99080015 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY J
(;ITV OF CUPERTINO BUILDING ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL
BUILDING PROJECT IDENTIFICATION
It1T LDING A,RESS: SANITARY NO. APPLICA' SUBMITTAL DAT
_ LIC - z
OW'LJfS�AMB: PHONE: U� COM1TRACTOR'S NAME: `O.
IR�NICIAI 469_ _ 'Jlr N/C CONTROLp
CHITECI'/ENGINEER: LIC NO: ADDRESS:17(p� NA; ID G ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ Y ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
❑of Z I hereby affirm that I am licensed ander provisions of Chapter 9(commencing JOB DESCRIPTION
WO with Section70fignalObvision 3 of the Business and Professions Code.and my license is RESIDENTIAL
F O in full force n�de�y �,/� /� P17RMI'1'ISSUANCE
QUU License�'IassLic. ❑SFDWL ❑KITCHEN REMODEL
it ZW Uafc �'?-(CAI G W APPLIANCES-RESIDF,MTIAI. ❑ADD]TION C1 PLUMBING RE-PIPE
Fly ARCHITECPS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z O y Z I understand my plan.shall he used as public records MODIFICATION
OZ'-'Ls UP TO 20J AMPS
; Licensed ❑INTERIOR ❑CHIM NBY REPAIR
FBF- 201-1000AMPS IMPROVEMENT SWIMMING POOLS
Oat I am ILDIiR DECLARATION ❑'
Q 1 hereby aRrm firm 1 am csempf from the Contractors License Law far the OVER 1000 AMPS ❑BATH REMOD.� P11R D MOLITI N
xx0.o L U fiillnwing mason.(Scaion 103 L5.Pusincas and Pm(useions Gdc:Any city or counfY SIGNS ELECTRICAL ❑ ER -
I+I a tt h which requires a permit m construct,alley,improve,demolish,or repair any suuenom
E�l
F'�cQ prim,ciu i...once,also require,the applieam fersuch pertain,file asigmtlnmemem SPECIAL CIRCUIT/MISC.
y-� that he is licensed pursuant the provisions of the Contractor's License Law(Chapter9
Wap0 (commencing with Scation]000)of Division3 ofthe Business and Profnssim,Code)or TEMP.METER OR POLE DIST COMMERCIAL'
a a C C that he is exempt therefrom and the basis for the alleged exemption.Any violation of El NEW BLDG/ADDITION ❑DEMOLITION
fx+1-w Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑f6OVE�MF
iy -ODSERVI E
r. not marcwne liftepmed Jullrmyempl
_� ❑ Laswncr of the memniny,or myempmyees mothewages as their ta 70,14,13 mien, SWIMMING POOL ELECTRIC
F will d.mi and mosmf.Taa isnm imena�moReree r,r-cam(neo vlwq,Bnsmenn ❑
aft.
3 m and Professions Cute:The Commences License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES j
propcny who builds to improves memuam and who does such work himself m through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECfR 1 _ lqcicl11 J1
sale.If.however,the building or inipmemmit is sold within tine year ofmmpletlon,the SQ. T7RAREA -'s)y .U,
er-baiWer will have the burden of posing that he did not build or improve for for,
pose of sale.).
El I,m owner of the property,inn exclusively contracting with IiccasW contractors to TOTAL:
consumer the project(See 7044.Business and Professions Code:)The Commaor s Li- By
se Law does not apply loan owner of properlyro
who bunds or ampvev thereon.and QTY. PLUMBING PERM FEE
who contracts for such projects with a contracmr(s)licensed pursuant to the Commctor's
License low. PERMITISSUANCE
❑ I am exempt under Sec. ,B&P C far this reason
ALTER-DRAIN&VENT-WATER(EA) VALUA'PION
Date
WOR KERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE, /1
w cr I herby affrn under penalty of,nUrry one,of Nr,following declaration
pCl have and will maintain a Cerifcmeof Cnmemto-ifiose.for Worker's Campers- DRAINS-FLUOR,ROOF.AREA,GOND. STORIES {� TYPE CONSTRUCI'IOt
cation,as provided for by Section 3700 of the labor Code,for the performance of the
work for which this permit in issued. FIXTURES-PER TRAP
13 1 have and will m.ianum Worker's Carni, eion Inseam,as required by Smetinn
370mul the
LL�.Npo(r^77Coal�for the pTe�domarnce oft he work for
t�wt hi(c�h phis permit is issued. GAS-EA.SYSTEM-I INC.J OUTLETS OCC.GROUP PN
My WorkA-tipl ,See came and Ic, L�je ilN6111fR GAS-W.SYSTEAI-OVERS(EA7 (�
CERTIFICATE OF EXEMPTION FROM WORKERS' 36z Q �'p
COMPENSATION INSURANCE GRIiASE/INDUSTRh WASTE INTERCEPTOR
(This section nee l not be,completed irate permit is for..moment dollars(SUM) BUILDING DIVISION FEES
or Icss.) GREASETRAP PLANCHECK FEE
I cenify firm in the preany manance of the work for which this pee Woo iswCour,e - SEWER-SANITARY-STORM EA.200 FT.
int employ any letxon in any non a em m the Worker.:Cour,en-
Z xmion Law�u�f Ca Ifo i.
AMI,
tical pe - ENERGY FEE
C)
O ApplicanMf rio L VI f L T C WATER HEATER W/VIiLT2LECl'R GRADING P131i
h NOTICE 10 APPLICANT:If,offer making this Cerificme of Exemption,you.should WATER SYSTEMnREATING
a ; become s.hjW lo the Worker's Compensation provisions suite Latin,Cod,you must SOILS FEE
forthwith comply with such provisions or this penin shall be deenmd revoked. WATER SERVICE
e, 0
Z) z CONSTRUCTION LHNDINGP.GENCY NEW RF,SIDF.N'I'IAL I'LMR, SQ, PAID
PAID
V p l for
rwhich rat that them isacn (Sec.30D.
agency for performance or Date Receipt It
� E' the work for which this permit is iaated lSec.lfi9T,Civ.CJ
0U Lenders Name TOTAL
tinder's Address TOTAL:
F CL I ecnify firm I have read this applicmion and ,are that the shove information is RUILDING FEE
Z correct.l agree to comply with all city and county ordinances and nam laws relating to QTY MECHANICAL PERMIT FEE
V Z buildingeonstmedan.and hereby atnhorl,represrnmtiv,ofthis city to enmrupn the t, SEISMIC FEE
xbeve-mentioned pmperly for inspersion purposes. PERMIT ISSUANCE
(We)agree to. ,indemnify and keep harmless the C'ny of Cupenino against - P,LECTRIC FEE
Iiabilities,jud6ment coats and expenses which may in anyway warm,against said City pLTT:R OR ADU TO MECH.
consequence of a gry finis pe a PI,IJM131NG FEE
APPLICANT DB N SAND WTI , ALL NUN-POINT AIR HANDLING UNIT fT01(1,000 CFM)
SOURC H LA 5. MECHANLCAI.FEE
eAIR HANDLING UNIT(OVER 10,IX)0 CPS) CONSTRUCTION TAX
Sigaure of Applin UCcmrvmm Q //Date EXHAUST HOOD(W/DUC)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Wlllmeopplicem or fair,.buildingoccupunlstmb or handle hermilmss material HEATING UNIT(TO 100.0011 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Heald and Safety
Code.Section 25532(x)9 HEATING UNIT(OVER 100.000 BTU)
[]Yec MNa
111iM1M1�i VEVI'ILATION FAN SINGLE RESID) PAID
W d me it limen in rntsa hefine pan gaipr Qu or devices which Dae Ree 't M
Ip gotta tinct tlOILER-COMP OHP OR IfU.00o BTU
it haardnus air contaminants as defined by the Ray Arta Air Quality Management ( )
Distrito." ^yy,`� T
Yes W'a BOILER-COMP(OVER IIXI,IXIO BTU)
Lhuvc real the i-..a'ma coal,reyuiremem¢under Chapter 6.95 or the Cali- AIR CONDITIONER ISSUANCE
fomia Health&Safc Co timet 2f 5,255]) 2553].I understand mm it the NEW RESIDENTIAL MECH. SQ.FI'.
haldingdiwn m �mavc ucnanL. lifi mibilitymoodythemeti'm 9^
of then . m. p , o Ceti I eofrkcu (/-F/r
Owner ramhom<d agent a Date TOTAL: ISSUED BY:
OFFICE