99090071 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL. V P R
ITNI
BUILDING DIVISION APPLICATIONQ'ERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION �Q
BUILDING ADDRESS: ��yp� SANITARY NO. APPLICA'l1UN SDBM1f 1'1'TAI.DATE
O V V. `? Ill
dh
OWNER'S NAME: 'k E: CONTRACTOR'S NA LIC O.
NIC CONTROL or
RCIII I'IiCf/IiNGINEER: 1.1 NO: A//OS glU 1, i ��J� ❑
gL
I1 �V
CONTACT PHONE: BUILDING PERMIT INFO
Lor
r
E:1 Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB M
w ��LLICENSED CONTRACTOR'S DECLARATION l TY ELECTRIC PERMIT FEE
1 herff
hereby arm Ill.,1 am licensed uder npownion,of Chapter 9(commencing JOB DESCRIPTION
O�Z with Section]OX)of Di vision Sof the Business and Pndessiono Cade,and my license is RESIDENTIAL
W O PERMIT ISSUANCE
F ly9 In FAR force and effa CSFDWL C KITCHEN REMODEL
GOU Duet _Como APPLIANCES-RESIDP.N'I'IAI. C1 ADDITION C1 PLUMBING RI PIPE
F Z W Dema 30 Cnmmamn
m6d ElMULTI-UNIT ❑MODIR CATH
ARCHRECI'S UECLARATI(
Z p y^ 1 under tznd my plans shall be used as public records PANELS MODIFICATION
OZ4- UP TO 200 AMPS CINTERIOR [ICHIMNEY REPAIR
F EQ t'.lal L.cao,ed Prufcssinnol 201-1000AMPS IMPROVEMENT CSWIMMING POOLS
CYC; OWNER BUIhUIiH DECLARATION OVER HWAMPS ❑BATH REMODELIREPAIR [IDEMOLITION
1 tY W G I hereby affirm that 1 am exempt from the Contractor','License Law for the
.O W FJ- following (Section]031 5 Business d Prof Code Any 'ty county SIGNS ELECTRICAL []OTHER
fatLLLLON whch 4 : pe tI c I I II p d Lh rep y t ours
�' priors I - 'L y lM1 ppl I( suchpc n fl .-g d namormot SPECIAL CIRCUIT/MISC.
y
that tp . uR p fthe C tat '.1 law(Chpmr9
al C COMMERCIAL:
ul�py0 feomn,natgwth Section]IMa)of D'v's'nn9ul 0c6ua was end Profcsxi n.Ctde)or TEMP.METER OR PULE INS'P.
Q.1 c C Ran he is exempt therefrom and the basis for the alleged exemption.Any sodic .of C NEW BLDG/ADDITION ❑DEMOLITION
X-a, Section 7031.5 by any x,plicantfar.permit mbja¢the applicmtl loo civil perthy of POWER DEVICES 0TENANT CFOOD SERVICE
not more than five hundred dollars WOOL IMPROVEMENT
FSQ D I,mowner of the pmpeny,or my anpinyecs with wagcx vuhcir sole nrmpcn,ation, SWIMMING POOL ELECTRIC
N wiltdothe w,,rk,.nd,hc,w.arm isnot lnrend,do,mfered l u,uls(Sec.7044.Brsm,c,, (] 1ER
uc 3 and Pmfosslono Code:The Contractor',Licence law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
properly,who builds or imprmcs thereon,and who does such work himulf or Ih,ugh
his own employees,provided that ouch improvements out not intended or oReted for NEW RESIDENTIAL ELECTR SQ FT.
sale.If,however,the building or improvement is sold within one year ofeumpletion.the SQ.FT.FLOOR AREA VSQ.FT.
owner-builder will have the harden of pnw'mg that he did noI build or improve For pur-
pose of nI II.), TOTAL
C 1,as owner of the pro,sclF am exclusively contracting with licensed contractors pr
cron..me,the pject ISIWCade:)
ec.1 .Business and Professions The Contmemr's Li-
auLaw does not apply manowner olpmlcnywho builds orimprovestheaon.and QTY. PLUMBING PERMIT I FEE
who armmets for such projects with It amoaemds)licensed Formula to the Contmaor's
Liccnsu Low. PERMITISSUANCE
❑ l an,cceupt under Sep, ,B&P C fonukowson
ALTER-DRAIN&VENT-WATER IEA) VALUATION
Owner Date ..,
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE I /3/ O I.
I hereby mfimr under penalty of perjury one of the following declamtione ✓l.0 `
I huvc and will mainmin a Conttleam of Coloem to self-i nxum for Worker',Cnmpea- DRAINS-FLOOR,ROOF,ARE A,CON D. STORIES 'TYPE CONSI RUCTION
cation,as provided for by Section 3700 of the Labor Code,for the performmncc of the
walk for which this permit is I...ed. F1XTURfS-PER TRAP
. I have and will maintain Works(+Compensation hvinence,as terminad by Section
6of the Labor Call for the performance ofthe work for which this permit i,issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My W", Comp�n:'tlnn lncumnce caricr and Palley number are' ../I /�/�
Grier: brLPP�,j-I+G PulicY Nu'.�GID-IB3JFiIVr GAS-IiA.SYSTEM-0VHR 4(EA) 310 �{1� r,
CERTIFICOMPENSATION INSURANCE
WORKERS' GREASEIINDUSIBL WASTE INTERCEPTOR F/
COMPENSATION INSURANCE BUILDING DIVISION PEGS
('Tbissection need not he completed if the penial it(or one hundred dollars 151Off GREASETRAP
or le„1 PLANCHECK FEE
certify that in the performance of the work for which Im, carmul is ivied,l shall SEWER-SANITARY-S'I ORM EA.200 IT.
not captor any person m any manner o,as nr bceome sobjceuu the Waken'Compete ENERGY FEE
ZZ salmon Lawn u(Califomia.Date WATER IIIiNI"ER W/VENT/ELECTR GRAUZZGEEE_��_�
O Applicant
N NOTICE s TO APPLICANT:IL after Conmakingthis Tenons f of Exemption.you should WATER SYSTFiM1t/1'RFATING 5 145 F"�B S 1
F'[ become a could,
to IM ..It E s Comb or 11, provisions of the Labor Cola. mull q t ,� V
fnnhwith eantply with web provisions ur Ill,permit shall h Jecmed revoked. WATER SERVICE
Q
a
CONSTRUCTION LENDING AGENCY NEW RGSNENTIAI.PL.MB. SQ.FT. P 1
V4p I hereby affirm that hem is a coRUmclion lending agency for performance of t
L16 H the work for which this permit is I.sued(Sec.3097,Civ.C.) TOTAL.
Q U Leader,Name
'TOTA1,:
Lender,AJdA,,
r �tI
y I ceni(y that 1 have read this application and Iwo,that the above inform nwa i, CS )LNG PEE
F' sA _E
covert.I agree to comply with all city and county ordinances and stale laws m1mingto QTY, MECHANICAL PERMIT FEE SEISMIC tT'
V Z building conswctinl,and hereby authorise apresenlmives ofthiscily menter upon the
abnvcmentioned pol for inspection purposes. , PERMIT ISSUANCE
(We)agree a,Irma mdemnify and keep harmle„the City of Cupertino agaimsl ELECTRIC FEM"
Iisbllllics,judgments.cousard expenws which may in any way acemeagainst said Coy ALTER OR ADDTO MECIL PLUMBING FEE
in mn.uyuence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL ON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
MECHANICtIJENJIf
E ULA ION �f
1Vl AIR HANDLING UNIT(OVER 10,(NIU CPM) CONSTRU
SOU
Signuumc it Applicuou Contractor I flaws I EXHAUSTHOOD HOUSING N&JION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building overprint stn,or handle fiamrdous mamrial HEATING UNIT(TO 100.100 BTU)
to defined by the Cupcnimo Municipd Cade.Chapter 9.12,and the Health and Safety \
Cute.Sation 25532(a)P
❑Yea sl`ty^(T/ HEATING UNIT(OVER 100.000 BTU)
VENT LAI]ON FAN IS I NGLI?RESID) PAID
nate Receipt N
Will the applicant or mr (wilding tecupon use cyuipmcm or device,which BOILER-COMPDHPOR 1X.000 BTU)
In bmardous air contaminants a,defined by the Ray Area Air Quality Marmg ramnl TOTAL:
mnicC' BOILER-COMP(OVER 100.000 BTU)
Ye,
I Lame read the haam ominal.,rerulretucnt.,under Chapter 6.95 of the Cali- AIR COSTA FIONER ISSUANCE DATE
forma Health&Safay Calc.Sectlops 25505.25533 and 25534.1 undemm�J that if the NEW RESIDENTIAL MECH. SQ.ET. O O �i
building espm
not currently have a tenant.that it i,my rsibility w i(y the, cow Y ( r
of m
ta
'ah ptio to issuance o(a Cc t
U n m on'ecJ agent Dte TOTAL: ISSUED BY:
OFFICE