99120048 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL 71NO. APPLICAHON
IT I NO,
BUILDING DIVISION APPLICATIONIaERMIT PI.uSmING MECHANICAL
BUILDING PROD C`1 IDENTUTC 11UN '
tSANITARY SUBh11 i'IAh DAI
BUILDING ADDRISS:
0Jt .RS NAME: n PHONE.: t� CO tACfUR'�NAMb hIC NO: CON'FROI.M
07 J �� 905
\RCHITECT/ G CER: LIC NO: AD RE9$ 0 `^z- nw
IU��7 S• IL SI O
CONTACT PHONE: BUILDING PIiRMII'INI°O
❑ Consultant Foes Paid by Applicant(Initial) BI,DG C[LLCI' PLUMB MECH
G.I . masa-cis ❑ ❑ �— ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby afifirn,that I am licensed under provisions of Chapter 9 mommeming
W0Z with Section 7000)of Division 3 Of lsusinus and l'mfessions Cssde.unJ my license is RPtiIUENTIAI
ILL-�� in full forecrndeffca. I'IiNMTT ISSUANCE ❑SFDWI. El KITCHEN RIiMOUEI.
aUV Liccnse Class LieI APPLIANCES-RESIDENTIAL. ❑ADDITION GI:PIPE
vFi6a Urns Cnmmmnr ❑MUCfI-UNIT ❑STRUCfURA
ARCHITECTS DECLARATION PANELS MODIFICATION
Z O r4 Z I undcrstund my pions shall he used ns public ree:nds UP 1021X1 AMPS
OZ-0 ❑IN'I'PRIOR ❑CHIMNEY REPAIR
�r!1~.a Licensed Pnir"intil 201-1000AMPS IMPROV EMEN'I' �SWIMMINO POOLS
OWNER-HUILDER DECLARATION OVER I"AMPS ❑BATH REMODEUREPAIR ❑DEMOI.1'I ION
C 6 1 hereby affirm that 1 am clent,from the Contribute,License Law for the ❑OTHER
K�W U following reason.(Scetion 70315.Business and Ihnfcssions Code:Any city lir county SIGNS ELECTRICAL
3 LL which require,a permit m construct,alar.improve,demolish,or repair any strucsure
F-'4'O< prior to its1 4 the ppl t for suchPermit in File a signedstatemenr SPECIAL CIRCUIT/MISC.
F, y
In,he licensed Pursuant tthe porvir,ince.ofth Condommes License1' (Chapter9 COMMERCIAL
W 00 (utnmencingwith Swan 70010of D'vi'on3 of tire Business dI " vs Cudc)or I'LMI'MhI'ER OR IN)LIi INS'!.
❑N
aq e C
thin he is escmpl Therefrom and'he basis for the alleged exemption.Any vialetion Ill
BLDG/ADDITIONElOh:M01.1'170N
p(.gLL Section"!031.5 by any applicant for a pemtilsuhjects the applicantmacivilpenaltyof POWER DEVICES ❑'fIiNANT ❑FOOD SERVICE
W H n mine than File hundred dollars($500) IMPROVEMENT
I-ZQ Q Las owner of the pmpenY.or my empinyen with wages as their hale compensation, SWIMMING POOL ELFCCFRIC OOTHER
fFa will do the work.and'hestruc'ure is not intended or offered for sele(See 7(W.Business
i 3 and Professions Cttdc:The Contractols License Law dues not apply to an owner of OUTLETS-SWITCHP_S-IIxNRES
,,,,,ay who build,nr improves thereon,and who does such work himself or thmugM1 NIiW RESIIJENTIAh ELIiCI'R S N'
hi,.own employees,provide that such intpmvere"Is an nal intcnAW ar ulrcred lar 4Q.:[:I¢IeLO('lR ARCA
$ISQ.FL
.sale. .suld within one carol nnetwo,am
owner-builder will havetbe burden of proving thud he did not build or Intpmve fur pur-
Thew If sale.), 'P(DAL:
T.as owner of the properly.am cxdusively contracting with licensed contactors ht
construct the project(Sec.7041.Business and Profichnm ss Cee:)The Comnctor's Li- ,i
PLUMBING PERMIT FEE
c w taw does not apply to w owner ofproperty whothads or improves themon.and Q'rV. DECwmowmmcds fmsuch projects with acowm
non(s)beemedpumuht
ant the Contructoes ��JEC 7ioa
I Licence Law. PERMIT ISSUANC17 J
Fj Inns list under See ,B&P C tiro this reason
AEPER-DRAIN&VVNT-WRI'ER(EA) " VALUATION
Ownor Date r
WORKERS COMPIiNSA170N DECLARATION BACK PLOW I'ROTIiCI'.DEVICE —_•'��- J1 /l
I hereby.,,Inns under penalty of perjury ane of the fallowing declandians:
0Ihave and will maintain aCcnihonre of Conwnunwlf-inzure for Walker's Corinth- DRAINS-FLOOR.ROOF,AREA.CONI, STORIES TVP HUCfB
xenon,as pmvided for by Section 37M of the 1.at or Cee,for the performance of the
work for which this permit is issued. PIX'I'URES-PER TRAP
she and will unit On W Lee,Compcmmion Insurance.as required by Section
1700 of the lather Code,lot the performance of the work for which this Tama is issued. CAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP e / rT M'NT32—
My Wo- 'xConq mmiopiwa a cami ,and Policy num /Y /Y' L-
Came, 01_pub,Na: fir t�� -]eja GAS-EA.$YBTI?M-OVlllid(EA)
CHR'I'1FICA1'E OF EXEMPT ION FROM WORKERSGREASEPINDUSTRI.WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
Utas section need not hcomtAcmd iftm Txnnitism,one hulalredolnn($IW) GREASETRAP PLANCHECK FEE
or less.)
Loy any that int he Kifivarnance work permit ller'Co.I shallmpen- SEW[R-SANITARY-S'T'ORM EA.2IX)14. ENERGY FEE
not employ any p-nnn in any mann-nn as to hecomc subjen to the Wnrkeci Compen-
z sinion Laws of California.Du¢ WAfIiR 111?ATER W/VIiN'I'/ChIiCTR GRADING IY[
Z
NOTICE
subjdject to the Worker afar making this Certifier'-of Hama)ion,you should WATER SYSTCM/IRIiA'1'I?
O Applicant
faunam APPLICANT H Sous PEE
's Cnmr<nvmm provisions of the meed ,ode.you mall
forthwith comply with such provisions or this permit sh511hdremcd rcvokcJ. WATER SERVICE
Q PAID
a
CONSTRUCT ION LENDING AGENCY NEW REMDEISTIAL PUIB. SQ.IT. Dam HcceiptM
O I hereby affimuhat there is a conswction Tending agency!ache pcannounce of
V
U F the work Por wM1ich th'IX permit is is,ucd(Sca.31191 Civ.C) 'TOTAL:
Q U1,eader's Nana' 'TOTAL:
1.-ndces Address BUILDING IEE
a 1 certify that I have mad this.applicution and elate that the above into mesion is
(n coned l agme ht comply with all city and county ordinances and slam lawsranting o QTY. MECHANICAL PERMIT FEE SEISMIC FEE
U Z budiingennswctim,mal herebyautaodle rcprewmativcsmRhin ch,locramnian Nc
alrove-memmural property for inspection Purlxnes. PERMIT ISSUANCE EI.ECfRIC FEE
(We)agree it,have,indemnify and keep handless the City of Cupertioo against
Iidilities,judgments,costs and expenses which may in any way accrue against said City ACT iR OR A DO TO MITCH. PLUMBING FEE
Inme'u,me of the grammg of this pc iI.
APPLICANT UNOI?HS' ITSA LI.COMPLY WI'TII AL1,NON-POINT AIR DANDLING I1NI'I'CTO 1140BB CFM) MFCHANICALFFE
CE REGI '1'1 S
•���_�� AIR HANDLING IINI'1'(OVER 11,000CFM) CONSTRUCIONTAX
Signal of App icanUCmnrm G Dam TiXHAUSTHOOD(W/DUC) HOUSING Nil'FIGAT1ON FEEi
I IAZARDOUS MATENIM S DISCLOSURE
Will the applicant or future building occupant sine lir handle ham Nous mmerial HEATING UNIT(TO I(0,0)0 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,radial,Health and Safety HEATING UNIT(OVER 10,0010 BTU)
Code,Section 1553200'?
Fl Ye, L]NO VIPvTH.ATION PAN(SINGLI7 lost—) I'AIII
Dam Recciplu
Will the applicam e,future building m oceupeuse submi nentnr device,which BOILER-COMP 13111'OR
c IW.IXX)BTU) O�
mit hvandous air e,mmunt ams as defined by the Buy Arca Air Quality Management
L
, ❑No BOILER-COh1P LOVER I(p.oBl)BTU)
AIR CONDITIONER Iti\UANC13 DATE:
mad the hamrmem mu Want,mquimmcnt+under Chapter fi 95 of the Cali-
&SLIP,,,Cec,Sections 255115.25533 and 25534.1 uectuand that if the N17W RESIDENT TAT,MUCH. SQ.FL
nut curmallyhaven luta,,tinh Lmry mspon,ihiliU at notifytheoceupornn rd,which must be amt prior is issnwme of aCenilicm-af OcrnpancI
Nmi rgcm
Date TOTAL: ISSUIiD tl
OFFICE