99070016 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY R Q 7 Q D
..CITY OF CUPERTINO BUILDING.-ELECTRICAL P
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL.
BUILDING PROJECT IDENTIFICATION
RUILI)ING ADDRESS: SANITARY IN APPLICATION SUBMITTAL DATE
100 ER'SN MF.:L1 4 C TR lOMS AM' //�� 1.'3-q
Y1 N/C COMROLX
CHI ' TIENC IN ER: LIC NO: R'SS: V ❑
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CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB NIECE
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTy ELECTRIC PERMIT FEE
1 hereby of irin mat 1 am licensed under provisions of chapter 9(commencing JOB DESCRIPTION
waZ with Section]0007 of tnaian3 of the Business rofealnt a a myllcenaels
X00 PERMIT ISSUANCE ElSFDRESIDENTIAL
04-1 in folic antic t El [I KITCHEN REMODEL
tQUU limns LIc.# APPLIANCES-RESIDENTIAL. ❑ADDITION ❑PLUMBING RE-PIPE
Q 6 Date ` Commctor
'Dart ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL.
CZZ 1 understand lmll bd republic MODIFICATION
unerstanmy pans, e usere puc.. UP TO 200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
01 Licensed Professional 201-1000AMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECLARATION�1 OVER I(00AMPS ❑BATH REMODEUREPAIR DEMOLITION
tY Q 1 hereby.(Sinn that 1 am exempt from the Contractor s License Lew for the
k 3 per,V following reason.(Section]onstr Business and ve.demob Code:Any city or county SIGNS ELECTRICAL ❑OTHER
u1 u,a which requires a permit re conswct alter,improve,h Permit o or repair any swment
f-LLO.I preanal.issuance.also residues the applicant for such permit mile asignd statement SPECIAL CIRCUIT/MISC.
uhu11� that he is licensed pursuant to the proviso-of the Contractor's License Law(Chapter 9
Cp0 (comenciii ion Sectlun9(00)of Divhian3 ofthe Brnin,s,and Porman.m Cale)- TEMP.METER OR POLE INST. COMMERCIAL'
m
that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 70315 byany applicant[at, ,mit sithpa,the applicant to.civil penalty of POWER DEVICES
r r� n moa than five hi n bed dallara($500). []TENANT [I FOOD SERVICE
E-ZQ Les ownerof the norm In as with wa es us thei...lecom tion, SWIMMING POOL ELECTRIC PROVEMENT
❑ Prose Y Yet in Y g Tznsa
W se and
dothework,and Caxdse he ctureCom isnot s Lieed nee aw dos of rp( ec.'N4 carr,of Business 0 HER
3m and Professions Cde:The Conuacmre LicenseLawdo does not apply elf ownerof OIITLEI'S-SWITCHES-Fl%lVRES
his o ny who Fuels,or improve.,thereon.and who does such wink himself or through
his own sive employees,provided that such impros sold w arc not intended or completion,
for NEW RESIDENTIAL ELECTR SQ FT.
sale.ghoweventhcve thngodenof.ementithat he ithinone Wildyear
a,improve for me SQ.FT.FLOOR AREA S/SQ.FT.
ws erbullJer will nava the burden of proving that he did via buil)or improve for pur-
pose oe sales TOTAL:
❑1,m owner of the property,am exclusively contracting with licensed onset tars i-
vomer the project(Secapply
to sur
weer of property
and rty who bei Coda:)The ev thence.
Li-
cence
i- D 0
nsclswdasnotchp r moo with
aommetaro whosedpds orlmproves Commicami QTy, PLUMBING PERMIT FEE
who contracts for then pmjccts with a contrecwrts)licensed pursuant to the Conunaors
License Law. PERMIT'ISSUANCE '�152—
JUL
2gg
❑lamexemptunder Sec. ,B&PCfiathismmW NV
isnet Dam ALTER-DRAIN&VENT-WATER(EA) VAL
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under pens of perjury one of the following dec aradum: By
❑ I have and will maintain a Certificate of Comentit)self-insure lin Worker's Compen- DRAINS-FLOOR,ROOF.AREA.COND. TYPE ONSTRUCTION
cation,as Provided for by Secuon 3700 of the Labor Cale•for the performance of the
work far which rhes(omit is issued. FIXT'URIS-PER'TRAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
17M of the Labor Code,for the performance of the work far which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My
W. p�Yj1 ,�mTPolic.lauakM' � V'„Il
GAS- AF .SYSTEM-OVER 9(A)amay �lrncy No
FCATFCERTIOOrN O
FROM WORKERS' a �'31
COMP17NSATION INSURANCE GREASIJINDUSTRL WASTE INTERCEPTOR
(This section mast not be completed tithe permit is forawhundtddollats(SIM) BUILDING DIVISIO
or less.) GRGASETRAP PLANCHECK ME
(certify that in the performance oRhe work for when this permit is is>ved,lshall S[WER-SANITARY-STORM EA.200 FT.
not employ any person in any manner m as m Tarnow subject m the Workers Camper- ENERGY FEE
ZZ cation Laws of Califomia.Date WATER HEATER W/VENT/ELECTR
Q Applicant GRADING FEE
tiNOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/TREATING -
become subject to the Worker's Cmnpensation provisions of the Lahr Cada you must SOILS FEE
forthwith comply with such provisions or this varmishall he deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW 0.1i.SIUENi'IAL PLMB, SQ.FT. PAID
V 0 l hereby elBrn that there is a construction lending agency for the performance of Date Receipt#
the work for which this permit is issued(Sec.3099,Civ.C.) Q
0 Lendefs Name TOTAL:
W LenJcisAddress TOTAL:SSa
• o
I certify that I have read this application and state that the above inroar mion is BUILDING FEE
ta/] correct.l agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
V Z building construction•and hereby authmue representatives ofthis city to enter upon the SEISMIC FEF.
aMwennentio red property lin'm,.a.n mr,raerPERMIT ISSUANCE
(We)agree to save,indemnify and keep larmde,s the City of Cupertino against ELECTRIC FEE
liabilities.judgment,,cost and expense,which may in any way accme against said City ALTER OR ADD TO MECH. S A 'X
inseyuenw to granting of this penlrir. PLUMBING PEE ,e 1.O
APPLICANT i ANDS AND �' \ LY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,1100 CFM)
SOURC TIO(Y. F MECHANICAL FEE
, r1 AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
SV in Ai0licaurnauContiontor DI EXHAUST HOOD(WIDUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant some or handle haurdous material HEATING UNIT(TO 100.000 BTU)
as def ed by the Cupertino Municipal Code.Chapter 9.12•and the Health and Safety
Code.Section 25532(04 HEATING UNIT(OVER 100.000 BTU)
El Yes ❑No PAID
VENTIhATION FAN(SINGLP.RPSID)M11TAL
pate Receipt X
Will the applicant or future building occupant use equipment or devices which
nit hazardous air contaminants as difn<d by the Bay Are.Air Quality Miummoem BOILER-COMP OHP OR 100,000 BT
TOTAL:
Ui.vaicfl BOILER-COMP(OVER IOLO1U BTU
❑Y'es ❑No
I v dthehaardoas teriala myuimments unser Chapter 695 of the Culi- AIR CONUI'TIONCR ISSUANCE DATE
forma atm& utility Cde.Sec ns 25505,'5537 cad 25534.1 on cast I that if the NEW RESIDENTIAL MECH.
W docs curre(dyhaven . vnt,that'n Yrespunslbany to notif the ace ant
th t. what Cenif
r luarixdamnt Da ISSUED BY:
' TSFFICF