99120084 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 110
CITY OF CUPF.RTINO BUILDING-ELECTRICAL. P 1Rb11T NO,
ItU11,nING DIVISION APPLICATIONIPERMIT PLumnmc.mF:cunNlcnl.
BUILDING PROJFILT IDEN'1'IF'IOATION
BUILDING ADDRESS:
SRNIIARY NO. APPLICATION SUBMITTAL DATE
T
OW>WS NAME,: �� PHONE, CONI' CTORS M LIC NO.
/Add � —CO L'.0 3 Z Lam/ .P "�/ C3 2 N/c7 co TRGI.a
GHITIiGT/ENGINEER: � C LIC NO: ADDRESS: ❑
CONTACT. PHONE: BUILDING PERMIT INFO
3 ) / Y ❑ Consultant Fees Paid by Applicant(Initial) RLDG ELECT PLUMB MECH
(a ❑ ❑ B? ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby afrom Nat 1 am liceosul under Provisions of Chapter 9(commencing JOB DESCRIPTION
°oO with Sectimio)(ilofnivisiat 3ofthe Enuncsxand I'yficurba Code.and my'cense is fir ISSUANCE RESIDENTIAL
Fad_ m full finite atldeBCrs'. S(I/ 0%GJ �S/'/ ❑SFOWL ❑KITCHEN REMODEL
�UW) License Close LIC.M APPLIANCES-RESIDENTIAL. []ADDITION [SL�BING RE-PIPE
ao<y Date— Conlrvdor
ARCHITECTS DECLARATION O MIJLThUNI'f O STRUCTMODIFI RAI
ATI6
T.❑m PANELS MODIFICATION
5w-Z IunderemnJ my plans shall be used as public records up TO 2(M AMPS
pAIR
�FO C1INTERIOROCHIMMINGP OL
F.. l�c hittnxJ l'nJ'evional 201-1(X10AMPS RAI II REMEN'f CSWIMMINGPOOLS
yydd
OWNER-BUILDER exempt lion CLARAfION OVER 100b AMPS O HA'1'I I NIiMOUE1JRE1'AIR O DEMQLH'lQN
O I hereby alum o That I am exempt firm rho Contnlemr's License city
for the ❑CTHIB
LL which
reason.(Section]construct.1.0.Baxiner.imd ve,d moll Cnde:Any city cur county SIGNS 131.ECTRICAI.
O which reyuiree n permit to nonthepiper,improve,demolish,Or repair any souclum
statement
That heslcensece,alsant to
he the for f the Compach ctor'micfile
se Lawdsmtctnol SPECIAL CIRCUIT/MISC.
y thmmormcgwith Srsuamtmh)of Division
ivions3nfthe Contractor's license Law(Chapter
to
0 fm,he is iihourfa areioo]l..it of Divisi for of theeged essandmn.AyviolaMe7 or TEMP.METER ORPOLE INST. COMMERCIAL:
6 a p tL See he is exempt therefrom and N<basis for the alleged.,patent
9.Any violation of OTEN IILDG/ADDITION O DEMOLITION
to Section 7031.5 by any nd"dianess($5n.it subjects the ppplicam macivil penalty of POWER DEVICES OIMPROV OFOOD SERVICE
I mare than five bond"dollars my employees
IMPROVEMENT
��O CLo Owner propcny,or is no[
moyceswithwagnasta,(Set. (M,L sale Busineson,s SWIMMING POOL ELECTRIC
will dathework,cudthe so Ccreistm.nLicenscurmleredawdo(ansate(Sec.to an owner
❑OTHIiR
and Professions Cede:The Comrannr's License Law Jces not apply m an owner n( OOfLEI'S-SWITCHES-FIXTURE'
property who builds or improves Inc.,.,and who don such work himself or through
his own employees,provided that such imprnvoinenta arcnot inrendeJ or nfercJ for NEW RESIDENTIAL ELEC'I'R SQ
sale.ll:however,the building or improvement is stilt)within nncy or', cnmplUion,the SQ.17.FLOOR AREA S/SQ.IrI'.
ner-buiHer will have the burden of proving that he did not build or improve IOr par
Ms'of sale.).
C I,as owner of the property,am exclusively contracting with licensed cnnlranors(11I OI L'
coromet the project(Sec.]1144,Business and Professions Code:)Tho Contractor's LL
ocnsc Law does not apply to he owner of property who builds or improves Theriot, it QTY. PLUMBING PERMIT FEE
who commix for such projects with a co tramagM licensed pudunnuo the ContmnOYs
License Law. I'1?BMD'ISSUANCE.
1 nm umai under Sec. .H&P C for this reason
ALTER-DRAIN&VENT-WATER(RAI VALUATION
Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penally of perjury one of the following declarations: 99001 —
C l have and will maintain a Certificate ofCOnsem to self-insure for Workers Corruption- DRAINS-FLOOR,ROOF.AREA,CONE, STORIES TYPE CONS'I'RUCfION
amino,as provided for by Section 37M of the Labor Code,for the perummnce of the
work Air which this permit is issuedFIXTURES-PER TRAP
1 haute and will mormin Worker's Gmtticnsmion Insurance,es required by Seetion AL
3700nf the Lubar Co ,for performunu:�afd�tework for which this penneitho,1,1said, GAS-EA.SYSTEM-]INC.40UI'LITIS (CC GROUP �AI�O
My War�au In �� hnlicy No
70 C1 GAS-E.A.SYSTEM-OVER 4 HAT 1p
Cartier:
CERTIFICATEOPE :MITIONIMOM WORKERS' GREASP/INDUSTRi.WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
('Thissatinn neW nor be compimed if the permit is(atone hundred dollmx(f 1(X11 GREASETRAP
or less.) I'LANCHf:CK FEE
I certify that in the performance ofthe work for which this permit is issued.)shall SEWER-SANITARY-STORM EA.210 FT.
not employ any person in any manner to as Femme subject to the Workers'Counties- ENERGY FEE
Oz amion Lanxt of Caffomia.Date WATER HEATER WNEWXLF.CfR GRADING ItiE
z Applicant
t.y t NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should Wq'IGR SYSTEM?RLA'1'ING SOILS Nifi
h 5 become subject to the Workers Compensation provision of the Labor Cade,YOU mon
WQ forthwith comply with such provisions Or this permitshall be,deemed revoked WATER SERVICE ^'--�•��,.,.,,,,,,,�
CONSTRUCT ION LENDING AGENCY N17W RESIDENTIAL PI.MB. SQ.PP. PIT
a z 1I to REcgip in 1
I hereby affirm that there is a conmmction lending agency funhe pertonnance d I
the work for which this Permit is issued(Sm.30)].Civ.C.)
L) Lcuder's Name TOT L
} {)•l Lenders Address TOTAL: /
I citify that 1 have read Ihw application and amm that the above information is BUILDING PE
F It
v0.: correct.I agree to comply withal)city and county ordinances and crate laws rolmingu, Q7y. MECHANICAL PERMIT FEE Ll
VS
Z building construction,and hereby authorize representatives of this city m enter upon the
EISMIC FEF.
ahm
rve- urnioned pmpeny for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep ham less the City of Continua against h:F'L7AICI!P,P,
liabilities,judgments,costs and penes which may in any way accrue against said City AL'IERORADDTOMECH
PLUMBING FT;E
in consequence of the grdnti (this permit
APPLICANT UNDER NDS AND• ..COMPLY WITH ALL NON-POINT AIR HANDLING UNITOO 10,INNICFM) -
MECHANICAL FEE
SOURCE BEGUI. NS.
..c Lr AIR HANDLING UNIT(OVER 10,000 CFM) CONS'fRUC'HON'TAX
Signature of Applicanl/Commctor Date / EXHAUS T HOOD OYMUCI') HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant Sunni or handle munitions material I]RATING UNIT(TO I00,(Nlfl BTU)
art def rad by the Cupertino Municipal Gale.Chapter 9.12,and the Heahh and Safmy
Code.Section 25532fa)^ I HEXPING UNIT(OVER 100,000 RTU)
f�
C Yes ON. VENTILATION FAN(SINGLE ftRSiD) PAID Dme Receiptp !7 a
Wlithenppiicaamfoune building..ford use equipment ordeviCes whlCh. BOILER-COMP(JHPOR IW.INNI BTU)emmn
it hrdnus air contaminants as def nod by the Buy Arca Air Quality Management 'TOTAL:
District!
C Yes No HOILF.R-COMP(OVER 100.000RfID
I have mndlhe hurundoua matuiUEre maniacs under Chapter 6.95 Of the Cid AIR CONDITIONER ISSUANCE DATE
BrnbtIdoes&r cLety Cade,Section25505,25539and255)4.I a.assay hIlvoifthe ry13W RES1138NTIAl.MLCII. SQ.IT. 12-
Owner
� J� C
holdingaHccua ten emm Cudc e.Soefi nm,lhnl it 553 rtx 125:34.[[Understand
thanrpanl
of the requirements which must he and prior In issuance of Cenificate of Occupancy.
Owner or amhorired agent Date TOTAL: ISSUED BY.
OFFICE