S0084 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL /s PERMIT NO
BUILDING DIVISION APPLICATIONTERMIT PLUMBING-MECHANICAL PprMsi r=QU
BUILDING PROJECT IDEFIFICATION *91TR
SANITARY NO. APYhICAT10N SUli MfITAL DATE
BUILDING AUIIRESS:
o 33 , G �c
(1WN'R'. AM•E:•f PHONE. CONTRACTORS NAME: LIC NO:
eGI NIC /\CONfR
'CEI,I'ECfIIiNGINI:Dy: LIC NO:C�J Al)UDSS: ❑ LJ(/S)r— `�
Ar-u Y �b PHONE: 2 BUILDING PERMIT'INTO
C) 'fAC'I`.
O Consultant FecS Paid by Applicant(Initial) I .I{I )l:_ FLECT PLUMB MIF:CH
•ILLY\ C Cy�7/�I` ❑ ❑ ❑
LICENSF.DCofirRAC1UR:5 DECLARATION QTy ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby alf en that 1 am licensed under provisions of Chapter 9(commencing
M.ZwithSminn 9(Np)ofDivision3 ntthc Business send Pmfcs', -Cod my license ie RFSIDFNTIAI'
O m PERMIT ISSUANCE
F rull farce and eRe I. ❑SFUW h ❑KITCHEN RIiMODEI.
iXF' IJccnse Cl s Lic.p
,`:_U
APPLIANCES-RESIDFMIAL ❑ADDITION F)PLUMBING RE PIPE
p..Z BI Dae Camme
m6a ARCHITECTS UECLARAT )N ❑MULTI-0NIT ❑STRUCTURAI.
~v=i Z I unJcn and my p ane sha11 he used its public records
PANELS MODIFICATION
OZ�O UP TO 200 AMPS El INFERIOR ❑CHIMNEY REPAIR
F�~LL1 Liccnwd Profe,xicied 201-1000AMPS IMPROVEMENT C]SWIMMING POOLS
OWNER-BUILDFR DECLARATION OVER IPon AMPS ❑BATH kl:MODEIIRI:PAIR ❑DEMOLH[ON
yi
CCL y�6I botchy affirm o nl 1 1 sculpt since the Count Code:A nee Law for the ❑O'I'l lliR
'a��d40yV which ire rewoa(Section 9031,5, r,aimr, and improve.
i,c.:iedi h.or Any tory or County SIGNS ELECTRICAL
u13 C N which,it, ires I'mn permit to eanxtract,u@x,rlfor'e,1,permit 1 or repair any structnarriare
I F��¢ prions us iesmmce,aLn requires the vpplinm far such permit flcesiyneJ smtemem SPECIAL CIBCUIT/MISC.
RMNy•.l that he is licensed purmammthe pmvisiom of lIle Contractor's License Law(Coup",9 COMMERCIAL'
I,z QC I..... acing with Section 901M))of llivisionJnf the lfusiness rnJ Rafessions Qdgm ITrHY.METER OR POLE INST.
Q.a a:Y that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DF.h101-,TION
-y Scene.7031.5 by any applicant for er permitsubjects the applicant to a civil penalty of POWER DEVICES ❑I'IiNAM1T ❑FOODSERVICE
ha or me than five handled dollars WERE). Ihy'ROVEMENT
=opl.as onvac,.fthe V.I.,,or my employees with wages as their sole compensation. SWIMMING POOL ELECfR1 IT FEE Fk-1
F, will do the work,and the stmewm is no,intended ser offend for ule(See,9011.Business 1170P
Wim and Prore,,,mr,Core:The Contractors License Law does
not apply to m owner of OVIILTS-$WIT 3 MATURES
property who bulldx or improves thereon,and who does such work himself nr through 'L
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIA L SQLL
Bale.it.however.the building m improvement is xnli wahirone year efcompletion,the
SQ,IT.FLOOR AREA S/SQ.1"1'.
rtender will have Inc homeli of prang That be did not build ar improve for pnr-
L as owner of The property,am exclusively ennrrncling with licensed contractors to
crammer the project(Sec.9044,BTuinesa and Prdcssioa,Cade:)TheCanlmetor's Li-
a s,Law does nor apply to an owner of property who builds or improves thorcnn,and QTY. PLUMBIN ,P• I FEE
who convects instal projects with a:xmtmetons)licensed proton d to the Contractor's
License Law. FERMI r ISSUANCE
1 vm exempt under gce. .B&P C for Nis mason
ALTER-DRAIN&VEST-WATER(I:A VALUATION
Owner Dae
WORKER'S COMPENSATION DECLARATION HACK FLOW PROTECT.DEVICE D
I hereby natural under Penalty of perjury one of the following declarations:
0Ihave and will maintain a Certificate of Consent to self-insure for Worker's Compen- DRAINS-FLOOR,ROOK AREA.COND. tiTOR1ES TYPE CONST R LIMON
sminn,as provided for by Section 3100 of the Whor Code,for the performance of the
work far which this permit is wsucd. FIXB'URES-PER TRAP
I have and will maintain Worker's Compensanner Insurance,as required by Section
3900 or Ile Labor Cn It,thane perI in lice of the work lin which bis pemlit ixiemrd GAS-EA.SYSTEM-I INC.4 OUTLI,TS (ICC.GNGUP APN
My Work c/vCin folicyNo.:ynt cr GASB-EA.SYSTEM-OVER4(IiAI
Gorier.--lltt[[��1ItC`AA�s Policy Na
CERTIFICATE F EXEMIMON FROM ORKERS' GRIEASF/INDUSTRL WASTEINT'IiHCEPD)R
COMPENSATION INSURANCE lilt DI AVISHIkaFIES
(This mcdom most and he omplemil if Ne permit is furore hundred dollars(SIU)) GREASETRAP
VhANCIIIiCK ItiE
or lusx.l
Toy any that in the any manner of the become
this permit iris Caal. shall SEWER-SANITARY-STORM EA.200 FT.
no,employ any Person in any manner so as m beconrc subject m the Workeri Camper- ENERGY PIAT
Z sation Laws of Celifomia.Date WATER HEATER W/VENT/ELECTR GRADING FE
Z0 Applicant t
NOT ICE TO APPLICANT:IL
after turning this Cerrilicaxem
e of Exemption,You should WATER SYSTEb1/rREATING
F "N"' heroine uhcctm,m Workers Com lion f the Labor Code,You must SOUS PEE
I rrso, womil hall
❑ufhwith comply with such prnvi,ian,orchis permit hall he deemed revoke]. WATER SERVICE.
y Q
CONSTRUCINLENDINGAGENCY NHWRESIDENTIA.PLMB. SQ.IDI. PAID
= 'Z IOUse¢ RcttiplN
Ihemhy nffmnthethmeisn mnswetion lending agency for the purfermanm of
� � the wnrk for which This Permit isisauW(Sec.3097.Civ.Cr 'TOTAL
O U lender',Name TOTAL:
r Lmdcr'e Addrt.as BUILDING PER
y 1 certify that I have mad this application and state that The aW,c information is
:F. h Concert.Iagem to comply with all city and county ordinance,and state laws renting to QTY MECHANICAL PERMIT FEE SEISMIC FEE
U Z building convection.and hereby authorize representatives offlum city to enter upon the
absvomeridoncd property for inspection purpnel. PERMIT ISSUANCE. ELECT FEE
(Wc)agree Ir save,Inde ify and keep hornless the City of Cupertino against
babiliticcjudgme empande swhich may inany way accmeagainslsoci City ALTER OR ADD TO MECH. PLUbiBIN. st[%r >
amsequence th ming thixpennit. 1`
APPLICANT NU TONE NB WILL COMPLY WITH A NON-POINT AIR HANDLING UNIT(TO IBIIW CFM) bfEC11ANICALPEE
SOURCE HE ULA
I � AIR HANDLING UNIT(OVER IO,INIOCPM) CONS'I'RUCfION TAX
Signature( AppllcanUCenlmetur EXHAUST HOOD(W/DUCT') HOUSING MITIGATION FEE
HAZARD S MATERIALS DISCLOSURE a
W IbeaPplicantrrare building oecupum store or handle huuMou,malenal HEATING UNIT('10 INE000 Ii'I'U)
it,defncJ by the Cupertino Municipal Code.Chapter 9.12.send the Health and Safety HEATING UNIT(OVER 100,0100 B'N)
Code.Section 25532RD?
❑Yrs El No VENTILATION FAN(SINGLE RESID) PAID -
Dam Receipt M
Will the applicant or faum building occupant use equipment or devices which BOILER-COMP OHP OR 100THX)BTU)
I baimduus it comaminana as defined by the BUY Arta Air Quality Management TOTAL:
lrctriet❑Yee F7 No BOILER-COMP(OVER 100.000 BTU)
I have mad the hazardous motenet royvirtmmnts under Chapter 6.95 of the Cali-
AIR CONDITIONER ISSUANCE DATE,
fomia Health&Safety Cade,Secroux 25501,25533 enJ 25534.1 understand that if the NEW RESIDENTIAL SUCH. SQ,FT.
nnllAimg does non currently have a¢nunL fluid teary rcnpmxlhility to co theoretical
of Ile rtgnimmmats which nun be"let prier in!',"an"of n Cell dicie o10nupuney.
Owner or nutnndmd agent Dale TOTAL: ISSUED BY:
OFFICE