI'ION
BUILDING ADDRESS: SANITARY NO. APPLI AU N SUBMITTAL DAT
JOG1244: jr E*q Cope C Oce
O NERI PHONE:- C NTH CfUR'SN E: I N
NIC CONTROAlm U,_kjr, pLp �/
nuc111'nicr/> cl `)III,)`fi:s. m 111 ❑
ONTACC 111ION17: f F y BUILDING PIiRNUT INF(
I
y /9_ `D � .�Q/a'p ❑ Consullan[Fern Paid by Applicant(Initial) BL ELESI' PEUMB MECH
LICENSED CONTRACrOR''S DECLARATION QTY ELECTRIC PERMIT FEE ,�
1 nertny afhrm thin 1 am licensed mtder provision.of Chapter 9 monomania, JOB DESCRIPTION
D a'Z with Scwiom7000)mf Doisioa3of IW Bminessand pmfcsyons A and myliccvcis RESIDENTIAL
:
WDD in PIiRMI'1'ISSUANCE
�IyF lull fares and effect. 1 ❑SFDWI. ❑KITCHEN REMODEL
a,UU Lacnac look APPIAANCIiS-RESIDEN I'1A1. El ADDITION ❑PLUMBING RE-PIPE
H Z W )aro r Conhacea7A Aua,
rn 6 d ARCIIITECEl DECL T O. MUl:rl-UNIT ❑STRUCTURAI.
IANIiI.S MODIFICATION
m Z 1 understand ter plans be asnl as pamm records
OZ�a UP I'O 200AMPS INTERIOR El CHIMNEY REPAIR
Licensed Professional 201.10MAMPS IMPROVEMENT C]SWIMMING POOLS
C d',, I hereby Rim ha Ilam
OWNER-BUILDER
from he Contractor's License Law for the OVER 10MAMP$ ❑BATH REMODfL/REPAIR DEMOLITION
a p
X 3 i U following mason.(Section 9031.5.Business and Professions Calc:Any city ,m county SIGNS ELECTRICAL ❑OTHER
W W y which requires a Permit to construct,alter,improve,demolish,or repair any structure
F 4m'�at prior to its issuance.also requires the applicant for such penniuo rile a signed statement SPECIAL.CIRCUIT/MISC.
�IyY that he is licensed pursuant he provisions of he Contmcmr's License Law(ChapterY
WCLOD (commcuum,with Section 7lXHpof Division Sof the Business trod lndcssinns Gde)m TEM P.METER OR POI.F INST. COMMERCIAL
a p,e C Nut hu is exempt therefrom unit Lou basis Iia he alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑OBMOLITION
iX-1c, Section 7031.5 by any applicant for a permit subjects beneficial to a civil lwnalty of MWI7R DEVICES
W w n marc thin rise hundred doll...(Stood) .[�REIPROV FOOD SERVICE
1.as owner of the pmpenYnr my cmploycez with wages as heir sole annpcnsadioo, SWIMMI I IMPROVEMENT
F will do the work.and the strucom is nod intended m ufi'ered for sale(See 76 Basin ❑OTHE
3 m and Professions Cute:The Condrasvda License Eaw dres nut apply to S
pmpeny won builds or impnrvo thereon,and who tines such xorA himal
his own employees,provided that such improvements art not intended m _1 NTIAL ELE
sale,B.however,thebuilding or improvement is sold withinone yearof cote WV= — S .FT.FLOOR ARBA SISQ.FT.
cnbuilder will have the burden of proving that he did not build or improve for pat
MMSMW
Fou or sale.),
1,nu owner of the property,tun cxclmively contracting with licensed contncm. '1 Ul'stootoL'.
m4md Ibc pr Jest(Sm.7044.❑usincsu and Professions GdeO The Courtrai
xe lAw docs not apply to an owner nl'pnrfeay who builds nr improves thercon.a TY. P M E
who contracts for such projects with a comracwrts)licensed puauant nr dM1e Comraaur's
License Law. E rr
I am exempt anter Sec. .H A i'C for h
So .TCN-DRAIN&VEM1T-WATER(FA) VALUATION
Owner Date /
W'ORKER'S COMPENSATION DECLARATION HACK FhOW PROT .DEVICE I/
I handy affirm anter Penalty ofperjuryone mlthe imeref Witter',
on,as and
rusidi l for by
ection 3 ere of ConsenuoCde,for the Worker's ceCormse.of'he
DRAINS-FLOOR,ROOF A :A,CONQ. STORIES TYPE CONSTRUCTIOD
on, d 'd If hth t 171X1 of the I M Cd 1 dM1 p I ddhe 111 - /
n 'I I' hh:f t L IlXI'URLS PER TRAP N
11' 1 '11nountun WsrkComecrounimI , ;,net, mu dbySctnm
),if tl ladva Code,future pef fdh kl wM1shhspemanissued GAS-LA SYS IUM I INC.4 W'f."' OCC.GROUP / ,AIN
�
My Worker's r �yy Ipxy ecamcr and Policy nm GAS-HA.SYSTEM-OVER 4(EA K �'(� V(0�
Catricr. HH NN PIONFRO:^� I/
CERTIFICATE.OF F:XIiMPT10N FROM WORKS GRF,ASFIINDUSTRL WASTEINTERCIi
COMPENSATION INSURANCE BUB,DING DIVISION IRIS
(Thiswcoion b=ed not be completed if the permit is forma,hundred dollars(SIM) GREASETRAP
or lens.) YLANCHECK FEE
I certify that in he performance of the workfor which his Permit is issued,l shall SEWER-SANITARY-STORM EA.2W FT
not employ any person in tiny mmmer.n as rad become subject to the Workers Compeer- ENI7RGY FEE
z xmen,Laws of Culdornin.Dare WAI ER IIIiA'TER WNENT/FI-EC R
zAf,,Icma GRADING PEE
y NO]WE 10 APPLICANT",ll,titer making this Ceniticae of Es rnptimt,you should WATER SYS'[EMO-REAPING SOILS FEF.��„-,�-
Ft become subject to the Worker's Compensation provisions of the Lahr Code,you mus,
bodbwith comply with such prnvixinns or his permit shall be deemed revoked. WATER SERVICE
7 z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLM9. SO.En PAID IDam� /ccs\ II I'I
U z I hereby affirm that is a construction lending agency for the performance ofIt
1l. F the work for which this Permit isis.uet(Sce.3097,CIv.C.) IIr, DEC A U11
C) U Lenders Nam,
W Icadul Address TOTAL:
I ecrify that I have read this application and state that the above information is BUIIAING 9E
sFs tq correct.l agree nr comply with all city and.runty nrdlnunees and sane law,reining m QTY. MECHANICAL,PERMIT FEE SEISMIC PEE
U z7, buildhgemsamciinn,unithewbyumhnricereprewmativesofthiscity munder upoode, --
uhovcnumani ed many fur a spealnn fam-lle'. PERMIT ISSUANCE IILECTRIC 1'EE"r---'"—_
(We)agree rat save,indenmify and keep harmless he City of Cupeninm against
liahillues.judgments,costs and expenses which may in any way accme againstsaid City nla'IiR OR ADD TO MECH. P1.UMHING FEE
in conequence of he grinding of his permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(10 W.0001 CFM) MECHANICAL FEE
SOO CEREGI�SOU CEREGId 1TIONS.
'l //_ AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Si naw of App cant/Comfuemr {�C Date EXHAUST I IOOD(W/DUCD HOUSING MITIGATION FEE
HA%ARDOUS MATERIALS DISCLOSURH
ill he applicant or future building occupant smrenrhmndlehtreardousmaterial HEALING UNIT(TO ISkOM BTU)
es dei sn=it n the Cupertino Munlclpal Calc,Chapme 9.12.caddie Health and Safe,,
25532(a)'I HIiATING UNIT(OVER 100,(X )B IU)
Ycs E]No VENTH.A'1'ION FAN(SINGLE Rf;SIO) PAID
Dat, Receipt It
Kill he applicant or future building occupant um,quipmem or device,which BOILER-COMP(3HP OR 100,00011PLU
it Wast us air mntamiwntx m AdinN by he Bay Arca Air Quellty Managcmem TO
ficr t E)No, BOILER-COMP(OVER 1 Oft"BTU)
ILose read the Mutat mmerials requirements under Chapter(195 of me Cali- AIR CONDITIONER ISSUANCE DATE,
fornix Health k Safety Cote,Sect a,25511.5,25533 and 25534.1 understand hat if be NEW RESIDENTIAL MECH. SQ.rE 9
hnilAing docs rams ntly hnv that It is danotoa,n Ibllity onmily the arvpam Z� (f' ! /
onbet 're. nu ' nms ;it,dnrmissaane„ftL'yly - rtaetnun y.
O art malimardagent /( Date "TOTAL: ISSUED BY.
OFFICE