99100081APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY st,:
CITY OF CUPERTINO HOILDING - El EC'PRICAL
BUILDING DIVISION APPLICATION/PERMIT PIAMBING • MECHANICAL
HULLOING PRf1JI ?LT IDEN'TIF'ICATION
PERMIT N�
SOOO I
Ali
BUILDINGADDRUSS. /�
/ zg.s 1 Ewe U1
����
SANITARY NO,
APPLICATION SUBMITTAL. DATE
/v
pal ER6N M PHONE
67 , P Z
Cl'
NTRACIOR'. SAM?: LIC NO'
/:" /„� •3f�
K /,�� /
"k -f/�s
NIC
C(INTIt111,M
q
.RCIIII'[LT/FNGIN[ER: � L�N(� 7/
A BSS _
CON'TAC'p PHONE:
(Ir �� �k A)i/
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELP,C'f PLUMB MECH
0 ❑ ❑ ❑
"Z
1y� O O
F W f
�FUU
N <4
F D m
O Z n z
F:4F W
11S i
R W sc
3
3 E.
LICENSED CONTRACTOR'S DECLARATION
I thereby ammt that 1 tan Eecaaed made, provisions of chapter 9 (wmmmmdag
with Sector Zf011),kion 3oflm Busiesssand Proeso oils Co l E, mndmylkenwiv
in full force and effect.
Lscnu_ has Contra
porn Conlruao r
GHIOUT'S DE IO
I understand my plans shall be mud as public records
Q ry,
ELI ?CTRIC PERMIT
FEE
JOB DESCRIPTION
RESIDENTIAL,
❑SFDWI, ❑ KITCHEN REMODEL
[]ADDITION ❑PLUMBING RE -PIPE
[:1 MULTI-UNIT El STRUCTURAL
MODIFICATION
[I INTERIOR El CHIMNEY REPAIR
IMPROVEMENT E] SWIMM ING POOLS
[I BATE RF,MODEf/RF.I'AIR 0 DEMOLITION
❑OTHER
PERMIT ISSUANCE
APPLIANCES - RESIDENT AL
PANELS
UPT0200AMPS
Licensed Professional
OWNER - BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Comracmr's License Law for the
follow ngmoson.(Section 7031.5, Ilnvinesc and Professions Gule: Any city m,unly
201- 1000AMPS
OVER IOgI AMPS
SIGNS ELECTRICAL
u+ t y
�<
which requires a permit to condrvm, alter, improve, demolish. or repair any swdure
poor wits issuance, also requite the applicant fracas permitto file m signal statemcm
_
SPECIAL CIRCUTUMISC.
that be is licensed pursuant m the provisions of the Communes License Law (Chapter 9
�•q0
d0. c
x
F. so
F_ Z T
4'
WSC
4�1
(commencing with Section of Division 3of the nosiness mad Professions Cotta) or
that he Is exempt theca nm and the husis for the alleged oxenu nail. Any viole ion of
Section 70315 by any applicant for a permit subjects tire applicant um a civil penalty of
m more than five hundred dollars ($500).
❑Lothe work, the pmpeny,rte nryemntended withweal for their sole 70,14. Business
will do the and the sumcmreixka's License awdoess of apply to owner of
and Code: The License Ldw does not apply to
THNI P. METER OR POLE INS' 1'.
COMMERCIAL:
❑ NI ?W BLDG /ADDITION Ml, lU1.ITIDN
El TENANT ❑FOOD SERVICE
IMPROVEMENT
❑OTHER
POWER DHVICIiS
SWIMMING POOL ELECTRIC
OIITLE'IS- SWITCHES- IIKNRHS
a
may whinny
over then' if
his o ny who Moilss or improves tsuch improvements anti who Joss match wnrk himselfo Ihmugh
his own employeese pmviJed that smh ent h wld v are not intended or offend for
aide. If. howeuc me building or improvement is sold within oneymr ofcompletion, the
NEW RESIDIiN'flAl. F.LIiCTR SQ FT.
SQ. 14. 1•lIX)R ARIiA
$ /SQ. 1'I'.
owner- huilder will have the burden of proving that he did not build or improve for pul-
p sec oT nuts).
❑ 1, its owner of the property, am exclusively contrmnng with licensed contractors to
I (TEAL
nsamet the project (Sm. ]BLI, Business and Professions Cmle:)'TLe Custom.,x Li-
censeLawdoesnotapplyto anownerof property who builds or improves thereon , and
QTY. PLUMBING PERMIT
PEE
'
who contracts for such projects with a contractors) licensed pursuant to the Continuous;
PERMIT ISSUANCE
s
°
License Low.
❑ IUm exempt under Sm. ,li& 1' C for this reason
weer Data
ALTER -DRAIN & VENT- WATER BAI
VALUATION
00
WORKER'S COMPENSATION DECLARATION
HACK FLOW PROTECL DEVICE
I hemby affirm under Penalty of perjury one of the following declarations:
�^
J VJ
huvcand will nmalmmlmoCen .. rol'Cralwat muff -mus, far Worker's Cmnpur
satinn, us provide) for by Section 3700 of the Labor Code, for the perforcumm ill the
DRAINS - FLOUR, ROOF, AREA. COND.
S'IIIDIS
TYPh CONSTRUC'T'ION
ark for which this permit is issued.
FIXTURES - PER TRAP
I have and will maintain Walker's Compensation Insurance, as required by Section
J](0 of the bar GWa,f the perlimnnnce ofthe war' which ms pe Elsie •d.
rp f-2 n Truer,
GAS- EA.SYSTfiM -I INCaUOI'LETS
U
ANN
GAS - EA.SYSTEM-OVFR 4 THAI
My Wnrk mmnn ice Sur. cccurricraad Pofi u'. 0
Cartier: Policy
E '1'1 ATEOFFXEMPTIONF OM WORKERS'
COMPENSATION INSURANCE
0�
GREASUINDUSTRL WASTE INTERCEPTOR
U DI ISIO I
S
(This section need not Beciandcm) if the permit is far one humd,eddollms($100)
or less)
GREASE'TRAP
PLANCHHO"EF3_
Imnify flaidethe performance of the work foTwhich this permit is issued.I Shall
not employ any pm>nn in any manner so as to because subject to the Workers' Compen.
SEWER - SANITARY - SEnRM F.A. 200 FT.
p
B
GY Flili
WATER HFA1 ER WNENT/F.LECTR
GRADING IBC
Z
O
rjT
h ;
p'1 Q
UZ
U O
F
U
satinn Laws of California. Date
Applicant I
NOTICE TO APPLICANT: If, mir, nwking this Cer ificae of Exemption, you should
hemnlet subject to the Worker's Compensation IF Woes of the LaMar Code, you mum
forthwith comply with such Provisions or this permit shall he deemed revoked.
CONSTRUCTION LENDING AGENCY
vn .C.) Ice
Ihereb ffirm that there is a construction leading for the rformmmn ul
the work fm which this permit is issued (Sat. 3(19], Civ. CJ
I Name
WATER SYSI EMR1117A'I'ING
WATER SERVICE
SOILS FEE
PAID
U:ne HmeiptM
NEW RESIpF.NTIAL PLMB. SQ. FT,
TOTAL.:
TOTAL:
BUILDING FIT
W
f�A
U,7.
orders
Lender's Address
1 certify that I have read this application and mate thad he above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
buildii,entitruction, and hereby amhorlae representatives of lhN city to enter upon the
QTY, MECHANICAL PERMIT
FEE
51 ?TSMIC FEIi
PERMIT ISSUANCE
ELECTRIC I'L'LS
abuse - mentioned property for inspection proposes.
(We) agate [,,save indemnify and keep harmless the City of Cupertino against
AFTER OR ADD TO MECH.
PLUMBING FEE
Iiabiloies.jud eat c nd expenses which may in any way accrue against said City
W,.c.f ing of this pmrrtih
'ANDS' AND WILL COMPLY WI'TII ALL NON I'UINT
_
AlI1 fANDLING UNIT fIY) III,IMI CNM)
MECHANICAL THE
AIR HANDLING UNIT(OVIiR 10,00(l
CONSTRUCHONTAX
Iris
'
Sig amre of ApillicantrContirmtor Date
HAZARDOUS MAMMALS DISCLOSURE
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION ITE
HEATING UNIT (TO 104),000 BTU)
Will Oeapplietal m fumrc building mcupmnl sorts or handle hazardousmaenal
V
to defined by the Cupertino Municipal Code. Chapter 9.12, it the Health unit Safety
Cade. Section 25532(a)?
[3 Yet; ❑No
HFATING UNIT (OVER 100.000 BTU)
PAID
Uwc Itc t
VENTILATION PAN (SINGLE RESID)
BOILER -COMP DHPOR 100,000 B'fU)
Will the applicant or future building uceupam use equipment or devices which
1
mil ha>mtlous onriabmminams m defined by the Bay Area Air Quality Management
TAI
BOILER -COMP (OVER 100,(100 BTU)
District?
❑Yes ❑No
AIR CONDITIONER
eve ren eleae mullat Zmaluemcats under Chapter 6.95 of cis Cali-
ISSUANCED ,
NEW RESIDP.NTIAL MliCH. SQ, FT.
hard. ahh & fiery •cH e., 25505, 25533 and 25534.1 understand Nat if the
bull ng slo y ba¢nart, Bad it is my resposexhility, to notify the eecupant
a qai ttu ie ust be net poor to isosceles, of ificme or Occupancy.
��
,..1A/ - ,
ISSUED IiYV �e�'v� 4
TOTAL:
Uwnc nra on eJ g m
OFFICE