99080066 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CI TY OF CUPERTINO BUILDING-ELECTRICAL PERM IT NO.
HUILDINGl11VISION APPLICATIONWERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
RGILDINO ADDRESS: SANITARY NO. .DATE
NER'S NAME: PHONE: CO RACTOR'S NA E LIC NO:
p SIC CONTROL If
ICI IITEGP/1 GINEER: LIC NO: ADDRESS: `r 11 I,rx ❑
CONIACF. PHONE: ` !la~/ BUILUINC PERMIT INFO
^t _11y� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT
PLUMB MMH
{Jb I ❑ .LJ ❑ ❑
LICENSED CO OR'S DEC RATION QTY ELECTRIC PCRMIT ITE,
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
❑d'Z with Section]000)ofDivision3of Ne Ru>inexs unJ Rexfessions Cale.and my licenu is
WHO PERMIT ISSUANCE RESIDENTIAL:
m full force end elle«
❑SFDWL CHEN REMODEL
<ZUU -leen Llak �/��3i y APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE 6 a cmc Contractor 1
ARCHITECT'S D[CLARAI'ION []MULTI-UNIT -1 STRUCTURAL
Z p r z I undecvona my plans shall W axed as public records PANELS MODIFICATION
O Z UP TO 21x1 AMPS
❑ E)INTERIOR El CHIMNEY REPAIR
Llccnwsl l'ndcuional 201-1"AMPS IMPROVEMENT (]SWIMMING POOLS
OWNER-BUILDER DECLARATION
aO .] OATH R ❑ -
K 6 1 hereby affirm that I am exempt from the ContractorOVER I(xOAMPS EMODF.IJREPA DEMJ.)L0
's License Law for the / �L
XLL F following reason.(Section 7031.5,Business and Professions Code:Any city of county SIGNS ELECTRICAL ❑OTHER
"0.
which requires a permit to construct,alter.improve,demolish,or repair any smayb re, la�,Q�' /]G
N J prim m iits issuance,also textures the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
,E W y< that he is licensed pursuant so the Nsfyid ism of the C.ntmaors License law(Chapter 9
W tYOp (commencing with Section]000)of Division 3 of the Business and Professions Coale)of TEMP.METER OR POLE INST. COMMERCIAL:
a q m y that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
iC Y. Section]031S by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
W^m - ❑TENANT ❑FOOD SERVICE
n l mitre than five hundred property,
ordollars y em
)' IMPROVEMENT
❑ Lo thewrk,anlued
the samclar myanpluyet,ilod oithwages r solr solee(Sec.
044,Buudun, SWIMMING POOL?LFC'1'RIC
' F❑ will dothcsvoek,ande The arcianot,Locem orOfferedawda for sol apply tt14a ownnc []OTHER
L3�^ prJerty Who
Cafe:TheContractor,thereon.
Liccnw Lawdoesnot rk hi slfowner m' OUTLETS-SWITCtiI!S-FIXTURES
progeny who miles Of improves t such..and who does such work himself f Nrd m
his own employees,e provided that such improvements are not intended or platted for NEW RESIDENTIAL,ELECfR SQ FT.
sale.ILhnwwenll havbuilding meudor en of percent(that he within one dear imprywetfor the SQ.FT.FLOOR AREA EISA f4.
owner-builder will have Ne burden of proving the he did not build or improve for par
pose of sale.).
❑ L as owner of en property..Business uchs and contracting with licensed can moo's U. TOTAL:
cause La The project(Sec.]Bee.warOfandrty bebusCode:)Theve,tianofsI.i-
nwotwdcesnmapplytoan with
a contractor(s)
whored pirommpen the Commeand QTY. PLUMBING PERMIT FEF.
who contacts for such projects with a eommmnr(s)Ileensed pursuant m the Cnntr cemYs
❑iJ'ars,Law. PERMIT ISSUANCE
oot exanp under Seo. ,H&PChrt Nls rmaun
Data ALTER-DRAIN&VEMI'-WATER(EA) VALUATION
CO�
WORKER'S P natty o!NSAIy(m DECLARATION BACK FLOW PR(yl'IiC'I'.UEVICF. /)o 0
I hereby etfirm under Penalty ul perjury,erne of the following declarations: VV VV
❑I have and will maintain aCenificmeof Conserv to self-insure foe Wofkels Cnmpcm DRAINS-FLOOR ROOF,AREA,COND.
sation,as provided for by Section 3700 of the Labor Code,for the performance of the I� TORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PP Vex ff-nQ
eve and will maintain Worker's Compensation Insurance,as required by Scaton 1 LEI' - 0
.] Iof the Labor Car,for the performance of the work for which this permit is issued. GAS-EA. F. h1111NU. V1
4 O ' TS- OCC.GROUP ^a//,,�APN
Cy W`rAefy Co rsatio ns nycgnmc Bad cy NaY=,, f GAS-EA.SY.S'TEM OVER 4(E SN
CERTIFICATE OF EXXEMP I ION(ROM WORKERS'M1�olet Zo
COMPHNSA]'ION INSURANCE GREASEIINDUS' TF INTERCEPTOR
BUILDING DIVISION FEES
,it mss.)r umiaaeannn nerd n.rneanmpleaninite perch is ra.nennnamd n.uars(auxB ekcpsETRnr t oo111CIV1
r` PLANCHECK FTE
l canify that in the performance of the work for whim this permit is lssued,Ishill '1,.
nm employ any person in any manner so us to Mamme suhjectmthe Wnekers'Compeer- S SA'Yrr'E11 M C2 O ENERGY FEC
0 z satin.Laws of California.Data WATER tIFA'lyp 2 ECTk`
Z Applicant GRADING FEE
fn NOTICE TO APPLICANT:If,after making this Ccnificate of Exemption,you should WATER SYSTEMOREAi'ING
hecome subject to the Worker's C.mpensation provisions of the Latin,Code,you must SOILS FEE
lE1 forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
UO CONSTNUCI'ION LENDING AGENCY NEW RESIDFNTIALI'LMN. SQ.FT. PAID
I hereby affmm that there isacon.aruaion lending agency fonhe perfnnnuntt of Date ReceiptM
IL P the work If,,which this permit is issued(Sec.1119],Civ.C.)
O U Lender's Name TOTAL:
L1a Lender's Address TOTAL:
I cati fy that 1 have read this application and slate that the above lot ....ttoo is BUILDING FEE
fZ) correct.l agree to comply wife all city and county ordinances andstae laws retain,to QTY. MECHANICAL PERMIT FE
V Z building construction,and hereby senorita rcpssentativesofthis city mentor upon theart
` above-rocramord property for inspection pur,o,ax.
(We)agree to save,iMemmfy and keep harmless the City of Cupertino again t PERMIT ISSUANCE. ELF
Iiahilitics,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MF.CH.
in consequence oftehgranting of this permit. PLUMBING FEE
APPLICANT UNDERSTA S AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT CIO 10,1X10 CFM)
GNICIA 'E
SOUR i -GU TONS
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Sign' rcofApplicanV ommernr Dam EXIIAUST IIOOD(W/DUC'O HOUSING MITIGATION FEI!
AZAR
MA iN1A1.S DISCLOSURP.
Will ere applicant or Tum buil ngcecupum store or handle hazardous material HEATING UNIT ffD I1X1,Blq BTU)
as detinet M1y the Cupertino Manic Code,Chapter 9.12,std the Health mW Enfcty
Code,Seaton 25532(s)'I HEATING UNIT(OVER 100,100 BTU)
D Yes E]No VENTILATION PANS INGLE RES ID) PAID
400 Date Receipt Is
Will is applicant or furore building eirby the B use equipment or devices which
emlhic'? us air contaminants as JeEned by the Ray Arca Air Quality Management BOILER-COMP(JHPOR 100.000BTU) xI]
Dishier^ TOTAL: O(.
❑Yes ❑Nn ROILIeR-COMP(OVER IW,I1011 BTU)
ynircnmen p AIR CONDITIONER
I have lead ere hazardous tmos 2 5 re n under chs lar h95 erne Calle ISSIIANCP,DATE
Bmmio Idi &Safety Gudq tions 211tu 2,553]end 25534.1 undersand(half f the NEW NESIDI!NTIAI,MBCA. SQ.FT. 9_
huilAii As :not aurenayl tonum,tont It ismy mvpunsibilitymmnifythtacupum v+j
nl t� ten nope of.Ccnificate of Occupancy.
Ow r amhoriud«gem s Data TOTAL: ISSUED BY;./
OFFICE