99080003 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 10ibyD D
CITY OF CUPERTINO RUILDING.ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION'
ItUILUING pDDRHSS: SANITARY NO. APPLICATION SUBMITTAL DATE
OW ,IHS NAME: I'I LONE: CO ACTOR'S NAME: hIC M1')'.
C'l'l Z t K NIC ONTROLp
MW CHITECFSNGINEER: LIC NO: ADDRESS: ❑
CONTACT PHONE: BUILDING PERMIT INFO
.A N `' Q e I_ 2 3 � ❑ Consultant Feu Paid by Applicant(Initial) BO ELECT I PLUMB ME❑CH
1^ LICENSED CONTRACTORS DECLARAAHONQ'TY ELBCI'RIC PERMIT FEE
1 hereby arum that 1.tri licensed under prodsin,.of Chepmf 9(eemnteneing JOB DESCRIPTION
OmZ .fall lirtcassrsm dm I�RCH ECT$DECL' meoN. 17 and my Lecmcis RESIDENTIAL•
with section TXO)of Divot t Jnfthc Futures,and Prof
W O PERMIT ISSUANCE
CzW _ 0 ❑SFUWL 11 KITCHEN REMODEL
aUU Licens Lm.sf— APPLIANCES-RESIDENTIAL ❑ADDITION C1 PLUMBING RE-PIPE
E-<—U
a Doc Convector
F-Ov) )N PANELS [I MULTI ❑STRUCTURAL
MODIFICATION
ZO Z'n- UPT02MAMPS ❑INTERIOR [I CHIMNEY REPAIR
f�.yFW Lim ess ul 201-100UAMPS IMPROVEMENT E]SWIMMING POOLS
�sLE; OWN. -BUILDER DECLARATION OVER IIIBOAMPS ❑BATH REMODEUREPAIR El DEMOLITION
C Q 1 heli y affirm that u n sempt from the Convector's License Law for the
sCs6 O a U fnbcourg reason(Section TIJLShcuxincns and Pndrseicns Code,Any city or count, SIGNS ELECTRICAL. ❑OTHER
W WO y which requires a Permit to construch almr,improve,dmndish,or repair any structure
prior in its issuance,asa require%the applicant musuch permit to file a signed statement SPECIAL CIRCUITIMISC.
} thathe is licensed pursuant to the prov6lmnsofthe Contrammrs License Laos Chapters)
Icy,tY�O (mommencing with Section 7000)of Division 3 ofthe Business and Professions CWP or TEMP.METER OR POLE INST, COMMERCIAL:
a a e C that he is wunto themrrom and the basis for me alleged commotion.Any violation of ❑NEW BLDGIADDITION ❑DEMOLITION
fxi'-a- Section 7031 S by any applicant for a permit w1jechithe spPhaanuo a civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
t tome than five hundred doll..(b500). IMPROVEMENT
ESC ❑ Ls owner Uf the prnpcny.or my employees with wages as their stile compensation, SWIMMING POOL ELIiCIBIC El OTHER
F• will do the work,and thestniclum is not intended connected fin sale(See,9004,Business
all w m and Professions Calc:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-IT%TURES
loopmrty who builds or improves thereon,and who docs such work himself or through
his own emplovees,provided that such improvements am not intended nr offered Inti NEW RESIDENTIAL.HI EGFR SQ IT.
salt.If.however,the building or improvement is.sold within one year ofecmplelion.the SQ.IT.FLOOR AREA SuSQ.FT.
owncrhuoldcr will have the burden of proving that he did not build or improve for pur-
` f.wle..
C1,as caner of he prnperty,am escluosely convecting with licensed contractors 1. TOTAL:
construct the project(Sec.7f1W.Business wool Professions tided The Contreemr'x U.
ceps Law does not apply to con owner of properly who builds or improves memon.and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a contrsctons)licensed pursuanun the Conuecrors
.terns Law. PERMIT ISSUANCE
I am exempt under Sec. .Is N 1`C for this mason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner [)am
hk N'ORKER:SCOMPENSATION DECLARATION BACK FLOW PROFECT.DEVICE
IF1 hereby affirm under pewhy of perjury one of the following decimations:
l have and will maintain a Certificate MComent to self-insure for W'orker's Cnmpem DRAINS-FLOOR.BOOK,AREA,COND. STORIES TYPE.CONSTRUCTION
satin,as provided for by Section 3700 of the Labor Cede,for the performance of the
work for which this pcman is ixxued. FIXTURES-PER TRAP
1 have and will maintain Workers Compensation Insurance,as required by Section
3710 of the labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM.I INC.4 OUTLETS OCC.GROUP 7e^APN 6
My Wn ueY eon lnsumnce carrier and Policy number am: GAS-CA.SYSTP.M-OVIiR d(EA) JJ
m ct.u'
Curries s)f717 Policy ON I ROM
OO
Cr: TIIrICCOMP NSAHO INSURANCE
WfIRK1iR5' GREASEANDUSTRL WAS[it INTERCEPTOR
COMI'IiNti A'FION INSURANCIi IlU1LUING DIVISION PEES
(This section need not be completed ifthepernot is formic hundred dollars(EI(N)) GREASETRAP
PLANCHECK PER
or less.)
I certify that in the performance ofthework for which this permit is issaed,l shall SEWER-SANITARY-STORM EA.200 FE
not employ any Person in my manner so as to become subject in the Workers'CUmper- ENERGY PER
Zsution Laws of California.Doc WATER HEATER WNCNDELECFR
Z2 Applicant GRADING FEE
NOTICE TO APPLICANT,IL after making cis Certificate of Esemption,you should WATER SYSTEMn BEATING
a (g)
serious, object to the Worker'.Contponemion provisimmid the Latxn Code,you must SOILS FEE
ti fnnhwith comply with such provlsionsor this permit shill no,deemed meeker. WATER SERVICE
Q
.t.7 Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PUMP, SQ,FT. PAID Date Receipt p
U Q 1herebv infirm that there is a construction lending agency lin the performance of
— the..,it for which cis permit is issued]Sec.3097,Ci,CJ
U Lenders Nunn, TOTAL:
lender's Address TOTAL:
{S] 1 mnify that 1 have read this application and state that the above information is BUILDING FEE
CL
F N correct.I agree to comply with.11 city arta .only incidence,arta store how,relatingm QTY. MECHANICAL PERMIT FEE
U Z building cmmboo..it hcreb,mnmrire repre.emadve.ofmis city m emelmon the sE15MIC LLE
al—,na:ntinred pmpmy fnr inspection PuEa sat. PERMIT ISSUANCE
(We)agree 10,141c.Indmnnily and ss keep harmlethe Cry of against
Cucnion againELECI'HIC FLII
liabilities,judgments,crisis and expenses which may in any way accrue against said City AhrER OR ADD TOMECH.
PLUMBING FEE
inconsun thERSTANof this permit.
APPLICAeqt 1 DBRSTANOSA UWILL COMPLY WE FM ALL NON-POINT AIR HANDLING UNIT 10,00010 CFM) MECHANICAL PEE
SOURCE IIF LATIONS.
AIR HANDLING UNIT(OVER I0,00)CFM) CONSTRUCTED T
Signmu f Iirmycon ac¢t Dam EXHAUST HUGE)OVIDUCT) HOUSING M ITIGATI N FEE
HAZA DcO" MATERIALS DISCLOSURE:
Will the than combine buildingoccupant once or handlehumNoes mamoul HEATING UNIT(TO 100,000 BTU)
as defined by the Cupenmm Municipal Code,ChapmF 9.12,and the Health and Safety
Code.Section 255320)! ]ELATING UNIT(OVER 10.0X0 BTU)
Yes No
[-] � VENTILATION FAN ISINGLF.RESID) PAID Doc Rcccipt
tl% es
Will the applicant or future building occupant use equipment or devices which
.r hazardous air communicant as defined by me Bay Area Air Quality Management BOILER-COMP(JHP OR 00,000 BTU) TO L:wbk'
Dismot? BOILER-COMP(OVER 110.000 BTU)
C]Yes ❑No
I have read the hazardous mmenal.s requiremems under Chapter 6.95 of the Cali AIR CONDE I'IONER �) ISSUANCE.DATE
fnmia Ilcalth , fiery Cine.Semon.25505,25513 and 2553d.1 undentnnd that if me NEW RF.hIDENTIAI.AfIiCH, SQ.IT. 7 '2
hvilAingdue. rcntlyh:rventnumt. m
that it is my respmihiloy to unify the occupant
cloonelui ncnnwhk'hmuslh nr In iswancc nl aCedilicatcof Occupancy.
Owner or thodaed.gem Doc TOTAL: ISSUED—
OFFICE