99120050 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY fJ
CITY OF CUPF.RTINO BUILDING-ELECTRICAL, PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT TING R OJECTNG.MI?CunNlc,u.
pHILMiNG 1'ROADLT IDILVI'IPICATIONr,:
II UILDINGADDRILSS. I'1'ARY NO. APPLICAI'10 SUIIM11-FAL DAT]
Cl 01 1J
1@C_N ME PHO CONT'' fIAME! I.IC NO:
/ V 000[[[ N/C CONTItOLp
ARCHITECT/]ENGINEER: LIC NO: ADDRESS:' ❑
COMI'ACP: PHONE: i/.',."t' `%"BUILDINGTERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG i ELrCl PLUMB MECH
0A P. ❑ ❑ ❑
IACENSFDCONTRACIORSDECLARAIION QIry' . tt ELECTRIC ILRMIT', tit. f ' .fy''FI:E:f t,
ntoreny ,n rrm n t 1 r 1 m d p renap,r 9(rumen mg - _ 'JOB DESCRIPTION',
"Z wimbarnn 9n(n)orD.,nnn3nnne Bas ad Profesxio:edit d yBe n.e. RESIDENTIAL:
goo ^ PERMIT ISSUANCE
f� in full tone nntl ef,d ❑SFDWL ❑KITCHEN REMODEL
RUF License Class Lit.p
6 ku APPLIANCES-RI3IDCM'IAL ❑ADDITION El PLUMBING RE-I'IPIi
z W Dole—- CoConnectorno
m6UCr
1
f❑N CMD.T1-DNfI' ❑ IARC11Tr(TS UFCLARATION I'ANIiLS MODIFICATION
Z O Z I understand my pians shall be used as puM1bc rcn,Ns
OZ 0,,., lIP1'02(NIAMPS INTERIOR ❑CHIh1NIiY REPAIR
f on MEN Licensed Professional 201-IIKKIAMI'S INUPROVEMIiN1' SWIMMING POOLS
�Y2; OWNER BUILDER DBCLAItATIONOVER IIItBAMPS ❑BAT]I REMODELPREPAIR^DEMOLITION
K C Q I heresy affront that 1 am exempt from the Contractor's License Law for the
�•O0.U following must(Section 7031.5.Basins, it Professions Code:Any city or county SIGNS ELEC'T'RICAL OTHER
LLLLO y which require,a permit to lamoracl otter,improve,demolish,or repair any structure
CC ffnn� prior to its issuance,also requires the applicant for such permit to file a signed datement SPECIAL CIRCDI'I'/MISC.
2 y mothet,licensed pursuant to the provisions of the Conoueors License Low(Chapter 9
ad <� (commencing with Section 70)(0)(if Division 3nfthe Business and Professions Code)or TEMP.METER OR POLE INS]'. COMMERCIAL
i a o C ]hut he is uempt 11amrrom middle basis for the alleged exanption.Any vhtwtr„t of ❑NEW BLDG/ADDITION ❑DEMOIA]ION
XmLL
Sarno.?"31.5 by any xpplican,far a pionand subjects the applicant o a civil penalty of POWHR DEVICES ❑TENANT [IFOOD SERVICE
nttun ban dive hundred dollars fS5n0).
i+ OTHERVEMF;N"I'
�+' < o the work,the pnpeny.mmycmpinyeewroffawages rsuld(Sm.coat,Business SWIMMING POOL ELECTRIC
p.0 will Florentine,Code:
The Connector,
intended orn.dorsorml apply
owner
El OTHER
�3 m and Prolcssions Gde:The Convacmr's Licemc law dors not apply m m owner of O1frLErS-SWITCHIiS-FIXFURIS
pmpeny who bmild.s or improves thereon,and who does such work himself or through
his own employee,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECFR SQ Pf.
sole.if.however'.the building or improvement is sold within oneycur ofcompletion,the SQ.Pf,FLUOR AREA SISQ.IT.
El
owner-builder will have the human of proving that he did not Wild or improve for pur-
pose tarsale.).
❑
lint owner of the prrlwnY ton exclusively contracting with licensed contractors to TUI'AL:
wase La does
ma(Sec.]f W,Business and Professions Cale:)'1'M1c es thrown,Li- .r • ^•• '('y ' s - f t,
wore Lmvdoesrs apply m,ts tower ofproperly who sdld.nr millstones and Qty,- �1,'PLUMBINC PERMIT 1. �,/,^� hEE -
whn contracts Ea such projects with a commnnr(s)licenced pursuant m the Contramora
License law. PERMIT'ISSUANCE
I mot mucin'[w B&P C for this reason
ALTER-DRAIN&VEMf-WARBR(EA)= VALUATION
weer Dam Os=I
RKF.R'S COM NSATION DECLARATION BACK FLOW PRO ECr.DEVICE Z O J O
I hereby red arm,ander penalty of,eGaiy one after following dmlamtion,: .J
I have and will maintain acerificauorconsentto self insum for Worker'.v Compen- DRAINS-FLOOR.ROOR AREA,COND. STORIES 'TYPE:CON SFR UC'I'ION
sminn.as provided for by Section 3900 of be Labor Cade,blithe Perron n em of the
walk dim which(his permit is ko,cd, FIXTURES-PER TRAP
I have and will maintain Workers Compensation Insurance,as required by Section - AA44����
3900ofineLabor Codc,knife pertmrancc of the work he which)his pemdl is iavued, GAS-EA SYSTEM. If
INC.4 O1X7S OCC.GROUP AYIN
My Worker',Compemaliun Insurance surae ami ierand Policy number ape: L
Cornier Policy No.: GAS-ITA.SYSTEM OVER 4(HA)
CERTIFICATE OF]EXEMPTION FROM WORKERS' GRIiA$PJINDUS'1'RI.WASTTiIMI'ITNCEPR�H
COMPENSATION INSURANCE _ BUILDING DIVISION Fp:E,
O'hiasectlonneadnmbecam,lalad lat ,e Perini,is for one herdecddollas($100) GRBASI_,I"A,
or less.( 1'1.ANCI IECK FEE
1 I certify that in the performance of the work for which this pvano(i,issued,l shall SISWE1t-SANI'1'AItY-S'IDIIM BA.2110 PI'. M-
r
not col,any persom in any Inattention,to lucmne subject to the Workers'Counted- ""1'1NERGY I EIi�
,Z, satian Laws of Califamia.Data WATER HEATER W/VEN'VELECfIt
O O
Applicant \ I tGRADING PLIiV
NOTICE TO APPLICANT:IL afar making this Certificate of Exemption,you should WATER SVSTEAf/1'RFATING I SOI
F"N" become subject rt me Worker's Compensation provisions of the Labor Codd,You must r
Atranwith um,ply with soh pnwi o.snr this permit shall hedecmedrevoked. WATERSERVICE '
5z CONSIRUCHONLENDINGAGENCY NEW RESIDENTIAL PLMB. SQ.FIT PAID Uute Receipt
U O Ihereby reform hot the,. ctinwmmioo lending agency forme pofo..rccof
Its We work for which this permit is issued(See 3197,Civ.C.)
CU I,cnder's Name 'rOIA :
O i.cn Ile,Address TOTAL: -
a _ BUILDING THE
I nfy the(l have radios uppl' t 1 tt that Ill. h n at
r7� umect (ogre o tplY suer aIle tY and ry announce, d.t o I tat n6l QTY.: / !'MECHANICAI.PERMIT ,'i RIF'
UZ building lom,armion and herehyaifin ie representatives ofanscty to anter upon the . SEISMICPEP.
show mmneared IF ly for inspection ma,sem. PHRMI'r ISSUANCE
Gard agree m save,indemnify and keep harmless the City of Cupertino regains, ELECTRIC FEE
linhilities,judgmm�ts,cnsn and expcnws whidh mayinany wayaucnuagaimssam City ALTER OR ADD TO MECH.
in nsequcnce of tM gunning of pis pennio. PLUMBING PEE
APPLICANT ONDERS'1'AND$AND WILL COMPLY Will,ALL NON-POINT AIR HANDLING UNIT('to lt.WtCFMI
MECHANICAL PEE
SOUHC ']CATIONS.
' AIR HANDLING UNIT K)VI!R 10,1100 CPM) CONS]RUC'I'ION'i'AX
.'igoatuw dAPPlican Cant' Data EXHAUST'HOOD(W/DUC'1) HOUSING MI'I'IGATION FEE
11A9ARDOI]S MATERIALS DISCLOSURE
Will mupplicam rrfuture buildingrxcucm,sore or handle hazanlous material BEATING UNIT(IT)110,0011 BT D)
as defined by the Cupertino Municipal Cotte.Chapter 9.12,nand the Health and SOlety
Codd,"this 25532(u)'! HEATING UNIT(OVER 100,000 RTU)
F1 Yes Fl No PAID
VENTILATION FAN SINGLERISID) Data Receiptp
( I Will the nppliwnt or Comm hulling occupant use equipment or devices which
snit hazallom air cnnumiaants as defined blithe Bay Arca Air Quality Management BOILER-COMP(3HP OR IW,IXNI BTU) TO"AI: 1
District!
ElYea ❑No 14011.13R-COMP(OVHIt IOgWt BTU]
I have mad the hazudnusmmand,no,ircmenu under LTaper 6.95 of me Cali- AIR CONDITIONER ISSUANCE LATE
bumps Health&Safety Code,Sections 255115,25533 and 25534.1 undemm�d that if the NEW RESIDENTIAL MECH. SQ.PC — 3 YF
buildan nnrcutren1ly haven tomnL thutd is myme mvibility to notify the occupant C
of It ows which mwo be ate,prim m ixvuanco of x Conneaut of Occupancy.
Owncror uhorizcdagent Dam TOTAL: ISSUED BY:
OFFICE