99110101 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY FCUPERTINO BUILDING ELECTRICAL. P R TNG.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL
BUILDING PROJECT 11)ENI'Ih'ICATION
BUILDING ADD�fDRESS. SANITARY NO. APPLICATION SUBMITTAL DATE
/� 1 v
OWNER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
FE t ' r� NIC CONTROLM
CHITFC7rtiNGII P&kl I.1C N AUDR[SS: •i Er ❑
CONTACT: - PHONE: / BUILDING PEP MIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
E] ❑ Iq ❑
LICFNSED CONTRACTOR'S DECLARATION QTY , ELECTRIC PERMIT .FEE
1 hereby alum that 1 am licensed under provisions of chapter 9(commencing JOB DESCRIPTION
WOO with Section 7")of Divi.skm J ofthe Business and Professions Code,and my license is RESIDENTIAL:
F-WO in full force an
PERMIT'ISSUANCE
ce-i- I,iren lass Lica ❑SFDWL ❑KITCHEN REMODEL.
rFi16a Uaac Cmnlm APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING R&PIPE
F-Pm ARCHITECTS DELL RATION PANELS ❑MULTI-UNIT ❑STRUC URAL
Z O y Z 1 undcrsmnd my plans,had semiarid,public records MODIFICATION
OZ-nQ UP TO 20)AMPS ❑INTERIOR El CHIMNEY REPAIR
1-�ntW Licensed Pmfessional 201-1000AMPS IMPROVEMENT
e' J OWNER-BUILDER DECLARATION ❑SWIMMING POOLS
Q I herehy air,,,,,thin I an,,ammpa fmm the Commmm's Liceme Law for the OVER 1000AMPS ❑BATH REMODEVREP IR ❑D,MOLITI IN
i65,O y U following nate m(Section 7011.5,Business and Profession Cde:Any city or county SIGNS ELECTRICAL ❑ HE
ns 3 Us 1" which requires a permit In conamal,aIle,Improve,d aparkh,nr relpe r any adicame —
O ua
primm its issnce,him Teem.,thctwplit,z I fursuo file ah penniule asigneddeterem SPECIALCIRCUIUMISC.
mm� ,hat he is licensed pure..„nt m the mr,kion,it the Commetnes License Low(Chapter 9 .00
Cap (c nntmencmg svhir Sect 7000)m Dnisimt 3 of mo[I ntainted Proteseinns Code)or 'TEMP ME'TBk ok PDh]±I COMMERCIAL'
dyiS c y that he is exempt therefmnl anti the basis for the alleged exemption.Any violminn of ElNEW BLDG/ADDITION ❑DEMOLITION
W^
t�ti Section 7031.5 by ar,upplirnl I r,o.nil subject,the applicant tun civil penalty of POWER
DEVICES ❑TENANT El FOOD SERVICE
Zpc not more thou rive hundred rotors(5500) IMPROVEMENT
"O ❑I.or owner of the prolcny,or my mnploy,es with wages as their sole com,martion, SWIMMING POOL Fk, , RI
will do the work,and the sarucmm is not Intended mollend for sale(Set.70,14,Business ❑OTHER
m anti Professions CoJc:Tire Comnmtor's License Law dues not apply to an owner of OUTLETS-SWI'TCiws-RXT B
�' .. property who builds or improves thereon,unit who dues such work himself or through
his own employees,provided that such improvements am not intended or offered for NEW RESIDENTIA1.El ECTR SQ
side.If.boweve,the building or ampmvesnent is.sold within one year ofcompietion,the SQ.FT.FLOOR AREA $ISO.PT.
owner-fodder will have the burden of proving that he did not build or improve for pa,
pose of mleJ. -
❑ 1,as owner of the pmpent,,am exclusively contracting with licensed contractors to TOTAL:
consumer the project(Sec.704T Business and Professions Cede:)The Commctors Li-
useLawdoesnotapplymanownerofpropertywhobuildsorimprovesthereon,and QTY; PLUMBINGPERMITFCB
who contracts for such pmjects with a contractor(.)licensed pursuant,.the Contmcmes
License Law. PERMIT ISSUANCE
❑1 am exempt under Sec. ,B&P C for this reason
ALTER-DRAIN&VENT-WATER(EA) NNqq�� VALUATION
caner Date
WORKER'S COMPENSATION DECLARATION BACK ROW PROTEGE DEVICE
I hereby aRrm under penalty of perjury one of the following dechr793r5o
atimn: 1
❑ (have anJ will mein,ein uCertiticme of Come...self-im.m for Wacker.C..,.- DRAINS-FLOOR,ROOF,AREA,COND.
cation,as provided for by Section 3100 of the Labor Chile,for the performance of Ne STORIES TYPE CONSTRUCTION
work fur which aria permit is issued FIXTURES-PER TRAP
❑ 1 have and will maintain W aves',s Compensation Insurance,as required by Section
3700 of the labor Cost.for the pammniance of the work for which this permit is issued. GAS-IA.SYS 117M.I INC.4 OUTLETS OCC.GROUP APN
My Cameorkcr'r�CpmppnsKigryln�uyp^ P anti y'tNo,nyln�rJye:� -eOlel GAS-EA.SYSTEM-OVER 4IRA)
C'ICCRRNFFI+CATTH OF HXEMPI']ON IBONIIWfORIRKKERRS''G 10_DefH
COMPENSAI ON INSURANCE GREASFIINDUSI'RL WASTE IN'T ERCEPIOR I
BUILDING DIVISION MILS
(This ecf,ion need not R d contple, if the permit is forms,hundred dollars(SEah GREASETRAP
tar less)Olds
pPX
I eenify that in the perfurmrue-dobe work for which this permit is...act,],hall SEWER-SANITARY-STORM IIA.200 IT.
not must,any person in anynt mr,sac nsmhesonnesuh,lert to the Workers'Compen- ENERGYPEE
O 7-c
'al fonl,uwsof California.Dom WA'ILRI{ENTERWNENT/ELECTR
O Applicant GRADING PEE
y NO 710:10 APPLICAN'n If,elor makim, bis Certificate in Exemption, on should WATER SYST BM/TRCAHNG
a F' become suhject in the Worker's Contpenxedon provisions of the Labor Code,you must SOILS FEE
LS7 forthwith comply with such provisions or this permit shall he deemed revoked WATER SERVICE -
Q PAID
CONS'1'RUCI'[ON LENDING AGENCY NEW RESIDENTIAL PLMN. SQ,Iq'. Daae Recei tq
V- O t here by amtm tat there isa ed(See.30 len ding agency for the performance of
Iti the wad 6r which this Permit is issued(Sec.JBH],Civ.C.) �'-
QU Lender's Name r, /,S\ TOTAL: 1
ul Lender's Address TOTAL: J
H G 1 eenify that 1 have rear this application and state that the above information is BUILDING FEE
fn correct.I agree to comply with a0 city and county ordinances and state law.
relating but QTYMECFIANICAI,PERMIT FEE
IJ ,� building construction.and hereby authorize representatives of this city to enter upon the ¢ISM
above-mentioned property for inspection purpnsa.
(We)agree o save,indemnify and keep bnrmlev the City of Cupertino against PERMIT ISSUANCE i ECTRIC FEE
liobilides,judgm 1s,costs and expenses which may in anyway accrue against said City ALTER OR ADD TO MECH.
in comequenr, fn ting of permit. P MBING HE
APPLICAN SANDS D Will.COMPLY WITH ALL NON-POINT AIR HANDLING UNIT LTO 10,000(1 CFM) MECHANIGAtrFE
SOU
AIR HANDLING UNIT(OVF.R 10.1100 CPM) CONSTRUCTION TAX
St ma .(ApplicenJC.n error . Date EXHAUST HOOD ted/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the apparents furore building oeeupant more.,handle hamnluusmmedal HEATING UNIT LTO 100,"BTU)
as defined by the Calandra Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532(a)7 HEATING UNIT(OVER l00d W BTU)
❑Yes xfJn VENTILATION PAN(SINGLE NEED) PAID .-
Date Receipt X
Will the air co am or future Building by the B use equipment or devices which BOILER-COMP QHP OR 100,00OBTU)
nit hazurJnus air cnnmminants on JetineJ by the Buy Area Air Quality Management TOTAL: .�
Damn
❑Yes WNn BOILER-COMP(OVER I0I1,0011 BTU)
I have m, Iz rc an orad,^ rnmms orotic,Contact figs of the Coli- AIR CONDITIONER
ay 4ul, p ISSUANCE DATE _
forma Health d' c al! Scuainns 25 5,25 3 a it 25534.1 undetswnd tat if the NEW RESIDEMDAL MUCIC SQ.Pf.
niilAinccl c a t illy dv ittrainjM olaclr, notify the occupant
aril m hid a i t a� mdlt Ccni7`ie'ofI
Ow r hirrothorterd age. Dnm TOTAL: ISSUED BY:
OFFICE