99100148 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY Cl I O V
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMU NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 39001
BUILDING PROJECT IDENTIFICATION
BUIL I 'At)27SS: SANITARY NO APPLICATION SUBMII'1'AL DNI I
OWNER E: �F PHOhjE: a RACr0R;S AML: LIC NO: NIC CONTROL#
/• C !
ARCI II PICT/ENGINFUR: LIC NO: ADDRLSS: ❑
PACT: PHONE: BUILDING PGRMIT INFO
/ ❑ Consultant Fees Paid by Applicant(Initial) RLDG ELECT PLUMB MF.CH
�j6 El L, -- ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEF. JOB DESCRIPTION
1 hereby affirm that I am licensed under previsions of Chapter 9(commencing
Cc'Zwith Samson 7111XB.f Division 3.fthe Busin.xsand l'mfessianx Ca.e,and myliemuis RESIDENTIAL:
O p 1117RMIT ISSUANCE
�tyF in full fomeande ❑SPDWL ❑KITCHEN ftIihIODEI.
QUU License Class Lic.p APPLIANCES-RIESIDENTIAL ❑ADDITION E)PLUMBING RE-PIPE
LL Oae Cnnvncmr_
�' A C ITELTS DECLA ON El MULTI-UNIT ❑STRUCNRAO
F 7 rn PAN[IS MODIFICATION
ypnZ I understandmyplans shall b used as public meamix
OZ�O IJPT02(%.AMPS I ❑IN'I'IiRIOR ❑CHIMNEY RHI'Alk
p4tuii Licensed professional 201-1000AMPS IMPROVP.MENT ❑SWIMMING POOLS
OWNER�BUILDER DECLARATIONOVER 1000 AMPS
❑BATH REMODELI2EPAIR El DEMOLITION
1 hereby affirm that I ren exempt front the Contracmr's License Law for the
aqqa55 O L U following reason.(Section 7031.5,Business and Pmussions Code:Any city or county SIGNS ELECTRICAL ❑OTUER
ywhich requires a permit u,ronxwct alcor.improve,demolish,m repair any suucmre
pHe,,.it,issuarre. .nequires ffeapplicant forxdch Permit o file a signed statement SPEC]AL CIRCUIT/MISC.
�} N thvi,li,xr,vd,mx...Ito the provisionsol'the Commcmrs License Low(Chupwr9 COMMERCIAL:
00'00 (commencing with Section 7")of Division 3 of the Business and Professions Code)or TEMP.MITER OR POLE INST. -
CL y q ,bat he is exempt therefrom and the basis for the alleged exemption Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
LL%1 N Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of POWER DF.VICFS DANT ❑FOOD SERVICE.
not more than five hundred dollars($500). NROVEMENT
Q ❑I,as owner of the pmpenY or my empinyces with wagesmtheir sole campensmion, SWIMMING POOL ELECT RIC
_ will do the work,and the structure is nmimended orotfered fassle(See.7M4.liminess R
W 3 and Professions Code:The Contractors License Law does not apply ro an act of OUTLETS-SWITCHES-FIXTURP_S
property who builds ar improves thereon,and who does such work himself or Nmugh
his own employees,provided,ha,inch improvements are not intended or offered for NEW RESIDENTIAL ELECTS SQ F f.
sale.If,however,the building or improvement is sold within one year of completion.line SQ.Fr.FLOOR AREA SISQ.FT.
mer-builder will have the burden of proving Nat he did riot build or improve for pur-
pose ol'svle).
Fl I.as Owner of the property,am exclusively connecting with licensed contractors to
TOTAL:
.mead the pro ur,(Sec.TW,Reim.and PrefcW...Come:)The Cantmanfs
nm Law dmonat apply man.wnelafpn,dy who hulldsor lmpmacx Nemon.and QTY, PLUMBING PERMIT FEE
who contracts for such projects with a contmctm(s)licensed pursuant to the Contmmat's
License Law. PERMIT ISSUANCE
❑I nm exempt under Sec. ,13&P C for this reason
ALTER-DRAIN&VENT-WATER IEA) VALUATION
)tuner Date 2_ ),576- 0
WORKER'S COMPENSATION CL
ON DEARATION HACK FLOW PROTLLT.DEVICE
I hereby nUnm under Penalty of perjury one of the following de rker's m:
❑.have and we for byneCion 37m Of the Labor
Code to Worker's Um DRAINS-FLOOR,ROOFAREA.GOND. STORIES TYPIi CONSTRUCTION
tatI..,as provided for mi Section)7110 of the Labor Gale,for the perfnmtmcu of,he
war ¢h chis Aaron is issuN. FIXTURES-PER'TRAP
have and will maintain Waled.,Compensa m.Interstice,us required by Section
3700olt In Gtde,for It peK me f the work for which this permit is issued, CAS-F.A.SYSTEM-IINC.40UTLEIS OCCGROUP APZ/
M Wor 's nsmiot In rune JI d otic t h 7
Came. m �
No.: fIOID lF01 GAS-EA.SYSTEM OVER4(EA)
CERTII9CATEOP E TIONFROMWORKERS' GRT;ASI/INDUS'I'RL WASTE INTERCEPTOR
COMPENSATION INSURANCE .BUILDING DIVISION FEES
(Thissecti.n need nm Mttrmpleted if the permit is forone hutmmJ dollars(SI00)
OR TRAP
or less.? PLANCIIECK 193E
I cenifythut inthe puforrimmeaf the work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 IT.
not employ any person in any manner so as to become subject the Workers Compcn. ENERGY FEE
z smion Lows of California,Date WATER GrP TER WNEoTIELECTR GRAVING FEE
z O Applicun,
fq NOTICE TO APPLICANT:If.arta,making this Cenui.te of Exemption,You should WATER SYSTFI.1?RGl'ING SOILS PER
NOoesubject to the W Ime,Compensation provisions f,he labor Cma,you must
forthwith comply wimsuch provisions or this pend shall be deemed revoked WATER SERVICE
u ❑
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL?LMB. SQ.IT. PAID ])-am Receipt p
U O kforw ichthithat
ermitthere ixnue (Sec.Tonlendingagamyfnrlheperfonnunmof
�'—' the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL:
O VLxnder't Name .
U Lender's Address TIYI'pL:
1 certify that I have read this application and state that the above information is BUILDING FEC
correct.l agree to comply with all city and county ordinances and smm laws relming to QTY. MECHANICAL PERMIT FEE
(.) be Idi ng conomminn,and lambym thoriae m,mxcnm(ives of t bis citym enter Olson'he SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE.
(We)agree m save,indemnify and keep handless the City of Cupertino against ELECTRIC PER
linbiliti.s.judgments.ctax and exlcmxcs which may sonny way accmc against said City ALI F:IX OR ADD'I1)NECK
PLUMBING FFIi
APPLICAe sof the DERST Nor this permit.
APPLICANT UNDERSTANDS AND WILT.COMPLY WITH AL1,NON-POI SIT AIR HANDLING UNIT(TO 10,U0(1 CFM) MECHANICAL P13E
SDGRGIi RF.OIILAT10N5.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature ofA,,1unm/CmimOar Dam EXHAUST HOOD(W/DUC) HOUSING MI I'IGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant Or future building occupant store or handle hauNons material BEATING UNIT(TO 100.0010 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 255720a0?
HEAPING UNIT(OVER 100,000 RTU)
❑Yes Fl No VENTILATION PAN(SINGLE RESIO) PAID Uma Recciptp
Will the applicant or future building occupant use equipment or devices which
emit hazardous air communicate,as defined by the Buy Area Air Quality Management BOILER-COMP QHP OR 810.000 BTU) T
District? BOILER-COMP(OVER 1miji10 it to)
❑Yes No
I have m, ahem us ma rials rcquiremcne under Chapter 5.95 of the Cali- AIR CONDITIONER ISSUANCE DAT,
lamm, h& d c e e, 'ecf ns 25505,8533 and 25514.I Par'vis
Char if,M1e NIiW RESIDENTIAL MSCI{, SQ.FT.
hail ' gd t ' 'e mond Netnism e'Emedadaymmid,the__..
A&
a sn nn n mus MF ounce of a Ceddicam of Occupancy.
Owner rauNoduda em Dam TOTAL' ISSUED BY:
o 27 4'
OFFICE