99120025 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES- SE BALL POINT PEN ONLY Z OOZS�
CI TY OF CUPERTINO BUILDING-ELECPRICAL P RMI NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
ItI111,DING PROJECT[Dt,.mr]F'ICATION
BUILDING ADDRESS SANITARY NO. APPLICATION SUBMITTAL DATE
C 6C6 2 5
)WNIiR'S NAME: �� PHONIi: t, NACTOR'S AME: L N(T ,5,
_ N1 NIC CONTROL#
.CHITECUENGI. ER: LIC NO: ADDRESS: ❑
CONTACT: PHONE. BUILDING PERMIT INFO
D — O [:]
Consultant Fees Paid by Applicant(Initial) BLDG ELECT P1_9 MECCH
1 l/J.�/ IrL`Nly
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby afar;;t than[ma neen,ed under Provi,io a,of Chapter 9(cormneacaa, )OB DESCRIPTION
OCZ with Sutiun100B.fDrvteon .f(hc HuFinesund rof 1 sCule.and license is RESIDENTIAL,
Wore, ,full force at PERMIT ISSUANCE
yl ❑SFDWL [I KITCHEN REMODEL
aV(~j License Cl ass Lic.p ANCES-RESIDENTIAL ❑ADDITION -1 PLUMBING RF.-PIPE
,ni c. Date Co."sao s
FDm ARCHITECf:S DECLAItAFION PANELS ❑MUCI'1-UNIT ❑STRUCTURAL
vaK- I undempo
andm,,Ixp,,hail beusedasblic accords MODIFICATION
OZ--'0 UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
(-v)F W Licensed Professimul 201-1000AMPS IMPROVEMENT 0SWIMMING POOLS
�Y E J OWNER-BUILDER DECLARATION OVLR IfXX)AMPS ❑BATH BE ODEIJ DF.12
C,C Q I hereby efftnt f un I un:exempt front the Co,,vactnt,Llceme Law 1'or the
46x13 F following reason.(Section 2031.5.Business and Professions C:da Any city or county SIGNS ELECTRICAL. ❑O 1ER
y which requires a permit to construct,tract,improve,demolish or repair any sauemre e
Fop priorn its issuance.also requires the applicant for such Permit rile a signed statement SPECIAL CIRCUIT/MISC.
f�y� that he is licensed Pursuant to the pros comes of the Commcmes License Law(Ch-"-'I
wl�m p,nnnmiain,with Sr,i..7000)olDivision 3nf;he Business and Professions Cn le)or TEMP.METER OR POLE INST COMMERCIAL'
6 6 e C that he is exempt dmrebour and the basis for thc Acged exemption.Any violisom of El NEW BLDG/ADDITION D DEMOLITION
ySection 1031.5 by any applicant fora permi,subject,the applies.,1.Or civil penalty of POWER DEVICES TENANT [IFOOD SERVICE
FZGno,more than five hundred dollars H5000. IMPROVEMENT
DLas owner of the property,or my employees with wages as Meir tole compensation. SWIMMING POOLL EL[CfRIC ❑OTHER
S�+H will clothe work,and nhn,aucmre iNoso menledonffrord fmsdc(Sec.9f W,Business
Lal�'m and Professions Code:'Ilse Counselor's License).aw does no,apply m na owner of OUTL]O S-SWI'fGHE$-PI%TURES
property who builds or improves,hereon,and who does such work himself or through
his oxn employees,provided that such impruvemm
es are not intended or offered for NEW RESIDENTIAL F.LECfR SQ
sale,If,however,the building or improvement is sold within one year of completion,the SQ.FP.FLOOR AREA EISQ.FT.
,worr-hudder will have the burden of proving that he dad non Wilder improve for pur-
pou or sale.)
Fl 1,as owner of the purser,am exclusively contracting with licensed contractors to TOTAL:
construct the peat IStt.1044.Business and Professions Cade:)The Contractor's Li- Q
use Low does no,apply to an owner of property who builds or improves thereon.and QTY. PLUMBING PERMIT FEE 7
who contacts for such projects with a cono-a a.r,)perused pursuant m the Contractor's
mj
License Law. PERMIT ISSUANCE
CJ 1 am exempt under Sec. .It&P C for Nis reasun
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Da„ 8.
,neer w
WORKER'S COMPENSATION D[CLARA'I'ION BACK PLOW PROTECT DEVICE.
I hereby affirm under Food,,ul perjury ane al,be follow,,,,declaranione, 9
Ihavcandwil,main(ainaCenilicareof Conunt,n.wlf-insuacliu Workers Compcn- DRAINS-FLOOR.ROOF.AREA.COND. STORIES TYPE CONSTRUCTION
,anon,as provided for by Section 37W of the Lahr Code.for the performance of the
work fan which this permit is issued. FIXTURES-PER TRAP
F 1 have and will ntnintnin Worker',Cmnpensmion loomence,a,required by Section
31IX0oft .bot Corp.lot they ream t ore of;he work( which,loi,permit is is„., GAS-EA.SYSTEM-1 INC.0 OUTLET'S OCC.GROUP AI'N
my r c s r u a ' CronPol Policy No. V' GAS-EA.SYSTENTOVER d(EA) _a I—O�
Carrier:
a nn X..
CERTIFICAIOF EXEMPTION FROM WORKERS' GREASFIINDUSTRL WASTE INTERCEPTOR
COMPENSA'T'ION INSURANCE BUILDING DIVISION FEES
(This Section need.,if be enniplearridNe perm,I,futurehundred dollar,gl(g) OREASE'1'RAY
1'IANCHECK PEE
or less.)
I certify that in the Nournratrc,ofthe work for which Ni,permit is issued.Ishull SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner or as m subject become subjeco the Workers'
Co.,.- ENERGY FEE
O Z ,anion Laws of C.IBornia.Date WATER HEATER W rVHN'LELECTR
O GRADING PEE
Z Applicant
NOTICE TO APPLICANT:If, herniating this Comficam of Exemption,you should WATER SYSTEMI BEATING SOILS FEE
became, object to the Workds Compensation provisions of the Labor Code,you must
CIl fonhwoh comply with such priumons or this permit shall W deemed mocked, WATER SERVICE
Q' C(1NSTHUC'I'ION LENDING AGENCY NEW RESIDIiN'l1AI.FILM, SQ,FT. PAID Date Receipt is
U 0 l hereby offunnhatthem is a con.swnina lending agency lou the perfomtancc of
U. F" ,he work for which,his permit is issued(Sec.3091.Ci,C)
Ulender',Name TOTAL:
Lendeds AJdoo, TOTAL'
1 amity,ho,I have road Nis applinni.n.,,of v.1.Ondahe aMrve ofarnwIin;t Is. BUILDING FEE
.F. to c neats.1 agreeonnply with m1 city atm county sdinanas and ante law,relating to QTY. MECHANICAL PERMIT FEF.
U Z building construction.and hereby authorize represemmives ofthi,city to enter no).the
SEISMIC PLL
abovomentioned property for inspection porpoises PERMIT ISSUANCE
(We)ngme w save indenimfy unJ keep hunnlu,the City of Cupertino ugaimn ELECTRIC FEE
Iiubili;ics.juJ,mcn;xc std ,wM1ich inuy in;my way accrue ugainnt sniA Ci(Y ALTER OR ADD'TO MECH.
PLUMBING FEE
n ce of, nl hisprmit.
APPLICANT 11 )E a NU. AN CO PLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IO.000CFM) MECHANICAL FEE
SOUR LA S.
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
S' natorc of Appb ,nVCma. or Dom EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupmt%fare or handle hamudous materia, HEATING UNIT(TO 100.000 BTU)
as defined by,he Coplanar.Municipal Code,Chapter 9.12,and the Her end Safety
Coda,Serum,25542001 ��fHEATING UNIT(OVER 1(0,0(X)BT D)
YL��^��
[3 Yes T' PAID
V ENTILAl10N FAN(SINGLE RESN) Datc HeaiptN
Will the applicant or future building occupant use equipment or devices which
mit Intuitions air contaminants a,defined by the Bay Area Air Quality Mana,ement BOILER-COMP QHP OR 100,000 BTU) TOTAL. •tom
Di"dia! BOILER-COMP(OVER 11X111(1(1 B'I U) �J
❑Yes xNn
I havere aha' materials requirements under Chapter 6,95 of the Cali AIR CONDITIONER ISSUANCE DATE
(osis Ilcahh ufe ode, sections 25 5531 and 255X.1 understand,hat if the NEW RESIDENTIAL MECH. SQ.IT.
building o uta my h mi loan;.@. ,;ray ro 'iny m ramify the occupant
of,h deli u n miv ora CcnlBcam ofoavpnny.
ant n ages Dae TOTAL: ISSUED .�
OFFICE