99080214 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY qq
oC.
CITY OF CUPERTINO BUILDING-ELECTRICAL ERMIT NO.
BUILDING DIVISION ' APPLICATIONIPERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
UUILDI/oAU�1�3 r /I 1 �(/ SANITARY NO. A ITTAL DATE
fee
OWNE ME: l " PHONE: CgN/TµIRA TORyS�/1 MB' CJ-CS ^ I 1 eL4fICiNOj�/ 7�I? N/C CONTROLp
CII INFER: IV IFW/ LIC NO: lKV_11/VLSr Aci/?I/ U/`h ,orS5 sa'IS lel CA ❑
CONTACT:a�I Ln PHONE: s•r BUILDING PERMIT INFO
�lVI Nall Lely $��3!5 n y), ❑ Consultant Ftxs Paid by Applicant(initial) BLDG ELECT P u MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby fi ref chat 1 em licensed under provis Teo o(C oad,i9(commencing JOB DESCRIPTION
OCz i@Smion]OIXB mf Division 3o(the Businasand Professions Cak,enJ mylicenu is
QW Op w PERMITISSUANCE RESIDENTIAL:
F-z nfua .Ch end eflcct. 37 ❑SFDWL [D KITCHEN REMODEL
aV�FUJ' License Cl ss G Lisp (�(- APPLIANCES-RESIDENTIAL
�<i Dam Comracmr 4-y--v.-Fi []ADDITION ❑PLUMBING RE-PIPE
F=y ARCHITE-=S DECLARATION PANELS ❑MULTI-UNIT []STRUCTURALO
Z!/1 Z� 1 understand my plans shall he used us public records MODIFICATION
J UPT0200AMPS
p [I INTERIOR ❑CHIMNEY REPAIR
a-.7 ul Licensed Professional 201.1000AMPS IMPROVEMENT SWIMMING POOLS
:'•] OWNER-BUILDER DECLARATION
Q 1 hereby affirm that 1 em eaemp from the Comracmrs License Law for the OVER 1000 AMPS El BATH REMODEUREPAIR DEMOLITION
7Rd'O y V fallowing reason.(Section 703 I.S.Business and Professions Cade:Any city or county SIGNS ELECTRICAL OTHER
yy131y F which requires o Permit to comaroo,alco,improve,demnlish,or repair any strocmre
FSO prior to its issuance.also requires the applicant for such permitto file a signed statement SPECIAL CIRCUGUNIISC.
ALL¢ that he is licensed pursuant 1.the Provisions of Committees rx LiceLos,(Chapter 9
M (commencing with Section 7")of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST COMMERCIAL:
6qi5 o q on,he is creatural therefrom and ilia basis union,alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W^N Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
not more than five hundred dollars('500).
F 2>' IMPROVEMENT
=a0 ❑Lo the work,the property,or myemntended with wages m Nei(ea 70mpeuemiess SWIMMING POOL ELECTRIC
F. will dothewons and the seContacture atnot s License awdoes(or
otsale
apply to an,Business []OTHER
63$ and Professions Cmlc:The Contractors theta's License Law does not apply s if owner of OU9'LETS-SWITCHES-FIXTORES
property who builds or improves thereon,and who nts a such work himself or through .
his own employeese provided trim such improvements within are not iyearof w offered fnr NEW RFSIULNTIAL ELELTR SQ FT.
sale.IL huwer will h builthe har impmvemrnt is at hedon wild or improve for put. SQ.FT.FLOOR AREA E/SQ.Ff.
ow enM1uiltler will have the buNen of proving rbm he did not build or improve for pur-
pou.f este.).
El I,as owner of the property,em exclusively conascuog with licensed contractors 1. TOTAL:
construct the Project(Sec.7044.Business and Professions Code:)Thc C.mn
mors U.
sense Law does not apply in an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEB
who aommms fnr ouch projects with o contrumor(s)licensed pursuunuo the Conductor's
License Low. PERMIT ISSUANCE
❑1 am escmpt nine,Sec. .B At P C for this reason
mer Data ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT,DEVICE
I hereby oRirm under penalty of perjury one of the following declarations:
0 l have and will maintain a Certificate ofComardto self-insure for Workers Compen- DRAINS-FLOOR,RODE AREA,COND.
saptinn,as provided for by Section 37M of the Labor Cods,fnr the performance of the STORIES TYPE CONSTRUCTION
I for which his
-PER TRAP
!]all orf the Labor Code,ain Worker sCompensation
or theperformance oft th
owork for which the Esmond is issued. GAS-EASSYSTEM-INC.4 OUTLETS
My Work Com cnan n lnsumn eeArler end Policy nu OCC.GROUP ANN
CaricaLf Policy No.: GAS-EA.SYSTEM-OVER4(EA) 3/1b la
CEKUFICATEO CXEMPTtONFROM WORKERS'
COMPENSATION INSURANCE GREASFJINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
('This aecuan need not be completed Him,penri t is for one hundred dollars IS 1001,or less.) GREASE TRAP PLANCHECK PEE
I certify that in the perform...I of the work for which this permit is issued,lshall SEWER-SANITARY-STORM EA.200 Fr.
not employ any person in any manner so as to become subject to the Workers'Compen. ENERGY FEE
,z sation Laws of Caldomia.Date WATER HEATER WNENT/ELEC R
O Applicant GRADING FEE
y NOTICE TO APPLICANT.If,after making this Ccrific d,at Finarmtion,you should WATER SYS]BM?REATING
a ; become subject to the Workers Conlpa.sntion provisions of the Labor Code,you must SOILS FEE
rv.t forthwith comply with such pmvisinns oT this permit into be deemed revoked. WATER SERVICE
0. �
Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLF11i. SQ.FT. PAID
V- I hereby which
thattherei isned(Sec.30 lending agency for the performance of Dete ceiptp
the work for which this Permit is issued(Sec.71y9],Civ.CJ
Lender's Name TOTAL:
Lenders Address TOTAL:
I eerily that 1 have read this application and stem that the above information is BUILDING FEE
taq c.red.1 agree m comply with all city and emumy nNinunces unJ stem Inws rearing m QTY. MECHANICAL PERMIT FEE
V building construction,and hereby awhonea representatives of this city to enter upon the SEISMIC FEE
above-mentioned perpery for inspection purposes. PERMIT ISSUANCE(Ws)agree m save,indemnify and keep harmless the City of Cupertino and ELECTRIC FEE
liabiliors,judgments.costs and expenses which may in any wayaccmea,mrs,said City ALTER OR ADD 10 MECH.
In cm,equeoce of the'mining of ILL,permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT DO 10,000 CFM)
SOURCE -0yX✓; ULATION�I_ � ) t/� MECHANICAL FEE
V-�`I-V`(////1✓' 'n7 AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
S oultal of Applic:mdCOmealm, me EXHAUSTHOOD(W/DUCE) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will dieapplicant.rfuture building occupant store.,handle hocanlous material HEATING UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(0)' HEATING UNIT(OVER 100,000 BTU)
I]Yes ❑No VENTILATION FAN(SINGLE RESID) PAID
Date Receipt M ,
Will the applicant or future building occupantuse Ana
uot ordmecs Manawhich BOILER
Do
(JHPOR W,000 BTU)
mit hamrdous air contaminants as defined by the Nay Area Air Quality Management TOTAL:
Disaicf;
Mow
C]Yes 0N BOILER-COMP(OVER IIX),0000TU)
I have read the bumrdous materialsAIR CONDITIONER
requirement under Chapter h.95 of the Cali- ISSUANCE DATE
fomia Hitgdoes&Safety Code,have
tend 25505,2s yy sp 255]4.1 to notify
Nm if the NEW NP.SIDP.NTIAI.MECH. SQ.FT.
building Jtn1& currently Sections
2 that it i113 responsibility m notify the had
if m t
of ti A! Prior In issuanceo�Cefti cute.t(Xcu
Ow r shammed gent �/ Z�)nt TOTAL:
ISSUED BY:
OFFICE