99070048 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -7Q04 K
CITY OF CUPERTINO BUILDING-ELECTRICAL.
_RMII NO,
BUILDING DIVISION APPLICATIONIPERNIFF PLUMBING-!MECHANICAL.
BUILDING PROJECT IDENTIFICATION
1
UILD11'.G ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
" I oho(ZN � I e 7 � n { .ry) I Q
OWN13R^'S NAME. I� PHONle CO CP
AOR'S NAME: LIICr-NO'
S`�' \ t yS'oc,a �k0 kb4 -n o3 SO�+v�215aL -1G-'y.3 I N/C ^CONI ROL#
^IIITECT/ENGINEEER: LIC NO: ADDRESS: n ❑
r" I'� jj7-s
CONTACT: PHONE: /7 BUILDING PERMIT INFO
(/�� I5 a��� ��-�D� Consultant Fees Paid by Applicant(Initial) /iP BLDG ELO PLUMB ME❑CH
(;o-V TbV I�� LJ
LICENSB)CON'TRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE
MWzI hereby off n,m 1 alts ueened nude,provi%ions of Chao 9 mnmmaneing JOB DESCRIPTION
W0 C) with Scnlon 7000)ofni,oio113Afla,Bnsinesaund Pfidx,ionx Co,I,andmy Fee...is RERH IDENIIAIe
00 PERMIT ISSIJANCIi
CUF In lull lirrcc anti eH � ./N fs1 ❑!FOWL, ❑KITCHEN REMODEL
GZU hEttn�Contractor
ontr S /a15%tIOt - APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBINGREPIPE
y Z w Dale eomam�-
ARCHITT:CTSDECLARATION El MULTI-UNIT ❑STRUCTURAL
ZOmZ I understand my plamhe
%hall used as public records PANELS MODIFICATION
UP TO 210 AMPS
Z ❑INTERIOR ❑CHIMNEY REPAIR
rnFyl Licensed Pru&s%ional 201-I000AMPS IMPROVEMENT SWIMMING POOLS
�y F;
OWNER-BUILDER DECLARATION OVER BN0AMI'S D BATH REMODEUREPAIR [I DEMOLITION
CLC'Q I hereby allin i that I ant ,xc u,from the Cmmoo,ou,License Law for the
o.06 U I'ollown (Section)031,5,Bminms and Pn te,a ns Code:An t 1 ❑(YCIiF.R
s<3 F g rousmn.(:cc ion Y ci Y nr coon Y SIGNS P.LIiCI'ItICAL
L LL LL N which requires a permit to cnn.amcl,alter.improve,demolish,or repair any shroi
_ 06
Prior to its issuance.also requires the applicant for such penva to file a signedstaumeni SPECIAL CI NCUIT/MISC.
Eby'' that he is licensed a mmum to he in,,mcm,of the Commicun s License Law(Chapter,9
Y C.QE fionineaing with Section 7010)of Division 3 of the Business and Profasiom Cde)nr TEMP.METER OR POLE INST. COMMERCIAL:
al no
a C C that he is exempt Ecmfmm and the basis for the alleged exemption.Anv viomd"n of ❑NEW BLDG/ADDITION P6.MOLUION
WoN Section 7031.5 by aoryappliwnt far.permit subjects the applicant In a civil penult,of POWER DEVICES
rn more than five hundred dollars f8500k ❑TF,NANT ❑FOODSERVICE
F Z Y IMPROVEME D
not
Lore dom five
do nrmyempinyceswilM1 wages.%Theirsolecompenxnlion. SWIMMING POOL ELECTRIC
�L willdnthe wad,andth ,,rdeus,1.nml notndedorollcred l'nrsxle(Sec.7(H4.B,iraev OTHER
W3 and Prnfrsdons Code.The Commetor's Liwnse Low docs not apply to on owner of OUTLETS-SWI'TCHITS-FIXTURES i p
propoeeny who builds or inipowei thereon,and who does such work himself or Ihnmgh Lr V I"
his(two mployee%,proed vidIII.,such improvements arc cont imended or offered for NEW RESIDENTIAL ELECfR SQ ill'.
sale.If.however.the building or improvement is sold within one year ofcomplenon.the / $QgL ARE �•l ��9SP1T
mer-builder will have the burden of proving that he did nm build or improve for Pur- (ee//Y
pose of sa10.
n 1,as oxner of the PntpertF.m exclusively comraeti.,with licensed contractors to TOTAL:
construct the potI(Sec.](44,Hm'itu,,and Professions Cash:)The Contractor's I.i
OO�
%e Law Maes not apply to an owner of property who builds or improver thereon,and QTY. PLUMBING ERMIT FEE J
who contracts for such pmjeeis wi:h a ctuumcror(x)licensed pursuant 10 the Contr ctor's rw.W W 1f'
License Law. PERMIT ISSUANCEr..•�
Ian exempt under Sec, ,B&P C for this lemon ACM UJViZYak. 1
ALTER-DRAIN&VENT- 'R(E VALUATION
OwnerDate
WORKRR'SCO MPENSATION DECLARATION BACK FLOW PRCTECT.DEVIC leo,Doo
1 hereby off ne under penally of pe lop'one of the following declaration%:
I have and will maintain a Certificate of Convent lose!-insurt for Workeh Compcn- GRAINS-FLOOR,ROOF,IREA,CO. . STORIES 'TYPE CONSTRUCTION
sulinn,a,provided for by Section 3700 of the Labor Code,fur the performance of the
k for which this permit is Issued. FIXTURES-PHEI RAP
Cj.1<tve and will maintain WarksFs Compensation Insurance,as required by Section d�
3700ol the Labor Cod,Iim theperountanceofthework lorwhich this pernal is issued GAS-EA.SYS'1171".1 INC.4 OUTLETS OCC.GROUT' APN
MYWork hCm ,%it Insumncc carzier and Policy norther ^ncrar�, /
Carrier: kc, Stu,5 A Policy No.:I-z A19`f(_401plr"' GAS-EA.SYSTEM-OVER 4(EA) Q.b
CERTIFICATE OF EXI3MP1'ION FROM WORKERS' GREASEANDUSIRL WASTE:INTERCEPTOR O
COMPENSATION INSURANCE BUILDING DIVISION FEES
or less.)
(This ucu.n.rodmat Necumplcted iftbe permit is forma,hurtdteddollars 05 NE) GREASETRAP
PLANCHEC E
I certify that In the penmmance nftbe work for which this permit is issued.I shallSEWER-SAN)TARY-STORM EA.200 IT.
mol employ no,person in m, taw, as us Fee oc xobject Its the Workers'CorrI GY FF, ,L
Z sulinn Lows ofCalifnml. Date WATER HEATER WIVENT/ELECTR INC,FEE
z Appliwnl Wit 11 1
L�
NOTICE'TO APPLICANT:IL Idler making this Cenilicme mf Exemption.You should WATER SYS'DiMll'RFAI'ING
; become subject m the Worker's Compensation pruvisiuns()I(he Latour Code,you mum BIS'q
Forthwith comply with such provisions or thisperook shall be deemed rcvmked. WATER SERVICH
0
=Z CONSTRUCTION LENDING AGENCY NEN'RESIDEVTIAL YLMR. SQ.R. D Date Receipt a
U O Iherebyaffinnthat then i......buetion lendiagageney for the pcdorm.nce of
Hissued the work for whichdii,permit is imd(Se,3097,Civ.CJ
ILender's Name l'OTAL.
LLT Lender's Address TOTAL:
y 1 wrofy that I have muMw
d this application and stale That the ae inf ration is BUILDING FEE
Ir ZI cnrzeml.I agree to Comply wish IMI city and county ordinances and stole laws rclallng to QTY. MECHANICAL PERMIT FEF.
V Z huildingttmnmction,snd hereby amhnrizc rcpr,wnmlivm of this city lovuu,,t nn the SEISMIC TEE
aMtve-mentioned pmpeny for initiation purposes. PERMIT ISSUANCE
(We,agree to save,indemnifv and keep harmless the City of Cupertino against ELECTRIC FEE
Ioldlitic%.judgments.costs and expenses which may in any way accrue against said City ALTER OR A DD'TO MECO.
PLUMBING FEE
in consequence of the granting of this permit.
APPLICANT UNDFRST///"DS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,01di MECHANICAL FEE
SOUR" TIO
lit
AIR HANDLING UNIT(OVER IO.q()CFM) CONSTRUCTION TAX
Signature of ApplicanUConWewr Date EXHAUST HOOD I W/DUCT) HOUSING MITIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or lumre building occupant.store or handle mosofiu.v material HEATING UNIT IT O 11X),000 BTU)
as defined by the Cupenino Municipal Cede.Chapter 9.12.and the Hwlth and Safety
Cale,Section 25532(a1P HEATING UNIT(OVER 100.000 BTU)
13 Y-1 `q�qo VENTILATION PAN(SINGLE RFSID) PAID Date Reeeip
Will the applicant or future building orcupanl use equipment or devices which BOILER-COMP(HIP OR IU1.000 BTU) s�[
it haeumv.,air cu,,no,,us as dclinvd by the Bay Arca Air Quality Management T(
aar1,0 B0 H.F.R-COMP(OVER 110,000 BTIJ)
0 Ye, T-4'
AIR CONDE LONER
I have read the h oke Sections
ds 5.25533 a under Chapter rsta d deaf Cali- ISSUANCE,DATE
fomiu Health&Safely Crdc,Scclians 25505.25533 anti 255:00.I understand thm if the NEW RF_SIDENTIAI.MECH. SQ.FT.
buildingd1p at cu mo`camIN
wnc that it is my reponsibil'1lymnnufy elle awpam ���
of tyrtt Iuiret(vnts rc t Ic tilt: once of a L'enif cadj 2��u`Ipare, CC
Owner or auto—•horized ager'— Dale 'I OTAL: ISSUED BY:
OFFICE