99090133 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING:ELECTRICAL P'
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
;;±;,•jt+¢t;tt'BI]ILDING•PROJIEC ,IDENTIFICATIONf((t{;j4?t}''I?1
OUILDINQADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
v .1 q 9
O 'NER'S NAME: PHONE: - CONTRACTOR'S NAME: LIC NO:
��'' NIC CONTROLp
RCHITEC`NGINEE LIC NO: AU R17SS'. ❑
CONTACT': PHONE1LDINrCTERMITi NFD;±ff::;
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
)h +7 h '}*r t {yy$ S i ittjj$$} 1:1 El ❑
LICENSED CON T +!RACTORS DPCLARAITON QTY, }s gilljfELECTRIC PERMIT #i pllfr{tyI ,n t•iFLL telt
1 hereby affirm that 1 licensedthat,p (Triple,apter 9(damme g Yt' JOB DESCRIPTION
lO�Z with Section 9000)of o is'on 3.flhe Bu. n d Professions Code and my licenseis RESIDENTIAL
F00 ,full forco anJ b/ PERMIT ISSUANCE ❑SFDWL ❑KITCHEN REMODEL
�yUgV Lieeru'eO�,. �� � Liaq 5� �3o29 APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RF.-PIPE
mdy Date Con ' S .
ARCHITECT'S Df:CLAItAT1ON ❑MULTI-UNIT' El STRUCTURAL
zoo,nz Iunderstand my,dor,hall be usedispublicrcuml, PANELS MODIFICATION
oz-
y'-' UP'1020h AMT'S El INTERIOR El CHIMNEY REPAIR
o
W Licensed Pmfeaaionvl 201-IOoOAMPS IMPROVEMENT ElDEMOLSWIMMING POOLS
OWNER-aeamm It DECLARATION Contractors
ON OVER IMO AMPS C1 BATH RT:MODEUREI'AIR El DEMOLITION
I hereby affirm Onto 1 nm exempt from the C"wer,C'a License Law far One
DC d fallowing reunn.(Saeuon]1131.5,Business and I'nofessiotu Code:Any city or county SIGNS GLEC'1'RICAh [I OTHER
1+13 WOy which q Permitt construct, hr ' p demolish, repair' y structure
�y� mart t I. q- .d PPI' If 'hp 'n [I 'g 1tform, SPECIAL CIRCUUUSHSC.
��ythat he . dpursuant I d p fth Contractors Lt L (C pler9
(....nam ng with Section 90W)nfDivision 3 oft he Business and Pmm,,on,Code)or TEMP.METER OR POLE INST. COMMERCIAL,
tc o U that he is exempt Therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Scala.7031.5byan,.p,Iedo,for.permit smooch the alapfcam to a civil penally of POWER DEVICES ❑TENANT �FQDD SERVICE
ra than Eva It dre4 do ($SENT)_
y'y:N "°'ro° IMPROVE EMI'
d Ol,as owner of The pmpeny,mmy employees with wages.,Ira r side compensation, SWIMMING POOL ELEC`F I
'T'Q will do the vork,ond the structure is not intended orolfered for sale(Sao 7044,Business OTHE
3mand Profession,Codre The Contractors License Law dues not apply to an owner of OUTLETS-SWITCHES-PIX
p ready who builds or it,romes thereon,told who does inch work himself nr through
his mon employees,provided that such impmvemcnrs are not intcntded or offered for NEW RESIDENTIAL ELECTR S
are.If,however.the building or improvement is sold within one year of completion,the SO.FL FLOOR AREA 5/SQ.FC.
er-hnilder will have the burden of proving that he did not build or improve for pur-
pose T i J TOTAL
❑ 1 f th property' I .' IYconnotef 6 11 licensed tmt t -
dant lifep J 't(5 9M48 . dP f. 'Citify)Th C t t L F '( 'IJ-1}/+i i: )'i
cause Law a tapply T fp perry whobila p Th d QTy I #tt PI-CMRINO PERMIT+A ? tY,£ SP PEE=?dS
xM1� t:[ such i t wihncont au.r(,)I wn:elpursuant t O Contractor - r.}: 4, ts.v-,.t,Ytl ties,+•u$��+.,& I i n i+ x» 1`.1
LicenseL PERMIT ISSUANCE SEP 2 ����
lam ext npT order Sec. ❑&PCfnnhie reason
�Ownu - Dem' ALIHR-DRAIN&VENT-WATER(P.AJ - VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
I hereby fffrm under penally ,f pedu, .art the following declaration-
n.
❑ IM1aveend wJl nmimalnaCertificme ofConsenTTo self-imam far WmIdo,cmmpen- DRAINS-FLOOR,ROOF,AREA,COND.
action,..provided far by Section 3]IX1oRhe Labor Code,fonhe performance,[the S'1'ORIBS 'TYPE CONSTRUCTION
rm
w rk for which this peit ix issued. FIXTURES-PER TRAP
I have and will maintain Worker's Compensation Insurance,as required by Section
37(I)oftheLaborGule,fnrthepedmmunaa mfihc work for which Thivpennitie isueJ. CAS-P.A.SYSTEM-I INC.4OHrLETS OCC.GROUP [yam APTe
ulse
Ca Work Qo e- nLSsyluna�prtierrrierPemd Po�Nheyy�u'ybg{a U/-_ 6 GAS-EA.SYS FTM-OVER 4BA) 7
CERTIFICATE OF EXEMPTION FROM WORKERS' 0
COMPENSATION INSURANCE_ I IGREASMNDUSTRL WASTE INTERCEPTOR -77 ",'4 r
(Thiesenionneinhot becnmunclad if the permil is for one hundred dollars Ps10 ) NULL 1¢'O)DIVIStO:F,Py$%„
mhasaJ - GREASETRAP PLANCHECK PEE
(certify ihminthe perform as t becomeork for whlchthi,parthe Wni rkers Courplmdooll SEWER-SANITARY-STORM EA.200 FT.
nal employ any pmcon in any tnanmer nm as to became subjecto,IM1c Workers'Compel- ENERGY PEE ,
cation LawIfo Date WA'CL'R HEATER WIVENT/ELECfR
Z
Q AP'krdr•a dila(J T GRADING FEE
!n
NOT WE TO APPLICANT.If,after making this Certificam of Exemption,you should WATER SYSTCMCREAI ING
F
become logical to the Worker'.Compensation provisions of the Labor Coda you most SOILS FEE
,.y forthwith damply with.wch provisinns.of this permit Shull he deemed revoked. WATER SERVICE ,
0. Q
CONS I'RUC GON LENDING AGENCY NEW RES I DENTAL TIME. SQ,FT PAID
U 'Z' I hereby atfmn that them is a cnmtmction lending agency for the performance of Date RbitterA
U .' hework for which this permit lx incued IS—3097,Civ.C)
W Lender'-.Name 'TOTAL:
WU IxnJ :AOd TOTAL'
F y
tti to of
II BUILDING PGB.1 rt fy that l have red This pi r I t t O h b f ' n i
corn o f agree t comply with II city d county ordinances d store laws raising to QTT
U building constructor,andhereby mIhmi,e reporathativesofthll city to enter upon the MECHANICALPER
SEISMICFEE
_ above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)as t s indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabililiea,jadgnte eosmOf ce, .. which may in any way accme.gainst slid City ALTER OR AILD TO MECH. PLUMBING FEE
in c
ooaWuenen the .vting of this permh.
APPLICAN ND IS AN ILL C MP WITH ALL NON-POINT AIR HANDLING UNIT 6010.000 CFM)
MECHANICAL PEE
SO .'IT
UR ON .
i _ AIR HANDLING UNIT(OVER 10,00)CFM) CONSTRUCTION TAX
gnamrc ofAppicanVComf Dam EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle laaeaNau,material I IEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(l)1. HEATING UNIT(OVER 100,000 B'TU)
❑VexJo VENTILATION FAN(SINGER RE5ID) PAID
Dae Receipt
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(7HP OR 100,000 BTU)
emit hmardauc air eonmmairmas as deflect by the Ray Area Air Quality Management L /
D..mlet' BOILER-COMP(OVER I00IM0 BTU)
❑Yea -11
AIR CONDITIONER
I hove red haled" nmmda.regnifemems under Chapter fi.95 o[the Cnli- ISSUANCE DATE
for Heath are Searle. 505,25533 and 25534.1 understand that Like NEW RESIDENTIAL MUCH. SQ.Ff. ' �?
huildin do of tlyaveat nam�hnt it' ter F�anxibility to notify the«cupnm
inn rens ,hie t ceraeedire entoren_
r com iced agent ` Data TOTAL ISSUED BY'.
OFFICE