99080151 (2) APPLkgANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 7 0 g 0 J 5
CITY OF CUPERTINO BUILDING.ELECTRICAh
BUILDING DIVISION APPLICATION/PF.RMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. ATE
C)390 fc.n �� (meg , j_ g9
0 NBR'S NAME: PP{ONE: CONBiR7C'I ORS NAME: I.IC NO:
/4l hsc-O I� �.��5� / NIC CONTROLto
RCHIFECT/ENGINEER: LIC NO: A ES: ❑
0 97 s• �aF.a.% 1ikal .
)NrACf: PHONE: BUILDING PERMIT INFO
� !�` ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
J V l F-1L_❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm Nm 1 am licaused under pmvisions of Chapter 9(commencing JOB DESCRIPTION
DC, will Sec non 7000)of Division 3 onhe Business and profession,Code,and my license is RESIDENTIAL,
O Ofall PERMIT'ISSUANCG
CWS License
effect. ❑SFDWI. ❑KITCHEN REMOOEI.
QVz V Licence Class I. X APPLIANCES-RESIDENTIAL ❑ADDITION 94061.ZHUNG RE-PIPE
yQi [)air[)airCCoontractor
ARCHITECT'S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
FON PANELS
R O y Z 1 underswnd my plans shall he used as public records MODIFICATION
0--4-0 UP 10 2M AMPS ❑INTERIOR [1 CHIMNEY REPAIR
a4t:W Licensed Professional 201-10MAMPS IMPROVEMENT 0SWIMMING POOLS
ps Y f_1 OWNER-BUILDER DECLARATION OVER ILW AMPS UR
❑BATH REMODEEPAIR ❑DEMOLITION
st 1 hereby M.shat I am cxcmol from the Conlmcom's License law for theas
3 LL U following reason.(Section 7031.5.Business and Professions Cade:Any city or county SIGN$ELECTRICAL ❑OTHER
calN which requires a permit to construct,aheq improve,demolish,or repair any sBunure
prior to its issuance,also requires the applicant for such permit t file u signed statement SPECIAL CIRCUIT/MISC.
F j•i
that he is licensed pursuant to the provisions ofthe Contractor's License Law(Chapter 9
W 6C (commencingwith Stied..700nof Division 3ofthe Businca,mad Professions Codeor Cnpgn4EpgleL�
wi ) IEMR MITER OR POLE INST.
that he is exempt therefrom and the antis fur the alleged exemption Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
�N Section 703).5 by any applicant for a Permit subjects the applicant a a civil penalty of POWER DEVICES
hot and.than five hundred doll..MUM. ❑TENANT ❑FOOD SERVICE
h Z> IMPROVEMENT
f=� ❑Lo the work,and
property,structure myotinareeawiNwadolposbeirmde 0LLB sines SWIMMING POOL ELF.CI'RIC ❑OTHER
f., will dmhework,andtheheCois bees License
do s not apply 7014,owner
os
LL�1—�_ and Professions Code:The Cnmthere.License law spec not apply s if owner of OUTLET$-SWITCHES-FIXTURES
a 3 properly who builds or improves thereon,and who does such work himself or through
his awn employees,e provided that such improvements an not intended ofcm offered for NEW RESIDENTIAL ELECTR SQ FT.
owne L however,the have
building burden
of improvement is mlhe did non ill or I completions the SQ.FT.FLOOR AREA EISQ.FT.
er-builder will have the huNen of proving that he did not build or Improve for olio-
psae of sale J.
❑ 1,as eny,owner of Ne Pmpnm.,Iacively c.a,...in,with Ilea dad utnrmnors to TO FAL
mmme,the project(Sec.71144,Bailouts and Professions Cade:)The Commetor's Li-
ninLaw does hot apply it)an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such Projects with a commctor(s)licensed pursuant m the Consmcto's
Licensee Law, PERMIT ISSUANCE
❑1 am exempt under Sec. .B&P C for this reamn
Owner DataALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE!
1 hcrehy air,-under penalty of perjury one of the following drelamtitnv
I have and will maimain a Cenifican all Consent toself-imine for Worker's Compen- DRAINS-FLOOR,ROLE AREA,COND. STORIES 'TYPE TRUCTION
14 Iron,as outside]for by Sarin.371 N)of the].aha Code,]or the pdifmn an.of the /
work or which this permit Is mad. FIXTURES-PER TRAP
1 have and will maintain Worker's Ctmpenmtion Insurance,as required by Section
37Wofthe Labor Code,for the performance ofthe work far which this permit is issued. GAS-EA.SYSTEM-I ENC.4 GOITETS OCC.GROUP
My Wor kColpenszti�y urge carbrand Policynla c til GAq_EA.SYSTEM OVER4(Eq) O
Currier 7 �• olicy No.: W—.
CERT] ATF.Oil EXEA ION FRO WORKERS'
COMPENSATION INSURANCE GREASEBNDUSTRL WASTE INTERCEPTOR
flhis station need not becomple el ifthe permit is forone hundred dollars(SIM) BUILDING DIVISION FEES
or less.) GREASE TRAP PLANCHECK FEE
I certify that in theperformmiaul'the work fill which this permit is issued,Tdall SEWER-SANITARY-STORM EA.200IT.
not employ any person in tiny intoner so as to become subject to the Workers'Comilla- ENERGY FEE
Z ,z satlon Laws of Calidmad.Data WA'I'HIt HEATER WNENT/ELECI'R
Applicata - GRADING FEE
fin NOTICE TO APPLICANT:If,afar making this Certificate of Exemption,you should WATER SYSTBMOKEATING
a ; Fredric subject to the Worker's Compensation provisions mile Lubar Gavle,you moat SOILS FEE
Uj forthwith comply with such Provisions or this proma,hall be deemedrevoked. WATER SERVICE
9L.
o z CONSTRUCTION LENDING AGENCY NEW RISID N 1ALP MB. SQ FT. PAID
L) O ]hereby affirm that then is a construction lending agency forthe pieformanceof Date Receipt#
IL F the work foe which Nis permit is issued(Site.3097,Ci,C.)
OU ],ad,,v Name TOTAL:
"U Lcndcr's Address TOTAL:
1 certify than I have read this applicat i n and state than the above information is - BUILDING FEE
ti corrvcl. agree to comply whh all Illy and conmy oNinancea nnA stoat laws relating m QTY. MECHANICAL PERMIT FEE.
U z holding construction,and hereby authorize representatives ofnhis city to enter upon the SEISMIC FEE
abave-memidned porgandy for inspection purposes.
(We)agree to save,indemnify end keep hmmless the City of Cupertino against PERMIT ISSUANCE, ELECTRIC FEE
Iiabilities,judgmena,costs and expenses which mayinany wayacerueagaiml said City ATTER OR ADD TO MECH.
in consequence of the griming add,Fern' PLUMBING FEE
APPLICANT UNDERST IS AN I COMPLY WITH ALL NON-POINT AIR HANDLING UN TOD 10,000 CFM)
MECHANICALFEE
' tRCE REGU TIO
8 -97 AIR HANDLING UNIT(OVER 10.014)CIM) CONSTRUCTION TAX
Sigt�i a�eof App OdorCamowdu v Data EXHAUST HOOD(W/DUCD HOUSING MITIGATION HE
HAZARDOUS MATBRIALS DISCLOSURE
Will the applicant or future building(secular,sore to handle hazardous material HC INC,UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Gate,Chapter 9.12,and the Health and Safety
Cale.Section 25532(x)'! HEATING UNIT(OVER 100.000 BTU)
❑Yes ON. VENTILATION FAN(SINGLE RES ID) PAID -
Dare Receipt N
Will the applicant infumrc building y the B use Area
Air col or devices which BOILER-COMP OBPOR 100,MW BTU)
it uct, us air contaminants as defined by the Bay Area Air Quality Management TOTAL:
n?
❑Yes 0N MOILER-COMP(OVER 100,(gO BTU)
I have read the humNou.s materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
Lima I leullh&Safety Cade,Sri,on,25505,25533 and 25534.1 understand That if the NEW RESIOHNTIAL MECH. SQ.FT.
huilding does not currently haven tenant,that it is my responsibility to notify the ace.p inn
til the re
which mu.m he nml prior to issuance of a Certificate til Occupancy.
Owner or authmizeJ agent Date TOTAL: ISSUED BY:
OFFICE