99120021 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE B L POINT PEN ONLY Z
CITY OF CUPERTINO BUILDING.ELECTRICAL PERMIT NO.
BUILDING DrvItiION APPLICATION/PF,RMIT PLUMBING-AIF.CHAh'ICAL "
BUILDING PROJECT'IDUSTB,ICATIITN'
99
If, TV
ADDRESS SANITARY NO, APPLICATION SUIIMI'ITAI.DATE
N q� e MCP nif
N RNAME: HONE: CONTRACTOR'S AME: NIC CONTROLM
e _µ2 P
❑11'I'IiC'1'IIiNGIN,ilt: .L'NO: ADDRESS I p ❑
CONTACT: PHONE: I IBUILDING PERMIT INFO
6 I O — I ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELLE PLUMB SUCH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT PEE
G al Z 1 haeny amt.,mal I ant fianaed ismer prnvixio.x of chaplet 9 mommendng JOB DESCRIPTION
lh Seeion70(10)of0ivision J the Businevsand Pit fe sem Code.alta license is RESIDENTIAL:
WOO ntfall moc/itr lc < PERMITISSUANCE
W ❑ADWL ❑KITCHEN REMODEL
< U Licenu( ; s L. PPLIANCES-kIiSIDENTIAL []ADDITION ❑PLUMBING kIi-PIPE
t') Dute CUmmen
w 1 n I TECTS DIiCLARATION ❑MULT'I-UNIT ❑STRUCI'URAL
Z O ti Z 1 undersand my plans shall be used as public records PANELS MODIFICATION
UP10200Ah1P5
OZ-0 ❑IMPROVk ❑SWCHIMNEY MING REPAIR
F admW Licensed Rofcssiowl 201-IWAMPS IMPROVEMENT C]SWIMMING FOOTS
al
OWNISR-BUILDER UIiC1.pRAT10N OVER IWOAMPS C1 BATH REMOD USE P ❑D 1 LITIO
C C d I hereby affirm Thal I ant exempt from the Contractor's 1 iccnse Law lia the
Y
OW O following reason.(Section 7031 5,Business and Professions Code:Any city or c,army SIGNS ELECTRICAL ❑O IEqR
3 W, which repaires a permil to construct.alter,improve,demolish,or repair any.aruclure `e f
F_-u•0¢ poor to its issuance,also requires The applicant for such permit o file a signed statement SPECIAL CIRCU UUM ISC.
� Y
that he is licensed pursrmitto the provisions of the Contmcrors license Law(Chapter 9
Wa00 (commencing with Section'I(MV)of Division Sof the Business and Profesio„s Code)or TEMP.METER OR POLE INST. COMMERCIAL:
dp,e That he is exe;npl thercfron,and the basis for the alleged cxcmptl m Any violatlon of ❑NEW BLDG/ADDITION ❑DEMOLITION
W^�N Section 7031.5 by any applicant for a front salow,the applicant Toscivil pcnallynr POWER DEVICESita (]TENANT [:j FOOD S17RVICH
F-=Qm mole than five hundred dollen D5W). IMPROVEMENT
Q Las owner of the pmpeny..r my employees wish wages ns their wle comPenmlion, SWIMMING POOL ELECTRIC
EFO will do the work,and menlruclum in an,intended or offered for sale(Si TBW.Business ❑OTHER
all an and Professions Code.The Contractors License Law does not apply m an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or Improves thereon.and whit docs such work himself or through
his own employees,provide)lhm such imprnvemmah arc not imm�JeJ or oTfurcsl for NIiW RESIDEN'ITAI.ELL'CTR SQ
sale.If.however the building or improvement is sold within nae yea a coupinion,dre SQ.Ief.FLOOR AREA SISQ,FT
own
crl,uilder will have the burden of proving that he did not hold or improve for Lam ataiih
-
pox of sale.).
❑1,as ovomr of the property,am exclusively c'nmmeting with licensed contractors in TOTAL:
tract the project(Sr,71W4,Buslnese and Pnd¢sions Cider The Contractor's..i-
sCLaw dnus nrn applymme—C-1propcny wImbuild—,meavives,hamm,.and QTY. PLUMBING PERMIT FEE
who contracts for such projects win,a commdnrts)licensed pursuanuo the Contractor
L,ceme law. PERMIT ISSUANCE
❑1 am cwmpt under Sec. .Is k P C for this reason ALTER-DRAIN&VEYI'-WATER(EAI VALUATION
Date
WORKERS COMPENSAI ION DECLARATION BACK FLOW PRO]ECT.DEVICE ten/ q
iter l hereby affirm under penalty of perjury one of The following dedaralion, I 1 a
Q I have and will maintain a Certificate of Cor id to self-insure for Workers Compete DRAINS-FLOOR.ROOFAREA.GOND. STORIES 'TYPE CONSTRUCTION
wtio.,as provided for by Section 3700 of she Lahr Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
I have mW will maintain Worker's Cormemation Insurance,m regain d by Section
37110n1'the Labor Cdlc.Ln lh perfnnnunce of The work for which this permit is ssncd, GAS-EA.SYSTEM-I INC.4 OUfLE FS OCC.GROUP APN
My Wo j i Policy /T/y�
Canner. policy No.: VoaP�IQ.CXJO�. GAS-EA.SYSTEM-OVER4(RAT
CERTIFICATE OF EXEMPTION MONT WORKERS' GRfiASFIINDUSTRL WASTE INTIiHCEPFOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need net be completed It the permit is rnrcme mummddoll.n(sl(X) t1R1iASE TRAP
nr Icss) PLANCHECK FEE
I cenifythat in the pe.rlimnarecoflhe work for which this peril is issuN,Ishall SEWER-SANITARY-STORM EA.2W FT.
not employ any person in any manner so m m hmme subjecno the Wnrkes'Coat ENERGY FEE
Z sotto.Laws of California.Date WA'ITR HEATER WIVENTMLECI R
Z O Applicant GRADING FEE
NOTICE TO APPLICANT:H.after,mnking,his Certificate of Emmplinn,you.should WA117R SYSTEMGREATING
F Imo" become xabjec,m the We,kn^s Cumpenaminn provisions of the Lahor Code,you mm� SOILS FEE
forthwith comply with such proviovarsnr this pnrh shall be Aecn,edrnvoked. VIA]17R SERVICE
0
� z CONSTRUCTIONLENDINGAGENCY NEW RESTDENTIALI'LMB. SQ.FT. PAID Dam kccciplM
U O Ihenby affir lthatthereem isisao construction lending agency for the performance of
F he work for which This[nnrout is isxned(Sec.301 Civ.C.)
Gla TOTAL:
Lender's Name
U4 LenAerie, TOTAL:
Lender's Aerie,
1 vethat 1 have read thiv application and suite that the above information is BUILDING FEE
F" Vat rify Coact.l agree to comply with all city and county ordinances and state laws refiling to QTY. MECHANICAL PERMIT FEE
U Z building construction.and hereby authorize representatives of,his city to enter upon the SEISMIC FEE
alrove-amntioned property for impeclien purposes. PERMIT ISSUANCE.
(Wel ngrce e;sa,•,in11 fy unit keep Immdess the Cil,of Cupenino against ELECTRIC FEE
liabilhics.jndgmcros, as and expenses which nwy in anyway acerae against said CllY ALA 17R OR ADD TO MECH.cosnwgoenee of 9 f f1his pen il. PLUMBING FEEAPPLICANT DE A SAN ILL C H ALL NO I-POINT AIR HANDLING UNIT(TO 10.000 CFM)
MECHANICAL.FEE
SOUR(' .'LU )NIS
' AIR HANDLING UNIT(OVER 10,011)CENT) CONSTRUCTION TAX
Si mlof pIav;TTCm or Dmc EXHAUST HOOD(W/UUCP) HOUSING MITIGATION FEE
HAZARDOUS h1ATERIALS DISCLOSURE
Will the applicant or Name Wilding occupant smre or handle hazardous material I(EATING UNIT(TO 10i BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safely
Cade,Section 25532(a)^ 1 , 1117ATING UNIT LOVER I00,M)BTU)
❑Yen' Al No VENT ILATION PAN RES I D) PAID Dmc Receipt at
Will,he applicant or future Wilding occupant use equipment or devices which
emit h rat dous air contaminants as defined by the Ray Area Air Quality Management BOILER-COMP(3HP OR 100.000 BTU) TOTAL.
District? BOILER-COMP(OVER 100,000 BTL)
❑Yes .
I have the tots mmcrial,m,maaorms order Chupmr 6.95ofthc Cull- NRCONIIIi'IGNIiR ISSUANCE DATE
tomia 11.11 Sal 'od Sections 255 -33 and 15534.1 underswad Thal d he NEW RESIDENTIAL MECH. SQ.1'L
Anil - g no, rely a amnanh sant' liy,o..life he rccuNm
hie uM be aCen,ficate of Occupancy.
atm , uJ agent Uuro TO'1'A L: ISSUED BY:
OFFICE