99090154 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY D
CJTY OF CUPERTINO BUILDING-ELECTRICAL P
BUILDING DIVISION APPLICATIONITERMIT PLUMBING-MECHANICAL
,',BUILDMGPROJEGT'IDENTIFICATION,,',: ;VI,
BUILDINQ.ADDRESS:' - SANITARY NO. APPLICATION SUBMITTAL.DATE.
n.
�3�7 Cdr., Cfit 9- 2�-py
AILVNER NAME; li PHONE: CO AC'FORNJAMME '� LICU:
NIC
to Z 5 C.) 9 S El
CONTROL.#
RCHITFCTMNGINEER: LIC N0: - ADDRESS: ❑
LUQ 47
CONTACT PHONE: - r;+;+is .;L,BUILDING'PERMIT[NFO `.`
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
Fra ❑ ❑ H- ❑
LICENSED CONTRACTORS DPCLARATION QTY + / ,EL2CTR1CPE.RMTT:,' yt+� } �. FGF (}f�
I hereby alBrn m t 1 licensed a p f Chapter 9(comms g - _ - r..:: , JOB DESCRIPTION
awZ wiN$eefon71N10)ofD"slon3 of the Bnxtnessand Pn fes inns Code emd myl ce tseis RESIDENTIAL'
WOO PERMIT ISSUANCE
FW in full force and effect ._..._ ❑SMWL El KITCHEN REMODEL
License Class Lic.# APPLIANCES—RESIDENTIAL ❑ADDITION 5'P66tG1BINO RE-PIPE
tOQ0. Dale Contractor
ARCHITECT'S DECLARATION ❑MULTI-UNIT El STRUCTURAL
Z p m Z I understand my plans shall Fz used as public records PANELS MODIFICATION
O Z 4.. OF TO 200 AMPS
F PAIR
4F: Licensed Professional El INTERIOR ❑SWIMMINGNEY POOL
201-IMOAMPS IMPROVEMENT SWIMMING POOLS
OWNER-RUILDLR DECLARATION
pC C < I hereby affirm that I am exempt from the Comrecmrs License Law for the OVER LBW AMPS El BATH REMODEVREPAIR [I DEMOLITION
�'3 F following mason(Section 9031.5,Business and Professions Code Any lily air county SIGNS ELECTRICAL []OTHER
r� which fequir u a permit m construct,el¢q improve,demolish,or repair any structum
duaheasisemncc,ala ore qui f 1. fiepnviditimnlfor Con perminoice...aw(Chaper9 SPBCIAI.CIRCUITIMISC.
�I thatheislicenwithSecond700)afDisiods3outhe a,,cc,,,,.CeropLawtsC.dOr9
w�p 0 (eat he is Ing with Semon]000)th basisfor of the aged sass and Professions Code)of TEMP METER ES POLE INST. COMMERCIAL:
d m c C4 Sen he is exempt therefrom and the basis for the alleged exemption.Any it penalty
of ❑NEW BLDGIADDITION [_1 DEMOLITION
kmW Seelon 90315 by any appllcentford permit subjects the applicant madvil peoahy of POWER DEVICES
• ❑TENANT [I FOOD SERVICE
>y tmu.as than❑vs,hundred dollars($500)eemployees
FSD ❑ Lo the work,and
property,onnyenntended with wages r ale(Sea 7W4,Business SWIMMING POOL ELECTRIC IMPROVEMENT
F' will do thework,antlthe swctureinnot lmonded or ntt red forsale
apply 7044,Business ❑OTHER
W 3 m and Professions Code:The Conductor's License Law dues nut upplY to an owner of OUTLETS—SWITCHES—FIXTURES
property who builds cr improves Ihereng.and who docs such work himself or Through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECT SQ ET.
sale.If,however,the building or improvement is sold within one yearofeompletion,the .FLOORAREA $/SQ.f?
mer-builder will have the burden of proving that he did not build or improve for pnr-
puss of ole).
I,as owner of the property,am exclusively contracting with licensed contractors no TOTAL:
construct tM1 project fS7094 Business and Professions Cade)The Contractors Li-
panic
Ten Law does not applyt f property who bolds or improves thereon, d QTY, 1;PLUMBING PERMIT+ -.r {,IFEL- r _
who lot r such projects mm
)ects with a contracr(s)licensed pursuant the Contractor's {,P
License Law. PERMIT ISSUANCE
❑ lamexemplinder Sec. ,B&PCfonhisreneon
ALTER—DRAIN&VENT—WATER(EA) VALUATION
r Date
WOR KER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby aff rte under Pastry of pail one of the following declautions:
I have and will maintain a Certificate of Comona to self-insure for Workers(Temper- DRAINS—FLOOR,ROOF,AREA,CONTI. STORIES TYPECONSTRUCTION
'inion,as Provided for by Section 37M of the Labor Code,for the pedomnence of the
work for which hes Permit is issued FIXTURES—PER TRAP
❑ 1 have and will maintain Workers Compensation Insurance,as required by Section
3700 of the Labor Code,for the Performance ofihe work for w hich this permit is issued GAS—EA.SYSTEM-1 INC.4 OUTLETS OCCGROUP /
Carrienduraw,J �IO�PN
M WurCourturo�te as once dinnerandPolicyq
Policy Nut i542$$ Y
tl
GAS - o
CER'I'IFIC—I ATE OF EXEMPTION FROM WORKERS' ev
COMPENSATION INSURANCE GREASIVINDUSTRL WASTE INTERCEPTOR E R R w 1 %a•$
(T'he,,dation renderer he cnmpletedif Nepermil is bsone hundrul dnllarc(5100) B I OIN�DIVLSIONF -Ssm
or less.) GREASE TRAP a R
PLANCHECK FEE
I certify that in the performance ofthe workforwhich this permit is issued,l shall SEWER—SANITARY—STORM LA.200 PT.
not employ any person in any manner so as to become subject to the Workeri Comped- ENERGY PEE
z ,`L, srtion Laws of Cali turns.Date WATER HEATER WNENT/ELECTR
0 Applicant GRADING FEE
y NOTICE TO APPLICAN'E If,after making this Certificate of Exemption,you should WATER SYSTEM?REATING
F^ become wbje0 or the Malacca Cmm-croution provisions of(he Labor Code,yon must SOILS PEE
W' ferhwith comply with such provision.,,his pecar,hall be deemed revoked. WATER SERVICE
1
a
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. i
U 0 k for wh affirm that thea issco (See 3dlending agency I.,the PeRnrnance of ��o Rw p#
LTs F
the work for which this permit is issued lSec.309],Civ.C.)
Q
Lender's Namry dnTOT"La
[IJ Lend Add - TOTAL G,r IJP 1-j'
W I rfylhtI o with. ppF-m dtatethatd ab format - - .f. ,. .. tai-.tt B ILDING,PLEY
h aorret legreet pIY 'th ll clY d q N en .and:rtel 'refer gt ,QTY. MECHANICXLPERMIT .-I': s t.+ FEEL,
U ,7. hu Id g tnmwm nn and busbymthoriz represenmf res of Ih's c p m emu upon the ++,t j` S 1 MIC FEE
abo a medtioned property fair impact...u p.,,vm. PERMIT ISSUANCE
(We)tons,1.leve,indemnify and keep harmless the City of Cupertino against E ESRICFEE
liabilities,judgments,costs and expenses which may in any way seems,against said City ALTER OR ADD TO MECH,
in asequence of the Granting of his penni1 PLUMBING FEE
APPLICANT UNDER TA AND ILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,00n)CFM)
USCF.REGULO MECHANICAL FEE
9-?-7- I AIR HANDLING CONSTRUCTION TAX
Signal ppli nUC Date EXHAUST HOOD ONMUCT)
BAZAR rOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building occupant store or handle hazaNarkedueeial HEATING UNIT(TO 100,000 BTU)
as defined by Ne Cupertino Municipal Code,Chapter 9.12,and the Heuhh add Safety
Code,Section 25532(a)Y HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑No PAID
VENTILATION FAN(SINGLE REBID) Date Rn 1
WdI the applicant or fusion bidding ocenpant use rquipmem or desires which
emit hamnlcus air certamidadds as defined by the Bay Area Air Quality Managctead BOILER-COMP LHP OR 100,000 BTU)
District,
❑Yes E]No BOILER-COMP(OVER 100,000 BTU) ,
I have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER IS$UANCFD
Linda Health&Safety Cede,SecI s 25505,25533 an1255 34.I understand that if the NEW RESIDEN'T'IAL MECH. SQ.FT,
building dons not carte has ant,merit is risibility in notify themcupem
o[Nere ¢h hs mu issuance ofd ifiwte of Occupancy. `[
r
Own ranch 'zed agent Date TOTAL: ISSUEU BP.
OFFICE