99120105 (2) APPLICAPITTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 12 0/ V Zj
CITY OE CUPERTINO RDILDING-ELECTRICAL PI7RMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLIIMONC-MECHANICAL. dim
BUILDING YRIIJECT IDEN'1'IFICATIUN
SANITARY NO. APPLICATION SUBMI MAI,DAT
BUILDING ADDRESS'.
4.760
OW :S NAME: PHONE CON' C'TOB:SN E L )' NIC CON TRol,#
aw If -/'�39 -
RCfIITF,CTITNGINEF,R: LIC NO: RESS: ❑
4sd
'ONTACT: PHONE; BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG EI1FCI' PLUMB MECH
❑ Ni ❑ IQ
LICENSED CONT'RACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIP'T'ION
I M1rrchy nmol mal 1 am licensed under provisions of Chapter 9(commencing
=aZ echo saaiun?oDnef uivi,ion3enne Bn,ine,.and sins stens Cndc.una my liana ix RESIDENTIAL,
W O PERMIT ISSUANCE
x-ir- LicenlseCcl`nd cB 2U Licp `� ❑SFDWL ❑K.UMBIN NG Ric-PI FE
I- U —� APPLIANCES-RESIDENTIAL. ❑ADUTTIQN ❑STRUC URAL PIPE
FW Doc Con rvidar DECLARATION ARCHITECT'S DECLARATION PANELS, ❑MULTI-UNIT ❑STRUCTURAL
F y Z I undennnd my plans shall he used as PUM1Iic records MODIFICATION
Z O4-o UPTO 200AMPS ❑INTERIOR [-]CHIMNEY REPAIR
oz..
E+14„#]W Licensed Professional - 201-1100 AMPS IMPROVEMENT E] INGPOQLS
�s1 ; OWNER-BUILDER DECLARATION OVER loss)AMPS E]HAITI RF.MODEhIREPAIR DEMOLITION
yy a y' 1 hereby affirm that 1 eat exempt!runt me Conbermil,License Law for the
uj a Q following retnoa(Section 9031.5,Business and Professions Code:Any on,or county SIGNS ELECTRICAL ❑O'THIiR —
W h" which requires a permit to construct,alter,improve,demolish,or repair any xwcture
�.�06 Vr url t I: q tb .ppl. hierarch p in II .6 cancrem SPECIAL CIRCUITIMISC.
There lots dp : ua h P : : fm C t h License 1 (ChapmrY
COMMERCIAL:
W a00 (Commencing with Section 9100)clDvtson 3ofthe Husncss
not C.: Gdc)or TEMP.METER OR POLE INsI'.
L L e thin he ix exempt therefrom and the basis for the alleged'-coal ion.Any violation of ❑NEW BLDG/ADDITION ❑DEMOL.ITION
W:2 Soceion 90311 byany applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FUOIJ51?RVICE
net more than fisc hundred dellars(8500). IMPROVEMENT
s� pl.as nwnerol the Pmpeny,mmymnploya,with wage,un their,ole mmpemntien, SWIMMING POOL ELECTRIC
❑Q'fIIER
F• will dwm
,kcnrk.and thearmaue ,raq intended olfercd for,:delSer,0044,Hostiles,
Lail m and Procession.Code:The Contractor's License Law does not apply m an owner of OUTLETS-SWITCHES-FIX'fUREs
property who builds or improves Ihavan,and who docs such work himself enhmugh
his awn emPloyces,provided that such improvement,are not intended or offered for NEW RESIDENTIAL ELECTR SQ h r
sale.If,hrow,%lbe building or improvement i,sold within one year or marpldioo,role SQ.FL FLOOR AREA VSQ.IT.
owere,locildor will have the burden of proving mat he did not build m Impmvc our Pur-
freeofsale). TOTAL: -.
❑I ufJineproper" I ,v ly contractingwith Focused ctet I'r
sonsImuffic prolisa(See
7044.B c,,and Profession,Cod ) 'to C t ,L-
PEE
I d ttapply toan fpr property h bardsp nd QTYPLUMBING PERMIT
whoamtmctslrwchp�cros wnM1umnvactnHq licensed Vunuam tothe Cu mcnd Up{
License Law. PERMITISSUANCE DEC
lam exempt under Sec. ,B&P C for this rea.on DEC
ALTER-DRAIN&VENT-WAITER FIG VA.
Ownu Irate
WORKER'S COMPENSATION DECLARATION BACK FLAW PROTECT.DEVICE
1 hereby affirm under penalty of permits one of the following dceloodua s.
ev
J l have and wdinerinwin.Ccnificmeof Commas.self-i ns.to fns Worker,Conolf- DRAINS-FLOOR,ROOF,AREA,COND. FTORIES TYPE )NS'I,UC'1'10
,at I.as ,,,video Iia by Section 9910 of the l.ubnr Code,for he perfnnnanee of the
w k forwhichfluk,cellisissued. FIXTURES-PER TRAP
I have and will maintain Worker's Compensation Insurance,as required by Section
900 oftbc Labor Cafe.for the performance of the work for which this Permit is Issued GAS-EA.SYSTEM-I ING,4 OUTLETS OCC GROUP �J�PN/
My Wnr rs mPc mtie�lY,tRs1�+c ter dPoIY_ ? �m.��l-��� Ip S-EA.SYSTEM-OVER 4 WA) �C 3
Canters M [J
CER'IFICATE OF EXEMPTION FROM WORKERS' GRHASEANDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION PEES
(Dissector need not becnmpated lfneperred is Forane hundred dollars(5 000) GR17ASETRAP PLANCHECK FHE
or lc„0
I,any an,
in 0tc an,i,comer oftho a b,bekbawdject ,permit is,heWokers Comfort SEIVER-SANITARY-SIT OHM GA.200 FT.
not cmPluy any pcnon In any manner en as m hcasme subject to the Worked Comfort
ENERGY FEE
Zi ration Lawson Culifsmia.Dare WATER HFA3'ER WIVENTPLECTR GRAVING FEE
OO AVPBc:tnl t
G NOTICE 10 APPLICANT:Il:al'Icr making his Cer idianc of P mnption,you 1M1uuW WATER SYSTEMcIREATING
f~ ctane sub ed to the Wnd rl,Cmn tion f he LaborCude,you.1.1111 soil's FEL'
he
J penia nmvisionxe
Pki � funhwim comply with such provisions nnM1is permit shall be deemed revnkW. WATER SERVICP.
Q
a
CONSI'RIICTIDN LENDING AGENCY NEW RESIDENTIAL PLMI3. SQ HE PAID
U nate Receipt#
1 hcrehy eosin that there Is a cumwctinn leading agency Ba the pc+[armanm of
the work for which this permit i,issued(Sec.3097.Civ.C.) 'TOTAL
Q Lenders Name TOTAL:
, Gia Lead—Addeess BUILDING II?H
1 verify thus I have read this application and stow that The above inlnrmahinn is
tH. tA visitor l agree to comply with all city and county ordinances and stare laws relating to QTY. MECHANICAL PERMIT PEE SEISMIC FEE
U building consmnmioe,and hereby-notice laPresenatives of(used,to enter upon the
those-ntenioned property for Inspection pmpones PERMIT ISSUANCE ELECTRIC FEE
(We)aglcc m save,indemnify and keep harmlc,s me City of Cupertine against
hatuditicx,judgmens,cast and expenses which may in any way accrue agereassid City ALTER OR ADD TO MECH. PLUMBING FEE
In wnxequenceof the granting or this formed.
APPLICANT UNDERSTA NILS AND WILL COMPLY W131I ALL NON-POI N'1' AIR[IAN DUNG ON 11(TO 10,0x)CFM) M12CIIANICAL FEE
SOURCE( ' �UyN'R/IAS.� / J,�G AIR HANDLING UNIT'(OVER 10.000 CPM) CONS'i'RUCTION'LAX
Signature of Appine Contractor Date EXHAUST HOOD Giod7 q ROUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haeardeu,material IIEATING UNIT(TO 101,00()TO
u,refined by the Cupcnino Muneopol Code,Chapter 9.12,and the Health and Safety HEATING UNI'!(OVER 100.00)BTU)
Code,Section 2553201)^
❑Ye, Fl No VENTILATION FAN(SINGLE RESID) PAID
Line Rva"I#
Will he ap,dirnnt or came holdne,oacupenl use cgtipmum or devices which BOIL ER-COMP(311P OR 110,000 BTU)
it ha'eanl a,air contaminants as dafincd by the Bay Arca Air Quality Management TOTAL:
istric@ BOILER-COMP(OVER 104000 B'TO)
❑Yes ❑Ne
AIR CONDITIONER ISSUANCE DAV
1 hove scud the hazardous ions materials 5,2553 cntd under Chapter 6.95 of the tribe
forma Health&$sling Coda•,Scniens 255!15,2553?and 25534.1 undemmnd mut tribe NIiW RESIIIENTIAI.METE
CII. SQ.E4.
building day/�tit cu I huvcaI 0 shat itixmy responoind y m notify the occupant
or mo rentyFme wMc roan lwp�onoi.xaanee era ecnireate�nf nonan,
//SS / iDla'CI' TOTAL: ISSUED BY:
savor suthar'vW' col
OFFICE