30251 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI'T'Y OF CUPH RTINO BUILDING-ELECTRICAL. PERMITNO. �O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL.
BUILDING PROJFcf IDENTIFICATION
BUILDING ADDRESS: \ ) SANITARY NO. APPLICATION SUBMI'fl'AL DALE
99' o 16-ve ln v ( 7—? 2 �6
OWNS 'SNAME: � PEI NE 9 CONTRACTOR'S NAME: LIC NO:
JJ NIC CONTROL#
RCHITECf/ENGINELR: LICNO:, ADDRESS: ❑
CONTACT. /PH'O'N_E:o BUILDING PERMIT INFO
L11 F-1 Consultant Fees Paid by Applicant(Initial) LDC IiLE PLUM MEc
••�LICENSED CONTRACTORS DECLAR TION QTY ELECTRIC PERMIT FEC
1 hereby aHiw thin 1 stn licensed under provinces,of Chapter 9(commencing IDB DESCRIPTION
DeeZ with Section 7")of Division 3 of the Blninessend Professions Csde,and my license is
�00 i PERMIT ISSUANCE 7I�ENTIAI.:
y, i NII force. effect
aFUZU License Cuss Lic.#. FOWL PLUMBING
RE PI E
NQw Date -Contractor APPLIANCES-RESIDEN'I']AI. A TION ❑PLUMBING NfiPIPG
a' ARCHITECTS DECLARATION - h1ULTI-UNIT ❑STRUCTURAL,
PANE 5
Z n Z, 1 understand my pions shall be used as public records MODIFICATION
OZ—Q UPTO MO AMPS C1 INTERIOR ❑CHIMNEY REPAIR
rim la] Licensed Professienul 201-1000AMPS IMPROVEMP
•.]4 OWNER-BUILDER DECLARA'110N NF
i 9 6 I hereby affirm that I am exempt from the ContractorOVER IIIIgIAMPS's License I,aw for the ❑RATH REMODRUREPAIR DEMOLITION
3 a U following reason.(Section 7031.5.Business and Profasima Code:Any city or county SIGNS HLEC RICAL ❑OTHER
LL LLO whicM1 mquima a pemtit nr conswct inter,impneve,denudixh,or reprir any stmrtare
prier to its issuance,also requires the applicant lot such permit to file a signet amemem SPECIAL CIRCUITIMISC.
i+ that he i..licensed pursuant to the provisions of the Contractor's License Lnw(Chupter9 •
S O (emnmencing with Sectinn]t00)of Divlsien7of the Business and Professions Code)er TEMP . 'f. COMMERCIAL:
CMHIHRORPOIHINS
4 q C Nat he is exempt therefrom end the basis fur the alleged exemption.Any violmom of ❑NEW BLENANT�fllADDITIOD� V OLITION
LLX] T Section 7031.5 by any applicant(or a permit subjects the applicant m a civil penalty of POWER DHVICES �.1. D Ai f�[�7
y not more than five hundred dollars(5510). IJ[y0 D SF.RVICC
Q pl,ns owner of the property,nr my employees wire wagcxm theirsolccampensmien, SWIMMING POOL ELECTRIC IMPROVEMENT'
aS�
will the work,and the mmcture is notlmended m offered fnrsale(Sm.70,14,13uslness ❑OTHF.RIt
and Professions Code:The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or impmvcs thereon,and who does such work himself or through
his own employees.provided that such improvements are not intended or offered far NEW RESIDENTIAL ELECrR SQ FT.
aide.lf,howevee the building or impmvement issold withinsne yearofcompleumb,me SQ.FT.FLOOR AREA LSQ.FT.
owner-builder will have the harden of proving thin he did nm build or improve for par-
nl's the 3
r of the property,nm exclusively comrading with licensed cnnwotors to
answn the project(Sec.]pL1.Business and Professions Cale)The Commgnfs Li- O3
n.Umv does not apply to an owner ofpmpcny who builds or impmvcs thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a commmm(s)licensed pursuant to the Contractors
License Lnw, PERMIT ISSUANCE
❑ mnxes
I exempt title,sec. ,UhVh this •asoraCa +-
�Owne Date ALTER-DRAIN&VIEN'r-WATER(EA) VALUATION
WORKIiR'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICEQ
I hereby affirm under penalty of perjuty one M the following declarations: �V
❑ I have and will maintain a Certificate of Consentto self-insure for Worker's Compere- DRAINS-FLOOR,ROOF,ARRA,COND. STORIES' TYI'F.CONS'I'RUC'110N
cation,as provided for by Section 37W of the Lahr Code,I,the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have end will maintain Workers Compensation Insuraaec,as required by Section
JAOofthe Labor Cone.fee the perfmaanceof the work for which this pewit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP' APN
My Workers Compensation Insurance carrier and Policy number are:
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE? GREASEIINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(This section need not he completed if the pewit is for one hundred dollars(SIM)
GREASF.'IRAP
or leas.) PLANCHECK FEE �.
Lcertify that inthe Performance of thcwmkkr which this permit , d,Eahall
not employ my Person in anymunnerso nxmbecome xnM1jecun the orkno'Compen- SEWER-SANITARY-STORM EA.2W FT.
ENI3NGY FEE /r
0 ,Z sauna l.uw.of California,Date WATER HHATER WNENT/L'LECTR -
z Applicata GRADING FEE
y NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYS'HEMOTEA'HNG
a ; become mhjmt m the Workers Cionumo ion pmvisinns of the Labor Code,you must SOILS FEE ,
W forthwith comply withsuch provisions or pewit shall ha deemed revoked. WprER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESHMNTIAL PLMB. SQ.FT. PAID
U 0 (hemby affirm that Nem is a consaucdon),diing agency forme performance of Dine eceip #
[tr (, me work for which this pewit is issued(Sec.309],Civ.C.) Aissis
O U Lender.Name ilt J OTAL:
Lenders Address
WW '
1 certify that I have read this application and state that the above information is BU DING
y correct I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FFE
U z building construction,and hereby authorize representatives ofthis city to macrupsm the S istalc4l 2
mass mentioned progeny for inspection purposes. PERMIT ISSUANCE
(We)ugrce m save,indemnify and keep hawleas the City of Cupertino against 1.1!
liahilltic..judgmats coxtx and e.penxswhiehomy in anywnyuccmc ogainstanid City ALTER Olt ADD TO MECI I.
io nvegtimen of the geantingof this permit LUM FF,E-
APPLICANTUNDERSTANDSANDWILLCOMPLYWITHALLNON-POINT AIR HANDLING UNIT(TO 10.110)CR1)
!. MIiCHANICALFEE t w
SOURCE REGULATIONS.
AER HANDLING UNIT(OVER FILM CFM) CONSTRUCTION'I'A
SignalureafApplicanUCommetor Date EXHAUSTHOOD(W/DUCT) {OIJSINO MITIG 'ION PEE
HAZARDOUS MATERIALS DISCLOSURE.
Will the.,icant or lbmi,building occupant store arhandle haevNom mvtedid HEATING UNIT(TO IMJXX)BTU)
rti
as defined by Ne CLpenn Municipal Code,Chapter 9,12,and the Health and Safety
Cade,Section 25532m)? 1 HEATING UNIT(OVER 100,000 BTU) _
-CYcs ❑No PAID
VEN'rILAI'[ON PAN(SINGLE BUSED) Dam Receipt#
Will the ter contaloramuse building occupantuse equipmentordManawhich BOILER-COMP hvmrdous yr contaminants a defined by the Bay Area Air Quality Management COMP(3HP OR 100.000 BTU)
LbmIdmIdue
TOTAL:Yev- - (]No BOIL[R-GGMP(DVER 1)(LIXIO BTU)
ave reed the hazardous materials is under Chater 6.95 ofthe Cali- AIRCONDITIONER
myuimmm� p ISSUANCE DATE
lm&Safery Calc,Sections 25505,355J3 and 25574.1 undemend mut if me NEW RP_SIDFMIAL MECU SQ.PT.snot currently havea tenant,that it is my responsibility to notify the necapantirements which must be met prior to issuance ofa Certificate ofacupancy.
authorized agent Ilene - IS UED BY:
OFFICE