99090184 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY U (�
CI TV OF CUPERTINO BUILDING-ELECTRICAL. PE MIT N(X.
(WILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENDFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT(
Ioy35 Sq,1 PCnccikJO Z�' `�9
'1TW`lER" M PHONE NA 1C: 3�L �J
NIC COMROLa
MW CHITECUENGINEER: LIC NO: W6`6- ,air ob n /' r j �C'//n ❑
CONTACT: PHONE: G ref' 1/JaM/}f;l C BUILDING PERMIT INFO
❑ Consultant Fecs Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
❑ ❑ ❑
LICENSED COMEACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby alum roes I am lim000d umder tiono rw al Chapter 9(commencing JOB DESCRIPTION
WOO with Sec11on9000)o(DArsiva 3ofnhc nosiness and Roresshn+s code.and my licenw is RESIDENTIAL:
ul0 `�'k PERMIT ISSUANCE
KUF- nlull force nnJ effect C-3 YJ / ❑SFDWL ❑KITCHEN REMODEL
QUU L-.-
Lu
ronse Class `� Lic.N APPLIANCES-RESIDENTIAL L1 ADDITION C1 PLUMBING RE-PIPE.
y G L Dale Comracmr
❑N ARCIIRECTSDECI,ART N - PANELS ❑MULTI-UNIT ❑STRUCTURAL
ZCrrnZ I atderstandmyplitm Anil beasedas public record. MODIFICATION
UPT0200AMP5
OZ-0 ❑INTERIOR ❑SWCHIMNEY
MINGPOOL
0:70 F'ul License)Professional 201-IIXM]AMPS IMPROVIiMENT EJ SWIMMING POOLS
CCow-1 dedIOWN12N-ItUI1.In f DECGRATLON OVER 100DAMPS ❑BATH BENfOOEL/REPAIR ❑DEh10LITION
Cad 1 hereby ufbnn the 1 am exempt from the Cun¢naots Liansa how for the k i U following reason.(Section 7031.5.Business and Professions Coda Any city or county SIGNS ELECT RICH �OTH R ,.p
W d te,h which requires a permit to conau et.alter,improve,demolish,or repair any swcturc wrl X le Ci C
E"LLonq' prix to its issuance,also requires Ncup,hmal tocsuctirade Ito file naigeed,uteorent SPF,CIALCIRCUIT/ SC
tem he is licensed pursuunuo the provisions of the Contractors License Law(Chapter 9
�aG�O (commencing witF Sectian]r1011 or Division3nfthe Business and Moressinns Code)or 'TEMP.METER OR POL IN T. COMMERCIAL'
Q.y e C that he is exempt there]
turn and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑D17MOLITION
�m Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER OEVICCS ❑TENANT ❑FOOD SERVICE
Spnl sen¢than five hundred dollars 0550 ). IMPROVEMENT
❑1,as owner of the propeny,or my emplivirms with wages as their sole compensation. SWIMM ING POOL ELECTR IC El OTHER
F will do the work,and the stracturc+s not intended or o0bred for sale Sm.1044.Business
6'3 and Prnleasiona Code:'IM1e Conlme otv Liscnse Law docs not apply to nn owner of OUTLETS-SWITCI I IS-FIXTURES
proper y who builds or improves themon,and who does such work himself or through
bio own employee,pre,ded that such Improvcmont,are not intended or ofrered for NEW RESIDENTIAL F.LW1g^ Q PT.
sale.ILM1swcvcr.the building or improvement is sold within one year of cumpletimn.the SQ.PT BOOR ARG $ISQ.PT.
owner-builder will have the burden of proving that he did not build or improve for for-
Lose of sale.).
❑1,ax nsvner of the propeny,am exclusively contracting with licensed mntracma la 1 I:
nnXlract IM1e pa(Sed.9044.Business and 11 fcssinmde:Th
Com:) Coun-urn's Li-
.¢Law does not apply to an owner of pmpcnY who builds or improves(her T BIN sE IT FEE
who contracts for such projects with a commctons)licensed pursuant m the Cont
Licence I.e., FE SSI CH.
I]I am exempt under Sec. .B&P C for this rt
A tR-,%.r&VENT-WATER LEA) VALUATION
finer Date
WORKI?R'SCOMPI]JSAT'IONDECLARATION FLOW PROTECT.DEVICE
(hereby ul in.em mons pcnifi nfperjuryoneoftheitione ng dcclrWorker',
m: U
,](have aowill maintainsCertificate of Conwm a+Code,furee Worker's Ccmrapan-
the DRAINS-FLOOR.ROOP.ARG,CONU. STORMS TYl'Ii CONSTRUCTION
moon,as provided for by Section 3]1X)of the Labor Coe,Ea the pertormonce of the
work for and
this permit is issued. I1%TORES-PER'1'RAP
1 M1ave and will maintain Worker's Corm of the
w Insurance, h required by Section
3 nl cine Labor Cnde,fm the perfornumcc of the work for which this perntit is issued. CAS-T;A.SVSTBM-I INC.40lI1'LETS OCC.GROUP !�f A _
My wa,kctsC rope wtin vmnc c d Policy nr'�j��a�:�
Currico��rpolicy
WF.IERS GAS-G.SYSTP.M-OVER4fG) 017
C: I ICCO PENSATION INN FROM WC RK13R5'
COMPENSATION INSURANCE GREASFIINDUSTRL WASTHIM'ERCCITOR BUILDING DIVISION FEES
(Un,-dion need nor he mn.plater!i I tin permit is for one hundred dollars lb 100 GRHASETRAP
nr less.) PLANCHIiCK FEE
- Loy any per int he anymndermorm of the wankfor subjectch to tic orkesCoLshall SEWI7R-SANITARY-STORM EA.2000 FT
col employ any person in any manner so as to become subject m Tic Workers Cangwn- ENERGY FEE
Z cation Laws of California.Date WATER HEALER WON ENT/F.LEE GRADING FEE
Applicant
pp
NO]ICH TO APPLICANT:If,after making this Cenincate of Exempuun,you should WATER SYSTEM/TREATING
P' ? become suhuct to the Worker's Connpstnion pravourds mf the Labor Code,you must SOILS FEE
limhwitb cotn,ly withsuch provisions or this permit scall he deemed revoked. W'AIFR SERVICE
�DZ CONS'I'BULL'ION LENDING AGENCY NEW RES]DEMIALPLM B. SQ.IeT. PAID
UO (hereby affirm that is a aommuction lending agency for the ryfhnaddim of Date Receipts
tt
U. t-^ the work for which this permit is issued(Set.3097,Civ.CJ
TOTAL:
Q U Lender's Name
Isuder's Address TOTAL:
�'s Z. I c,nil'y that I have read this upplicmiun and ,are that the alove ioformaion is BUILDING FEE
Z.
U Z nilding agmclacomply
and withall city and county mathescsand stem laduccup u'lie QTY. MECHANICAL PERMIT FEL'
V Z building umewction,and hereby amhome rtpresenmtives of This cip'menmrugm the SEISMIC PEE
abrve na ntionsd property lies i napcctinn....corse' FERMI r ISSUANCE
(We)ague u+save,indemnify and lues,handles,the City of Convention against ELECTRIC FEE
Iiablluire.Ptdgmenu,ena.c trod expenses which may in any wayaceme against said City ALTER OR ADD*10 MECH. PLUMBING FEE
in crmsequanca of the grinning of this permit.
APPLICANTUNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING ONIT(TO 10,000CFM MECHANICAL FEE
SOU H ...i}iyy.UTI NS. q
�. /Z /Tone
AIR HANDLING UNIT(OVER 10.00)CFM) CONSTRUCTION TAX
SignalCJJJo Al IicanOa
Commeno / EXIIAUSI HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
W011 theapplicxnlor loom huildlny ueeopva snrrc or fumdlc hwunbus ounaial HEAIING UNIT(I O 10,000 B U)
m defined by the Cupertino Municipal Calc,Chapter 9.12,and Ilse Health and Safely
Code,Section 2592(0)] HEATING UNIT(OVER 100.000 BTU)
❑Yc.a [J No VENTIGTION PAN(SINGLE RE.SID) LAID
Data Receipt a
Will the applicant or none huiWing occupant use equipment or device'which
.nit hazardous air connotations as defined by the Bay Arca Air Quality Management BOILER-GUM('(3HP UH 101.070 BTU) TOTA
r -
District I
E3 Yes F1 No 9(111J3R-COMP(OVER IlX1,000 BTU)
I re,crcadlhu huvv
dounatedm
als ns under Chaffer fi95ofthe Calk LIR CONDITIONER ISSUANCE DATE
fnmia Health in S may Cade.Sections 25505.25533 and 255)4.1 undvsnnd that if IM1e NEW RESIDENTIAL MECH. SQ.PT
hulldoig does no menlly M1avnaanant,thatitlsmyms,msibllinytonntifytheaceupant
of thu v hich nmsl prions,issuuna nfu Cenilie.yg�Occ[7u�palySy. ,
Owns nr authorfrad agent Y` Calif v I TOTAL: ISSUED BY.
OFFICE