99120022 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES,U,E BALL POINT PEN ONLY ZOk9 Z Z
k.,UILDING
ERTINO BUILDINC-ELECTRICAL PERMIT NO.
VISION APPLICATION/PERMIT PLUMB NG-MECHANICAL
IIUILDINO PROJECT IDEN'TIF'ICATION
SS: A SANITARY NO. APPL CATION SUBMITTAL DATE
: �� PRONE: (+ TR ORS N ML': J
LL 'iTe[7_ N/C CONTROLa
ctIITEC1'/T 'i1N :R: LIC NO: ADDRESS: InNcWorloLPa ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PL MR MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby arfir+t that I am licensed ander proviomr..of Chapter 9(cammnncing JOB DESCRIPTION
MXZ with Section 701)(Bofllt is tithe Bmineesa 'n Qd dmyliccnx is RESIDENTIAL
- :
F 0l� in full force ar _ PERMIT ISSUANCE ❑SPDWL ❑KITCHEN REMODEL
y�{L Liccmc Class Lica ANCES-RF,SIDENGRAL ❑ADDITION ❑PLUMBING RE PIPE
aL Dam Conmac ,
F.,Dm ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑$TRUCI'URAL
Z O'er Z 1 understand my pians shall M used as public records MODIFICATION
pz47 UPT02MAMPS ❑INTERIOR CI CHIMNEY REPAIR
QEF'j Licensed Professional 201-UCOAMPS IMPROVEMENT (]SWIMMING POOL$
OWNER BUILDER DECLARATION
C ❑ 0D' IR ❑ M LI'TIO
Q i heherebyat0mt Ihot 1 um exempt Gum the Contrnemr',License[.a.I'or the
OVER HIIXI AMPS BATH R 1
X3 Or V following reamn.(Section 7031,5.Bmmea and Professions Code:Any city or county SIGNS ELECTRICAL NER
W LL N which requme,a pnmit to coo,ord.alter,improve,demolish,or repair any stmemm
0Q rt
prioo its issuance of to requireepp
s the livern funuch peond to File a signed.amement SPECIAL CIRCU[TIM ISC.
y�i +hut he is licensed pursuant lm life pruvi,ions of the Connector's Lionse luw(Couple,9
pJ� o (commencing with Section 900(dof Di...ion Sol he Basin...find professions Chief TEMP.METER OR POLE INST. COMMERCIAL
c.a e C mat he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
cd^_y Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES EITENANT 0FOOD SERVICE
not inure than five hundred doll..(5500)' =WqIMPROVEMENT
D 1,us owner of the propeny.m'my unlPloyec,with wages ns lhcirsnle nmtpemniun SWIMMING POOL ELECTRIC
�F� will Jct w
flemic.to J lhe,buchme is not innmdeJ Dotitercel fit sale(So,.Ill Business ❑OTHER
i 3 m and Professions Code:The Contrarow%License Law doe%not apply m an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon.and who does such work himself nr through
his own employees,provided thin such mo ovemem,art not intended nr off crcd far NEW RESIDENTIAL ELECfR SQ FT.
wle.if however,t he buildmgnr impro,c cm isaold within one youofmmpleti.mme SQ.FT.FLOOR AREA $/SQ.IT.
owner-buildcr will hove the burden of proving that he did not build or improve for par-
lose'if ole').
❑ 1,a,owner of the property,am exclusively contracting with licensed contractors to TOTAL:
construct he'on"(Sec.1044,Business and Prof..ran,Cede:)The Contractor,Li-
xLa.doc.nmapply n.on owner of propmm y who bwlor in+pave,thereon.and Q'TY. PLUMBING PERMIT FEE
who commas for such projects ,in a contract(s)licensed punnor,o the Collaterals
License law. PERMIT ISSUANCE
0 1 sm exempt under Sec. ,B&P C far this reason
ALTER-DRAIN&VENT-WATER TA) VALUATION /l.n
,er Dmc lY-S/
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
affirm I hereby am under penalty of perjuryone of me following decloatimi, asi, 3
❑I have and will maintain a Cenifenteof Conscnoo self-insure for Worker's Cmnpen- DRAINS-FLOOR.ROOF,AS P.GOND. STORIE .1YPECONSTRUCTION
...fano as provided for by Section 3)00 of the[,.No Cade,forme performance of the
work lin which this parol,is lamed. FIXTURES-PER TRAP
C3 1 have and will rommain Worker's Compensation Insurance,as required by Section
3900 of bbaarrCodye...fathep Rormance of the work for which this peamit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
Clamee v KJ-1 CJ In aopa+l'AiePolicy
P)icy lstt: 00
U 1 (f�L'.ILIGVWk GAS-EA.SYS'ftiM-OVER4(EA) _ C16—i+/YL
CEk1'I FICATE 01;EXEMPTION FROM WORKERS' v 1 �/V�+
COMPENSATION INSURANCE GRF,ASEfINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(Thi,smtion neN notMcompincd if the pcnnit is(Drone hundred dollars(5100) GREASETRAP
m Icxs.) PLANCHECK FEE
Icenifymat in the perfmman"mObe work for which mi,permit is i su¢d.1.hall SEWER-SANITARY-STORM EA.200 FT.
tot cnlPloy any petnan m any manner eo a,o bccmne subject to the Worker,Campen- ENERGY FEE
ZZ soon.Law,of C.Iffom .Date WATER HEATER WNENT/BLECfR
Applicant GRADING FEE
y NOTICE TO APPLICANT:IL of e,making this Certificate of lixcmptiom,you should WATER SYSTEM/TREATING
F ;
became subject b the Worker's Compensation positions of the Lahr Code,you most SOILS FEE
q fnnhwimcnmply wpm loch Nollommhis permit.hall M devoted revoked. WATER SERVICE
W Q
UZ CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL YLMB. SQ.Ff. PAID
U O k I.,wyafBrn thamit i isaced(See 3097.Cin,agency for m<pcRnrmantt of Date RtteiptN
I.L F the wad for which This permit is issued(Sec.1041.Civ.CJ
O Lcrdc,,Name TOTAL.
U I<ndda Address TOTAL:
Fy I certify Ihot I have read this application and state mat-be above information o BUILDING HE
to correct.l agree to comply with all city and county mdrimes and one laws helmingm QTY MECHANICAL PERMIT FEE
U Z buildingmmuucuum,and befcbyamhonce repre.emnives ofmi,chym enmr upom the SEISM IC FEE
above-mentioned prnpcn fm inpmction Pulp c'. PERMIT ISSUANCE ELECTRIC PEE
(We)agree to r e.indemnify and keep harmlos.the City of Cupertino egainst
liabilities,judgmem costs espenxs which may in any way accrue against said Ciq' ALTER OR ADD TO MECH.
�mwctumecto mgr +(this it. PLUMBING FEE
CANT D' . AN SAN It.LC MPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.(100 CFM)
. 'UI. 5. MECHANICAL FEE
AIR HANDLING UNI'I'(OVER 10.0(10 CFM) CONSTRUCTION TAX
Sly reof App lcanUComm Ume EXHAUST How W/BucU
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will mefipph,rolurfamre huilJingoccupum.vom orbunAlc hefrodousnale,al HEATING UNIT(TO 100,000 BTU)
at delincJ by the Cupertino Municipal Cade.Chapter 9.12,and the Health and Safety
Crdc.Scctiun 25532(0? HEATING UNIT(OVER 100,00()BTU)
El Ye, VNo VENTILATION FAN(SINGLE RESID) PAID
Date Receipts
Will the allpair canam or tumor holding ay the[s tax Area
Air Qu or devices which
mit hazardous ala comaminams acs JcOned by me 13ay Arca Air Quality Management BOILER-COMP QHP OR IIXLfpO RTU)
TOTAL:
Uisvict^. BOILER-COMP(OVER 100,000 BTU)
Cl Yc. )K�o
41 ,111"
vrvh i. Hull gaimmen'anter Chapter h 95 of the Cali- AIR CONDITIONER I$$UANCP,DATE
himode. '¢ m,25 5,25 SIJ,1 under and thin if the NEW RESIDENTIAL SUCH. SQ.ET.
buildyh responibilnymnotify the mcupant
oftIf wMena ort s softCertificamofOccupancy.0 nn Doc TOTAL: ISSUE /
OFFICE