99120050 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 'J'�Q
CITY OF CUPERTINO BUILDING-ELECTRICAL a ER IT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
LDITN DRESf: �r -SANITARY NO. APPLICATION SUBMITTAL DATE
IL
O�ry`ER'S NAME: PHONE: TRACTORS NAME: LIC NO:
W I�I(pIh Ci 55—!9 z/0 LN C N/C CONTROL#
ARCHITECT/ENGINEER: LIC NO: lr AD ESS:. �J J ❑
0 J< J0,Az, .BIwb
CONTACT: PHGNE: BUILDING PERMIT INFO
a S 3-0b (g ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
rat. ❑ ❑ �—_ ❑
LICENSED that ID CONTRACTde,p DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that 1 am If the Bu under provisions of Chapter 9(commencing JOB DESCRIPTION
qpZ with Senion]000)of Division 3of the Business and Professions Code,and my license is RESIDENTIAL'
F O
in force and eHem, PERMIT ISSUANCE,
Ot W F r ❑SFDWL El KITCHEN REMODEL
b-U U License Class Lin.p
mQ6 Date Contractor APPLIANCES-RESIDENTIAL ❑ADDITION CaTLQRlBIN,�G RE-PIPE
ARCHITECT'S DECLARATION PANELS FDr� MULTI-UNIT STRUCTURAL
'Z O y 7a I understand my plans mall homed.,Public records MODIFICATION
OZ-q UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
FElLLLL] Licensed Professional 201-IfNX1AMP5 IMPROVEMENT
aW ..1 El SWIMMING POOLS
COWNER-BUILDER DECLARATION OVER 1000AMPS ❑BATH REMODEUREPAIR El DEMOLITION
1 hereby affirm that 1 nm exempt from the Cnmrudor's License Lew for the
F.�y U following reason.(Section]031.5,Business and Professions Cade:Any city or county SIGNS ELECfRICAL ❑OTHER
which requires a permit to construct,alter,improve,demolish,or repair any structure
fn JJJ priorm its issuance,also requires the applicant for such Permit to file a signed summand SPECIALCIRCUIT/M19C.
P. that be is licensed pursuant to the provisions of the Contractors License Law(Chvprcr9
W aO (commencing with Section 7")of Division 3 ofthe Business and Professions Code)or TEMP.METER OR POLE INST. OAL
d y o C that he is exempt Nerdmm anA the hasis for the alleged exemption.Any violation of rW BIAG/ADDITION ❑DEMOLITION
i� WN Swti ve 7031.5 by any applicant for a permit subjects the applicant to a civil penally of POWER DEVICES
C not more than five hundred dollar,($500 . TENANT ❑FOOD SERVICE
sc D
SWIMMING POOL ELECTRIC IMPROVEMENT
4 Y2 will do the work,and the suvcture is net intended oroffemd for sale(Sec.]O44.Business COTHER
and Professions Code:The Convector's License Law does not apply to on owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements am not intended or offered fon NEW RESIDENTIAL ELECTR SQ FT
sale.If,however,the building or improvement is sold within one yearof completion,the " S F ORAREA VSQ.ET.
owner-builder will have the burden of proving that he did not build or improve for pur-
❑pns1-nf salon. l j CC Q
1,as owner of the property,am exclusively confessions with licensed contractors i- TOTAL: �J - V
construct the es not(Sea o an ownBuser
of and property
fessionswho lute Code:i The Cs thereon', nLi-
come
c c law does not apply to m owner of pmpeuy who builds or improves thereon,and QTY PLUMBING PERMIT FEE D C of
who contracts for such projecu with aparticipants)licensed pursuant o the Contractors G ��
License law. PERMIT ISSUANCE �t ,
❑ lam exempt under Sec. ,B&PCfor this reason
99
Date
ALTER-DRAIN&VENT-WATER FA) VALUATI
nr
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the following declarations,
LO]Ow(ehave and will maintain a Certificate of Consent to self-insure for Worker's Comped- DRAINS-FLOOR,ROOF,AREA,COND. STORIES ECONSTRUCTION
station,as provided for by Section 3900 of the Labor Code,for performance of the
w k ich this permit is issued. FIXTURES-PER TRAP
nr have and will maintain Worker's Compensation Insurance,as required by Section -
3700ofthe LahnCudafor the perfturanceof the work for whichyana permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCG GROUP AD
Carrierr 's Co pe_jIbrt atiay)nsyrpn Is'Pnl yNo.rand ��� A��C9 0 GAS-EA.SYSTEM-OVER4(EA) ll
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFJINDUSTRLWASTE INTERCEPTOR BUILDING DIVISION FEES
(This vection deal net becampleted if the permit is furore hundred ddllars(SIM) GRPASR TRAP
nr less) PLANCHECK FEE
I certify that in the performance of the work for which this permit is issued,I shall SEWER-SANITARY-STORM EA.2M FT.
znot employ any person in any manner so as to became subject to the Workers'Comped- ENERGY FEE
action Laws of California.Date WATER HEATER W/VENT/ELECTR
O Applicant I GRADING FEE
y5 NOTICE TO APPLICANT:If,after making this Certifies,of Exemption,you should WATER SYSTEM?ftEAT 1NG
F Fw beco nc uil jam m the WOdrees Compensation provisions of the Labe,Code,you most SOILS FEE
Wforthwith comply with such provisions or this pecousleall be deemed revoked. f WATER SERVICE
Q
CONSTRUCTION LENDING ng agency
NEW RESIDENTIAL ELSE. SQ.PI'. PAID
U work
by whichaffiran Ria Pe them isa issued(See
agwdy for the Performance of Date Receipt#
Oi-+ the work for which this permit is issued(Sec.9097,Cie.CJ
ULeashes Name TOTAL:
{t:
Leashes Address TOTAL:
I certify that 1 have read this application and state that the above information is BUILDING PP.E
r ry correct.I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
7a. building construction.and hereby nnthod:e representatives of this city p.color upon the SEISMIC FEE
ahove-menitoned property for impeedi n purposes. PERMIT ISSUANCE,
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way came against said City ALTER ORADDTO MECH.
in consequence of the'pantin'of this or . PLUMBING HE
APPLICANT UNDERS ANUS . WILL COMPLY WITH ALL NON-POINT - AIR HANDLING UNIT(TO 10.000 CFM)
SOURCEREG LAT S, MECHANICAL FEE
�, AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Ap IicenVCo or Date EXHAUST HOOD(W/DUCT7
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU)
its defined by the Cuperiao Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532(a)7 HEATING UNIT(OVER 100,001 BTU)
Yes ❑No PAID
VENTILATION FAN(SINGER RESID) Date Receipt#
Will the applicant m future building by the B use a u it Qu orMinidevices which
t haza,dnus air contaminants as defined by the Bay Arca Air Quality Management BOILER-COMP(3HP OR 100,0110 BTU)
TOTAL:
District? BOILER-COMP(OVER I0NI,IX10 BTU)
❑Yes ON.
(have read the hezdNods marorials rcquircments under Chapter 6.95 of the Cilli- AIR CONDITIONER ISSUANCE DATE
fornia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does not company have a tenant,that it is my responsibility to notify the occupant
of Has,appointment,which most he met primp.issuance of.C mficate of Qcupancy.
Owner or authorized agent Date TOTAL ISSUED BY:
OFFICE