99090001 ICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 6!1 wo
QF CUPS TING BUILDING-ELECTRICAL, P ITN
IN
DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDEN'TIF'IC'AT'ION
DSESS.. SANITARY NO. APPLICATION SUHMI ITAh DATE
�o� &C VIEW � - 9
;S NAM I. PHfINE: RACT(lS5 NAME: LIC NTT
` RA 5E L/L/' NIC CUNT'ROLM
''i t H1IFC'1'l1?NGINEE :—_ Q LIC NO: ADI -S - I ✓t'i�l.� ❑
I N.
CONTACT: PHONE: BUILDING PERMIT INFO
IT ❑ Consultant Fees Paid by Applicant(initial) BLDG ELECT PLUMB MECH
A11n ❑ ❑ ❑
LICENSED CONT'
CHIP
DECLARATION QTY ELECTRICPERMIT FEE
1 bureby alhnn war I am heettaee under nrovLaan,Oren Prot 9(contraction, JOB DESCRIPTION
o�ZwilhSa,lianTaadinD .,am3onheBodup.,eaadProexxium
O C e.,ndt ylicenseic RESIDENTIAL:
O
Fs'— in full force and effe< z PERMIT ISSUANCE ❑SPDWL ❑KITCHEN REMODEL
eo
<-U Licence Claes Itis# _ APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
y Dam TSDECIr
ARCf11'I'F.CT'S DECLARATION ❑MULTI-UNIT ❑STSUC'TURAL
Z HO ran Z I undemvnd my pl...shall he used as public moral, PANELS MODIFICATION
OZ�a UP TO 2011 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F4Cei� Licensed Professional 201-1000AMPS IMPROVEMENT El SWI M MI N G POOLS
OWNER-BUILDER DECLARATION
C k W J OVER IOW AMPS L1 BATH RHMODEI/REPAIR El DEMOLITION
C Q hereby.(Sinn that 1 1 mumps front the mannas Co License city
o for the
CJS O y U following rmroa(Seaton 903L&Business,. ,uandrProfevetmcc h.., Any city or amn,Y SIGNS ELECTRICAL ETHER
Tal 41r+y whir to
is issuance,
.perms,re cnmwer,alto,improve.Jeermit t err repair any awmal men,
�.-OQ that hourscensed........ymiss, applicantforsuchpermit,o The ese Us.(Chaptenn SPECIAL CIRCUIT/MISC.
,Lar he is licensed pursuvnl70 06)provisions of the a Bmvin or's and
Proe ssio(Chapter9
Wp:QOM (commencing with Section]qNl)nTDlvtonn3 of the Foxiness vnd Professions Codc)or TEMP METER OR POLE INS'L ER
d y o eC Thal he is exempt therefrom and the basis I the alleged exemption.Any violation of BLDG/ADDITION [I DEMOLITION
W m Suction 71131.5 by any applicant lot a permit wbjecP the zpphevnl In u civil Penn],,of POWER DEVICES 1EITENANT ❑FOOD SERVICE
not mom than five hundred dolly..($5 W).
IMPROVEMENT
1,its owner of the property.or employees with wages as their Bole compensation, SWIMMING POOL ELECTRIC
HO wJl du lhewerk,and thae,mc,ure is solimendeJ ontRered❑orale(Sec]W4,Hueinece []OTHER
m and PrturAunc Cale:The Cor,,,hr's Lleense Law docs in.,red,m an nwner ,I OUTLETS-SWITCHES-PIXTURGS
property who builds or improves thereon,and who Jots such work himself or through
his own employees,provided that such improvements am not:mended or offered for NEW RESIDENTIAL ELECTS SQ PT
,site If.however,the buildingarnmprovenmm is rold within one yearofwmpal n,IM1e t �� SQ.Fr.FLOOR AREA $/SQ,Pn
puser-builder will have the burden rproving that build not build orimprove furper-
.eoCsalc.).
E] I,vs owner of the prtpony,mu eselusively contracting with hi,sw l ennnactors 1. TOTAL'
rostrum the project(Sea 7044,Business and Professions Code:)'Me Convect-Li-
eUmvdoes mnapply no an ewnerof property who build,onmprove,thereto.and QTY. PLUMBING PERMIT FEE
who contracts forevch pro,el,wl0t a contractors)licensed punuan,It, he Contractor's
License Law. PERMIT ISSUANCE
1 am exempt under Sec. .H&P C for his reason
Owner Dam ALTER-DRAIN&VEST-WATER(EA) VALUATION
WORKER'S COMPENSATION DIELARAI ION BACK PLOW PROTECT.DEVICE O
1 herneby sh t under penalty of pegury one of the following declarations: ///
I have and will armnmin a Cernificmeof Cousenn,,riff-,nmrc for Worker's Conrpen- DRAINS-FLOOR,ROOF,AREA,GOND, STORIES "YPE CONSTRUCT ION
anion,as pnrvideJ for by Section JAIO of the Labor Cole,for the performance u[the
nwhichw:peel d. PIXTUSES-PF.R TRAP
11 d ill cunt Worker C req t Insurance. required by Section
99101 ff,LM Code,l th.performance of work for which thispr. nis issued GAS-EA.SYSTEM-1 INC.4OUTLETS OCCGROUP APN
MyW k CypR ya� IySyr{t Policy b Fyp�,2I[�[/f/�:
Currier' �'y'lI/f / �` 'y No.: `� Y GAS-EA.SYSTP.)1-OVER 4(EA) .. .�
CERTWICAtH OF P,XEMITION PROM WORKERS' """" - -
COMPIiNSA'I'IONINSURANCE GREASFJINDI�STRL WASTEII IE EPTO BUILDING DIVISION FEES
CT hlseccrionnculnon be er ldcd i f the permit, mm hundred dol tan 151 W) GREASE-I'RA�11�� 1 i ���
or IcseJ PhANCHECK PGE
I certify that in the purn....tncvof IM1e work for whichthis permit is issued,,shalln
-
S F:WEIt-SAN.TARY -1 1.Fid2 .FTQ I ISI
not employ any pmt in any mrs
anneo:w to famous,famous,subptm
ject to the Wnrkcre' pen- - � ENERGY PEE
en
zz ,union Luws of California.Date WATER HEAT RW/VENT/ELECTR s
C Applicant J GRADING FEC
p) NOTICE TO APPLICANT:H;after making this Certificate of Exemption,you should WATER SYST 1/f RENTING }
f"r ha'orm ati tai m we Workers Cmnpposition provisions if she Labor Code.you must SOILS PEE
forthwith annply with such provisions or this peril shall be deemed revoked. WATER SERVE EB+/ .21 1
Q
7z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB.� SR FT, PAID am Be,Tpi#
V Q I herebyeltirnnhatthem is u construction lending agency for the performance of
PTH the work for which this Prr,aii,,issued(Sec.}1141,Civ.CJ I TOTAl�n1� , 4�
Ixnders Name `
LUL1 Lender's Address TOTAL: BUILDIN)IEEE JtT
C 1 certify than I have read this apPbcullon and state that the above information is
.Hut N cored,I agreed comply with all shy and or ry ordinance,and rude laws refit QTY. MECHANICAL PERMIT FEE
V z buildingm-armlion.and hereby nuthnrre,ruprasemmivesofwh ray ,,can,opon the SEISMIC
do,e ner, oil property for inspect, npurp we PERMIT ISSUANCE
(We)agree to sm,:admnni and keep harmless IM1e City of Cupertino vgaimt P,hECfRIC FP�S� �,���
linbdine,'u t cosrsande ,which mu ymrrywayaccrueagaim,,md C,,, At,]ER OR ADD 10 MECII. F�
ase PLUMBING PEE
c prex surnpyy tis Perrot,.
n LICAN'I'e VDERST �ANDW . 2-q
ALL ON OINT AIR HANDLING UNIT(TO O,WOCPM)
'OURCER d ilf lfS. MECHANICAL PEE
J 4 AIR HANDLING UNIT(OVER 11,000 CFM) CONSTRUCTION TAX
66nv cnf ppfcam/Cntmemr Data / EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will nhevpplicann or future hoildingonvpunlsmrenr handle bnranfousnmmrlal HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapmr 9.12,and the Health and Safety
Code,Seeninn 25532(a)^ HEATING UNIT(OVER I00,000 BTU)
Yes No
VENTILATION PAN(SINGLE RESID) PAID Dam Receipt M
Will the applicant or future building occupant use equipment or devices which
it bacromes air contaminants as defined by The Buy Arca Air Quality Munvgentmn BOILER-COMP(}HP OR IIHI,IIW B'TU) T( L:
District" BOILER-COMP(OVER 100,000 BTU)
❑Yes ❑No
AIS CON UI'DONF.H
IIh h 'N 'I. y I: J Ck pl figs Iwo Cali- I$$ NCE/DpJT
fn - hh& story Code S I 5505 255 3 J 25534.1 d r I the f we NEW RESIDENTIAL MISCH. SQ.FE
Id' g d y t 1 n n h t t Y ty I o d e Pa l
of lh rf n.- h t umaprnno +ra en a
urized age n /"aurc TOTAL: ISSUED BY:
OFFICE