99090089 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY Cl 0 LiW
CI'FY OF CUPERTINO BUILDING.ELECTRICALFERMI
BUILDING DIVISION APPLICATIONMERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
AI0 2 I c 13Lvn. •uvE2rIND soty 5'f
OWNER'S NAME PIIONF.: CONTRACIY)H'S LIC NO'
N/C COM' OLp
HITIiCI'/P ' INElilt; N LIC
NO. ADDRESS: T ❑
Af6AMI'enil 1l S•J•CA ZS
CONTACT': PHONE: BUILDING PERMIT INFO
1 ❑ Consultant Fees Paid by Applicant(Initial) BLOC ELECT PLUMB MECH
sTON 5o�1-15 oa d ❑ ❑
LICHNSEDCON'I'NAUMR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby al o.that I am hanard ander provhdom of chapter 9(commenting JOB DESCRIPTION
Z with Section 1pOBof Divis n3ofihe Husineamid Professions Ctde.tnd my licenuis RESIDENTIAL
FW-12 lallturccande Tcc. —1 PERMIT ISSUANCE:
mF m / il, S, ❑SP'DWL ❑KITCHEN REMODEL
lF.UO hren ci hicp
NQa Uac �I`i- Contractor < APPLIANCES-It1iSIDEN'1'IAI. 75 ADDITION ccc❑fff PLUMBING IPIi
�m ARCHIT[LTS DECLARATION PANELS I❑MULTLUNIT IpsSTRUCTURAI.
,FO ro Z [understand my plans shall W used as pudic records I MODIFICATION
UP 10 AMPS
)L-C ❑INTERIOR ❑CHIMNEY REPAIR
Licensed Professional 201-INIOAMPS IMPROVEMENT L]SWIMMING POOLS
OWNER-BUILDER D[CLARA'I'ION OVER HMAMPS �AATH REMODEIJREPAIR [I DEMOLITION
I
:=W, 1 hereby affirm that I on exempt from the Commctors License Law for the HE
d following reason.(Section 7031.5.Mines,;nd Prnfexsions Code:Any city m county SIGNS IiLE
LL y which""mines a perms to convect,alter,improve.demolish,or repair any structure
C)Q prim m ns ismanse,also mquireslhe applicant ranch permit to file a signed xummem SPECIAL C 1
}-� that he is licensed pursuant m the provisions ofthe Commctors License Law(Chapter 9
1 C0 (na.murneing with Section Division Sal the Business and Pmlessions Code)or TEMP.METER OR POLI?INST '
.a e C That he is exempt therefrom and me basis for the alleged exemption.Any violation of DG/ADDITION ❑DEMOLITION
LL Section 7031.5 by any applicant for a permitsubjeas the applicant a civil Penalty or POWITR DEVICR
. an nm�re mon Ove hundred dollars lbsIX)1 ❑FOOD SERVICE
�=En I,as owner of the n les eav with wa�n,^s theirsnle core ansatlnn. SWIMMING IVR) SPENT
f ❑ props y.mlily corp r s n
F will do the work.and the strvclnrc is nal intends)or offered for sale(See.7 Husine.as
ICi1'm and profession,Cale:'Pic Contractor's License law Joos not apply to an owner of OUTLETS
property who hadds or improves therum,and who does such work himself or through
his own employers.provided that such improvements me not intended or rtered for NEW RI3S1' L
sale.ILhowever,the Wilding or improvement i.sold withimeneyceraf completion,,the )OR AREA VSQ.IT.
ser-builder will have the burden of proving that he did not build or improve for pur-
no5c of sale.).
L m owner al the ou,ny,not exclusively cn omens,with licensed contractors to TOTAL:
msWet the project(Sec.9044.Business and Prof..iota Ctde:)'T is Convaetnr'u cenw law Jars not apply to an owner of property who builds or improves thereon,and QTY. PI. PERMIT FEE
who contracts for such projects wish a contractods)licensed pursoanl m the Contractor's
License Law. PERMIT ISSUANCE
❑T am exempt under Sec. B&P C for this reason
ALTER-DRAIN&VE WA RV),. VALUATION
ItuUt
Oner Oac
WORKIiRSCOMPF,NSAI-ION DECI.ARATION BACK FLOW PROTECT.DEVICE F
I herebysfflnnunder pereltyof perjuryone of the fallowing cleclamliom:
I huveard will maintain a Cenilicate of Consent m self-imme fur Workers Compcn- DRAINS-FLOOR. Lft STORIES TYPE CONSTRUCTION
,arnica,us prnviJed for by Satiun 3900 of the Labor Codc,for the Iwfi+mmnee of the
work for which this#emit is issued FIX'T'URES-YIiN TRAP
T have and will maintain Workers Compensation Insurance,as required by Section
3llb ofthe laMu Code,for the performance orthe work for which this permit is issued. GAS-EA.SYSTEMA INC.4 OUTLETS OCC.GROUP
My Worker's Compensation Insurance carrier and Policy oumber are �^ u
Carver: Pali,No.: GAS-1?A.SYS TEM OVER 4(EA) V /
CERTII'ICATE OF EXEMPTION FROM WORKERS' GREASFJINDUSTRL WASTE INTERCEPTOR /
COMPENSATION INSURANCE BUELDIL4GD ISION PETS
('Phis vectionnecJom heuuopleaed It the mon is hn one hundred dol Ins 0100) GREASE TRAP
or less) PLANCIIIiCK hP.' 2
I certify that in theperformeno,ofthe�,bework forwhich this pennitis issued,Inball SEWER-SANITARY-STORM EA.200 FT.
oI employ soy peau ' � r not It_!vt-'T�me aani«t so he worker:coral=n- ENERGY rEE
O Z smian LOWS W Wo rOly V �T WATER UEATEIt WIVEN'r/CLEC'I'R
O Applicant ser Q C` Al GRADING E
z NOTICE TO APPLICANT:If,after makiny this Cedificate of Exempili you should WATER SYSTENU REA'ING till
SOILS PEE
a7 become Indni t tubW..kcr'a Cmopersation provisions of the Ludt Coda you must
LA I nnhwith cmnply with such provisions or this pernin shill be deemed revoked. WAFER SERVICE
UO affirm CONisa m'IONL6NDINGAGENCY NEW RESIDENTIAL PLMB. SQ.IT. PAID Dec Receipt#
I hereby orpt thin there hem isnswmion lending agency for the prrPormam nof
LL E•' the work for which this permit is issued(Sec.3119].Civ,C.)
Lenders Name TOTAL:U IsnJcrn AAJmss TOTAL:
I cantly aha I have mad this upplioanion sad aunt that the above information is BUILDING E
41 It
F fl) caro G.I agree m comply with all chy and comuy mb umes and stns laws Muting m QTY. MECHANICAL PIiRMIT PEE PE
UZ building construction,and hereby authorim representatives oflhis city to enter upon the SEISMIC FEE
aMrvwnemiored propvrty for inspection perptsee. PERMIT ISSUANCE
(We)^gree m save,indemnity and keep harmless the City of Cupertino again.vt ELECTRIC FEE
Iiabditiec,judgments,costs and expenses which may in any way sector against said City ACI FR OR ADDTO MITCH.
PLUMNING FEC
in consequence sof the granting $this permit.
APPLICAREULATIONANDS AND WILL.COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,0010 CFM)
MECHANICAL FF,
SOUH REGULATIONS.
�— �Cf qp rpfk /dist 9-v-pq AIR HANDLING ON]'I'(OVEB 10.000 CFM)�X( / CONS'T'RUCTION TAX
1 ,i sore ApplieadiComoreon Dote EXHAUST HOODGYMUCS) HOUSING MITIGATION FEE
HAZARDOUS MATi?Rl A1.S DISCLOSURE
Will the applicant or furors bu Win cupum.anrc or handle haeallous material HEATING UNIT(TO 110.0X0 BTU)
as JdincJ by the Cupanino Mii io;y. ale,Chapter 9.12,ami the Health and Safety
Code.Sudo^2553200y. HEAPING UNIT(OVER 100.000 PTU)
❑Ycx VENTILATION FAN(SINGLE RESIU) PAID Date Receipt is
Will the applicant or future Willing occupant use equipment or devices which
tit naxsrdrus air conlamJ inanu a.v d by the Hay Area Air Quality Management BOILER-COM11P(3HP OR 100.100 BTU)
❑ TMW
t'ec [�N OUILL'R-COMP(OVER IW.001)BTU)
I have read the hazardous mxmdnlx reyuirrmrnta under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
funds Health&Safety Code.Sections 25505,25533 and 25534,1 unJcrstand thus d the NEW kESIDIiN'FIAL MECH. SQ.14. ^ q .- <--
building
building not cmmody have a tenant.that it is my resptmsibility to notify the ascapamt % _ 2. > 7
ol�nts lin i m the roar prior m issuance of a Cenifcue 0f Occup' y.
1 Gwmer�r eulhnrvTganDate TOTAL: ISSUED BY:
OFFICE e. 1�