99110025 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CJ O 2-15
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERN'IIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: 4 SANITARY NO. APPLICATION SUBMITTAL DATE
`2 0 o o q
OWNER'S NAME: PHONE!: CON1'RACE ff IR'S NAM': ,IC NO
AMLW��I.L [, �� J IMg, d( 21,. YV �-S'I/j 33 NIC CONTROL#
RCHTEECT/ESGNEER: LIC NO: ADDRESS: ❑
2-13 Y V-Vt,; " cc tti (O LL
CONTACT: PHONE: BUILDING PERMIT INFO
CDRSB11aB1 Feu Pail by Applicant(initial) BLDG O PLU❑MB MOx
2S `/2 O 33
LICENSED C(1NTRACI'OR'S UECLARATIONQ'TY ELECTRIC PERMTP FIiG
hereby affirm that 1 am licensed ander provisions of chapter 9 tgommendng JOB DESCRIPTION
0c,ace, with0I of Ui
staics.700via/g��lofthc Business anJ fessions Csale,and my license is RESIDENTIAL
F�S in full farce and effect.J7 "o 't PERMIT ISSUANCE ❑SFDWL E3 KITCHEN REMODEL
aUU
ices, so S
<.n -J / APPLIANC1!S-RESIDENTIAL ❑ ❑
ADDITION PLUMBING RE-PIPE
Q Uatc-g Cnmrumor
ARCHUHCPS DELI. WION ❑MULTI-UNIT ❑STRUCTURAL
PANT.Ll
Z p y Z 1 understand my plans shall be used as pts c records MODIFICATION
OZNC UPT02MAMPS [I INTERIOR ❑CHIMNEY REPAIR
FAL Licensed Professional 201-l")DAMPS IMPROVEMENT (]SWIMMING POOLS
C
W S; OWNER BUILDER DECLARATION OVER 1000 AMPS C1 BATH REMODEUREPAIR ❑DEMOLI I'ION
w a• 1 hereby affirm That I ren exempt from the Contractors License Law Por me
X 3 U following reason.(Smion 7031.5.Business and Professions CWe:Any city or county SIGNS ELECTRICAL ❑OTHER
W c*N which pa,a ev a permit to customer.sues,improm
ve,demolish,or repair any mmemrt
It,0a priorits issuance,also mxNd .,Ihe applicm m
forch vannitun fleasigned statement SPECIAL CIRCUIT/MISC.
y}V that he is licensed purmtmt to the pnwlvnns ofthe Contractors Licmbc Law(Chapter 9
ft
WW (commenting with Section 7000of Di omat 3 of the Business and Proles.ssmCode)or TEMP.METER OR PULP INST.
i
d a e that he is exempt mertfm rnand the basis for the alleged exemption.Any vmiman of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any applicant for a pertniixubjects the applicant to a civil Penalty of POWER DEVICES TENANT ❑FOODSERVICE
not more Than five hundred dollars(3500). IMPROVEMENT
FqZQ ❑ Inn'awneroflheprnpeny.or tnycn+pinywswilM1 wa6esasthclrnole nnn1comion, SWIMMING POOL ELECTRIC
2�G will do[lie work,and the shucture,is not intended moRercd Tuttle(See T),W.Business ED 01
Wm and Pm(essions Calc Ute Contractors License Law does not apply to en owner of OUTLETS-SWITCH S-FIXTURES4140
a 3 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 for NEW RESIDENTIAL F.L.ECfR SQ FT. /
,ale.Il,however.the bnilding or ntpmverri iold within one yenrofeninpinlun.The .FT.FLOOR ARTA LSQ.FP.
ter builder will have the burden oI'proving that he did not build or improve lar pur-
pose of sale.),
h as owner of the propeay,am exclusively contracting with licensed contractors To TOTAL:
ommuet the project(See.")Baa.Business and Prufesxions Cale)'Ihe Cmnmctor's Li-
Lies does nm apply m an owncrof property who buihL or hu,no,es Tharc on,and QTY. - PLUMBING PERMIT FEE
who contracts for such projects with v conwctor(s)licensed pursuant to the Contractors
License Law. PERMIT ISSUANCE
❑1 am exempt under Sec. .H&P C for this reason
ALTER-DRAIN&V17NI'-WATER IEA) LU DON
Owner Use v
WORKER'S COMPENSATION DE!CLARAI'ION BACK FLOW PROTECT.DEVICE /�
1 Herter elfirm under penalty of penury one of the following aedarahons: 0
I Traversal will mvintuina Ccnihca¢nf Conxnuusdf-invuref Worker's Compcn- DRAINS-FLOOR.ROOF.AREA,COND. STORIES TYPE CONSTRUCf10b
sation,us provided for by Section 3700 of the Labor Code,for the performance of the
work for which This permit is iswed, FIXI'U R ES-PER TRAP
C] I have and will maintain Worker's Compensation Insurance,as required by Section
3700slits,lade Code.for the Performance of the work for which this permit is issued GAS-EA.SYSTEM-1 INC.A OUTLETS OCC.GROUP MIN
My Workers Compensation Insurance carrier and Policy number art: GAS-EA.SYSTEMOVERa(EA)
Currier: Policy No.:
CUR I'119CA1'80FIi%EMPI'ION I7ROM WORKERS' GRT:ASI%INDUS'fRI.WASTE INTERCEPTORCOMPENSATION INSURANCE BUILDING DIVISION PEES
(ThisseNanneceralhccomplctd ifthcpermit isfmanchundrcdda1lars($100) GREASETRAP
or less.) PLANCHECK FEE
Imuifythat'mme dovnmmeaftheworkfor spend stbl shall SEWER-SANITARY-STORM EA.2fM FT
rntpluY any"int in n so to to beam +T is Cumpcn- 1!HGY FE ,I
OZ satins Laws I alidimi unncr WATER DRAPER W/VEIJTTLECTR IR DING I:Eff— I k
APIAit
z O NEI T APDL NT:If,after making This Candles of Exemption,you shoulJ WATER SYSTEM)TREATING St1rL5 FEE
a ' buanme xubjea to t is
Cou,s nsatian Prov +m o(the Lahr Cdc.you must
{T.1 Earhwilh eumplyw.Iii such nulkiornor this pantit n'hull he dcanialmvaked. WATER SERVICE
•0. ~
Z) z CONSTRUCTION[.ENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. D
U p T hereby aftion that Them is o construction lending agency for The Performance of p Data Receipt Er
U. the work for which This permit is issued(Sec.3097.Civ.C.) Oy��
QU Lender's Name O
} TOTAL:
Lcndcr.Addmss
1 I certify that 1 have nation,application and scant that the above infomadmin is BUILDING FEE 7
F to correct.I agree a+comply with all city and county ordinances and scam laws relaing to QTY. MECHANICAL PERMIT FEE �O
SEISMIC FEE
U Z buildiegeonstmction,mod hereby authorize represemctives oflhiscity to enter upon the
abo e-us"trotted no, ,far In..account purpmu'. PERMIT'ISSUANCE
ELECTRIC Ff.]:
agree it)save.indenm
ify and keep harmless The City of Cupertino against
Iiafill ies.Jjeunclfllh�
costs and expenses which may in any way vccme against said City ALTER OR ADD TO MUCH. PLUMBING FEE
in enmeygmntin6 of this permit.
RSTANDSAND\"LI.COn '.Y WITH ALL NAN-POINT ATRHANI)I.INGUNITpolo.(xx)CT'M) MIECHANICAL PEE
I INS.
AIR HANDLING UNIT(OVER I0000 CFM) CONSTRUCTION TAX
Signs er Applicanl/Contrdctor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
I IAZA 11) US MATERIALS DISCLOSURE!
Ville upplivnnt or fuwm buildingum,musmmor handle hnmNou,neineial HEA'T'ING UNIT(10 I00,00n)BT U) /J�� -
as dcOnd by the Cupertino Municipal Code,Clmpter 9.12,and The Health and Safely `—/ 1S
Coda Section 25532(a)° HEATING UNIT(OVER 100.00)B'FU)
❑Yes E]No VENTILATION PAN(SINGLE BUSH)) PAID Date Receipt# YJ�•5i
Will the applicant or morin bnilding nnuupv n sae eyuipmcm in devices which BOILI!N-COMP(31111 OR❑M,INM BTU)
:mil Tornados,air contaminants as dcfnd by The Bay Arca Air Quality Management TOTAL.
Disnirt? BOILER-COMP(OVER 100.000 BTU)
Dyes 0N
I have read the haaaamm,nee,nals rets under Chumr 5.95 of the Call- AIR CONDITIONI!R ISSUANCE DATE
forma He th&Safety Cde,Sectio 5 . 255 aM 235}1,1 understand that if the NEW RISLDENTIAL MECH. SQ.PT.
building canmeurmnTlymort a .t Ipmsibilitymnmifytheseeupast
of The s 'nu which meq .s ce uCenihcme of tlxcuptncy. r /
O ramhnrimA age
Orae TOTAL: ISSIII!U HY: G7
OFFICE