99100120 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 00 1 a—O
CITY OF CUPRMPINO BUILDING-ELECTRICAL. PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
4:l1'i' *401 BUILDING PROJECT IDENEAFICATION Ll
BIIILOINGADDRF-_SS: SAN]DRY NO. APPLICAFION SUBMITTAL DATE
?�21 SvlSunl be. Cu I,tJ0 GSbI�
OWNIiR'$NAi �wlz �h� PHO Ii^ �' �NAME� � LICNO: N/C CONROL#
' "V SI /tea !/ 1; ��£QS
RCHI'ILLT?:NGINEER: LIC NO: ADDRESS: A (l El
CONTACT: PHONE: it 1?I';i1 BUILDING PERMIT INFO,,,I�,
A p�LO �y `/A�J��7 5�5 I J ] ❑ COnsultant Fees Paid by Applicant(Initial) BLDG ELEC LUW MECH
1:1 ED ❑
LICENSED CONTRACTORS DECLARATION " •1 ! I ' ' f "L.t �' '1J1 ll I
Ih by nosed tl 1 d deP '.' n. fChaPler9(nnnmu g QTY IIt" ! 1 '�LL�CTRI}C:PER
MI'Fy��It�IIl, �;l FFEEr:Jtjl JOB DESCRIPTION
QaZ IIhS t ]01X0 tl'U 3 fthe l3us dPr f .ioax Code,and myl e+. : 'x T•[p
O O� PERMIT ISSUANCE(yF 'ntlullf nlllcty,wFUWL, ❑PLUM KITCHEN RH.PIPI.
VyQ� Uule eeU � 2e�{—Comra�
APPLIANCES RESIDENTIAL _ ADDITION El PLUMBING It I:�PIPC
ARCHI'TECT'S DECLARATIONId, L1 MULTI-UNIT 1 STRUCTURAL
'lln I'ANI;I.S
Z Ot�'� IumIca,andaa,dma,,h.1I heusednspublieteemdx MODIFICADON
O Z�� LIPTO200AMPS - ❑INTERIOR OCHIMNEY REPAIR
Licensed Professional 201-IRMAMPS IMPROVEMENT 0SWIMMING 1-001S
Y OWNER-BIJILDER DECLARATION OVER 10(If1AMPs ❑BATH REMODEL/REPAIk (]DEMOLITION
I hereby effina mat I am exempt from the Contractors License Law for the
X 3 d U following reason.(Section]11315.Business and Professions Code:Any city or county SIGNS E CTRICAL - OOTHER
tIl a(ZI which require,a Permit m rnnnrvct,aper.imprmve,tlemolish,or repair any Slmcune �!�}
FLLq pinion.its is...nee,aLo oeyuires the applicant momch permirao fileasiRometamen, SP(, LCIRCUFUMISC. ��✓
fes} That he is licensed pursuaalto the provisions of the Commmex License Law(Chapter9
u1=O0 (commencing with Section]DA0)of Division 3 of the Business and Professions Code)or Til RPOLL INST. COMMERCIAL:
L a o,y Iha,he is Hemp,therefrom and the basis for the alleged exemption.Any violation or 0 NEW BLDG/ADDITION 0 DEMOLITION
X^N Section 7031.5 by any applicant for a parratiubjects the applicant ,,a civil prontyof POWER DEVIL
of are man Dvc hundred dollars($56B). EITENANT 01'OOD SERVICE.
I_-Z Q, I.as owner ofthe norm bees with wages as their sole cont minion, SWIMMINVOOL .LEC IC IMPROVEMENT
FC ❑ Prole Y my employees 8 Pe T
I I dm the work.and the strvcwre is not intended or offered for sole(Sec.7044,liminess DOTTER
a3 w and 11..bestir,Code The Contractors License Law does not apply to so owner U( OUTLETS-S -FIXE ES
property who oyer,Ur Improve,(hereon,ane ser aces men wotk bed m m m d for
his own owever.the provided thnt such meat is me9t,arc nM intended yr oRered for NEW RESIDENTIAL EC SOFT
mle.IthmId,rw,thc buil hamolrlimpd,niinithat hail miare lmildorcomplctRa,the SQ.Ff.FLOOR AREA bISQ.fT.
eor selecr wit l h:rvc the hunlen of Proving that hadid nm M1uiIJ nr bnpnwe for Pur
0 corselet
I, nwnyt..me pmpoay,an,oxnludvand contracting..tong with lieensal movant a J- TOTAL:
constructl 1 Ills ]1004 B J Nor Ltd J Ch ClI' It' t +y r !' r 1 ft ' 1 II t)'t n 111
ectese 1 I pplr n fproperty n builds r'np :d , d Q�ry 1+. PLUMBiNC PE12MITt, a FEC• 1 } '
whoa mbun 11 r'tall r jeeswith.v ntraon(,)In,iaedpueaum(,,,he C boa nn', nuu".e. iz 1.,11 �.
License law. ,�r• PERMIT ISSUANCE
0 lam exempt under Sec. ,B&P C Dnda,Tcmon
Came,
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Date '
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby ulErm model pewlty of perjury one of the following declarvtions: v
I have and will maintain a Certificate mf Consent to self-insure for Worker's Compere DRAINS-FLOOR,EDGE,AREA,COND. STORIES TYPE CONSTRUCTION
salion,as provided for by Section 3]00 of the lahor Code,fair.performance of the
for which this palmi,k issued. FIXTURES-PER TRAP
have and will outWorkers Compensation Insummce,as«strained by Section
.]OOH the labor Cade.for the pcdormance of me work for which this permit is issued GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP PN,
My WohSj;,S,CnmPensmion Insurance camernndy No.nyTh�er sq L
Carrier: j"�J�G�� Policy FROM
sl � GAS-IiA.SYSTEM OVER 4(EA)
CERIIPIC OMPE SATIONIONFRAN WORKERS' GREASUINDUSTRL WASTE IN'FERCEPfOR 0
COMPENSATION INSURANCE BUILDING DIVISION IT13S
[This section need not rte completed iOhe permit is forone hundred dollars($llq) GREASE TRAP or Ics,J PLANCHECK FEE
I certify thin in the perrmnnance mfthe work forwhich this pernal is issued.l shall SEWER-SANITARY-STORM EA. I FE
not employ any permn in any Amnon se as to become subject to the Workers'Cmnpen- 200ENP.RGY FEE
O Z nulnn l,uwsolCulifnrnia Due WATER H EADIRW/VENT/P.LECTR
Q Appllcmtl GRADING FEE
h NOTICE TO APPIJCAN'F.If,eller making this Certifican.of Excntpllnn,you should a WAI'L'k SVS'fGMlIREATING become subject le the Worker's Compcesmien previsions of the labor Code,you must SOILS FEE
Andav l n,enid,with such pavlwoas yr this permit shall le deemed area ded. WATER SERVICE
CONS TRUCTIONI.ENDING AGENCY NEW RESIDENTIAL PLATE. SQ.19t PAID
V O work
rwhichaffirm this that there ismed(Section lending agency for the perfnrmunee of Date Receiptp
Lks the work for which phi+ln'mtil is i+sued(Sec.3097,Civ.C.)
Leri N TOTAL
Leaders :
(r Address TOTAL
,may 1 versify th,I have lead,h'. PPI'atinn and note that the utxncinfiltration nx ,. -- L . 1., t__ 1 1 -1 -'1-, BUILDING ELF:
to cttrtect 1 g , c ply lh II y rcoymy UNinances and nee laws relarng,U QTY' dl MECHANICAL PERMIT s fj', 1 FCE it
LJZ building :moron said hereby authorize representatives ofths city m enter upon the t .t �•"+ 4 SEISMIC FEE
aMve mentioned property for impaction puyws¢' PERMIT ISSUANCE ELEa,,
(0.'e)agree m save,indemnify and keep hannleas the City of Cupertino againstI�>""�^-_-•�
liabilities,judgment,,cons and expenses which may in anyway acerve against said City AITER OR ADD TO MECH. /
f the t f this t PL MBING FEE6
an nscyuenceo gran Ingo Penni. � ,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0,00(CPM) !
SOURCE REGULATIONS. M CHANIC�^FEE
AIR HANDLING UNIT(OVER IO,0k1 CPM) C NSTRUCTIONTA%/ Z 1999
Signulumol AppllcnnVCoana,ml Dale EX HAUS T GOOD(W/DUCT) Oil)USING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will t neelplicunt mo tulure bra'(dna,UCUupant Aire arm cle humninto,leaed:d HEATING UNIT(TO 100,000 BTU) 1l/
C refined by the Cupcdine Municipal Code,Chapter 9.12,and the Health enA Sofnyi
Code,5ectinn 25532(n1^. HI3A'TINO UNIT(OVER 100,000 N'1'll)
❑Yes ON. PAID -
VIiN3'lLA'1'TON FAN(SINGLE NESIDI Dine Receipla
Will @e applicant it,Lilac milding occupant ore equipment or device,which
tiriat h Ansloo+air contaminants as defined by me Bay Area Air Quality Moragmnent BOILER-COMP(3HPOR 106,0(10 BTU)
TOTAL:
0islp
❑Yes ❑No BOILER-COMP(OVER 100.Of100,00(i
I have rear the heevduus ma¢dals mluiremenu under Chapter 6,95 of the Cali- AIR CONDITIONER ISSUANCE DATE �'1
famia Health& ofic"Code,Sit...25505.25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.El O �— A
huitding u bine a mml.dire i,is my respo b Iymreally,thc occupant / Q
Aft is use M mel prior n.ies,Ij)f�Fp Q�(Jc[)c ty,ancy. 1 �
OWru,r or:wtt rued agent /(J •••/// //yl,Or,T TOTAL: ISSUED BY: ' C�
OFFICE