99080131 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECPRICAL P
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
11A \JLAKNTF_
BUILDING PR(YdECT IDENTIFICATION
DU ILDINQ,L7URESti: SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'S NA ? PHONIi: CONTRACTOR'S NAME: LIC NO: _ 1 T
3S iwArf
GINIC CONTROL#
'HI'1 URENNEER' L C O: AD RESSb:� TIO �- ❑
coNTncr; PHONE: HUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
1:1 El YJ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that 1 ant licensed under provisions of chapter 9(eommendng JOB DESCRIPTION
POp with Sation]000)of Uivision3of the Business end l'rofexSm SCole,and mylicenxis PERMIT ISSUANCE RESIDENTIAL:
CIF in till tierce and come 2 7
V Lieetse �s Lic 7Q- �SFDWL ❑PLUMBINREMODEL
aZV -�€ass—�_L—V APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING Rf:-PIPE
ti<L Dam C
ARCHITECTS DECLARATION (I MULTI-UNIT El STRUCTURAL
Z p I understand my plans shall be used as public rccoNs PANELS MODIFICATION
CZ-0 UPT0200AMPS El INTERIOR El CHIMNEY REPAIR
a�Iqq';
Lf,ens ed Professional 201-I000AMPS IMPROVEMENT SWIMMING POOLS
C�2.4 OWNER-BUILDER DECLARATION OVER lftW nMPS [I BATH REM EI 'P IR Eh OI QN
W' Q I hereby nlBnn that I am exempt from the Contractor's License Law for the CiK+
iiqq55�L V fallowing reason.(Section]W 1.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL Guin u+LL O which da,r es a pefmil to cnoarucL he,.improve,demolish•or repair any structure _ ___f
.a7 prior to its issuance,also acquires lheft,licnm forstmhpennilm ftleasignedsmtcmenl SPECIAL CIRCUIT/MISC.
�} that he is lanced mmawet to the provisions of the Conmacto/s License Law(Cludler9
g�OO (commcnmiug with Section 7000)of Division 3 of the Business and Professions Code)or TEM P.METER OR POLE INET. COMMERCIAL:
L 6 p¢ that he is exempt therefrom end the basis far the alleged esempnitn.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
k'^4
Section](131.5 by any applicant for a permir subjects the applicant m a civil penalty of POWER DEVICP_S
ul—y El TENANT ❑FOOD SERVICE
not more than five hundred grope ty.or y employees
IMPROVEMENT
6 wi kasowner k,the property.orempinyeca witlttered asmeinole......en......, SWIMMING POOL ELECTRIC
m. wdl dedicPath Wans and lM1'I he lareunnts sherd Card,do for at pply.]f144,Bne,os []OTHER
and arty who
Com improves
Cnmmctoos Ltceme Law does not apply a if owner of OVI'LFTS-SW'ITCI31?5-19%TIJRIiS
6 3^ pigmy who builds or improves thereon,and who does such work himself or through
his own employeese provided that such improvements ore not intended or offered for NEW RESIDI?#TIAL ELECTS SQ t4.
sale.ILhower will have theburdimprovement iseold withinone year imprveloathe SQ.IT.FLOOR AREA ASQ.FT.
owner-builder will have the harden offsetting that Iia did not huI1J or improve for Aur
pose of sale.).
❑ i,as owner of the p amny,a roacts
exclusively contracting with Itcensed numto TOTAL
construct the project(Sec,7014,Business and Phomminns CNet The C'son—v rs Li-
cerise Law does not apply to an owner of propeny ishe builds or improves thermal,and QTY. - PLUMBING PERMIT FEE
who contracts for Stich projects with a conlrachods)licensed pursuant o the Contractor's
License Inw' PERMIT ISSUANCE
❑ I um exempt under Sec. ,B&P C for this reason
Owner
ALTI7R-DRAIN A,VENT-WATER IEA) VALUATION
_ Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE �Ds ^^
I hereby affirm under Penalty of Perjury one of the following declarations: eCJ
I have and will nminmin a Certificate of Consent to self-insure for Worker's Conflict- DRAINS-FLOOR,ROOF.AREA,COND, STORIES TYPE GGNST'RGGTIGN
salon,as provided for by Section 37M of the I.aho,Cole,for the peffore once of the
work for which this permit is issued FIXTURES-PER TRAP
❑ I have and will maintain Worker's Comper,efi n Insurance,as required by Section
3700nfthe Lahm CMe,for Ne perfmmdereofine work ffoor�Ywhhii[chitb�is Permit is issued. OAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP /({7
My Wovk�CryputEM pr( Poliay Nn.e,add ; thtf&M�O` GAS-EA.SYSTEM OVER 4(EA) 3/! `e p
Cauiee l�f �••/ IP t
CERI'IFICA'1'E 01'EXEMPTION FROM WORKERS' 6
COMPENSATION INSURANC17 GREASE/INDUSTRL WASTE IN'I'I?RCEPTOR
BUILDING DIVISION 'FS
Ghix action nmd nor be completed if the permit is fnrone bootie#Jollms D I00) GREAS121'RAI'
nr lww7 PLANCHECK PI?B
Ic:nify that in the pefforoance ofthework for which this pcmtil is issued.I shall SEWER-SANITARY-STORM EA.2W PT.
nal employ any person in any manner a. IR'by yryjQ�the Workers Compcn- ENERGY FEE
2 satin.Law C lifor9. Dae 77
� O Applicant"Cl'! LV1 �= WATER HEATERW/VENT/ELECTR GRADING FEE
tiNOTICE TD APPLICANT:If,ulmr making this Cemlieam of Exemption,you should WATER SYSTEM?REAHNG
a ' Become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS PEE
forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
Q
UO CONSTRUCTION LENDING AGENCY NEW RF_SIDENTIALPLMB, SQ.I'C PAID
l herchy that here issued Sce.3 lending agency tor pedormunce of Dam R rpt
I1r F. thewo's for which lhispermit is issued(Sec.309].Civ.Cd
Lender's Name TAL:
C,
1-cmi Addmea TOTAL:
1 I ccnify That I have real this application and stere Thal the aMwe information is BUILDING FEF.
tti CI) conal lspreemcomply with all city end cnumy oNinances and state laws relining to QTY. MECHANICAL PERMIT FEE
Vz, buildingconswnion,and herchy authorize mpmsenmtiva of lhiscitymementpon the SEISMIC PEE
above.mentioned progeny for inspection purposes.
(We7 agree m indemnify and keep harmless the Chy of Cupertino ugaitst PIiRMIT ISSUANCI? ELECTRIC FEE
lidbilities,j nce11 a osis andexpenxs which may inany wryaccraeagainst wid City ALTER OR ADD TO MECH.
in"'re cna n' cgr n This porn- PLUMBING FEE
APPLICANT DF ANT 'All WIL YWITH ALL NON-POINT AIR HANDLING UNIT(TO I0.0%)CFM) MECHANICAL FEE
SOU -UL NS.
_ AIR HANDLING UNIT(OVER I Maps)CFM) CONSTRUCTION TAX
•nature olAppbcant/Car nr (late EXIIAUST HOOD(WMUCD HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Willlheap,hemt or future building uecupam wore.,handle haermemas material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health tmd Safety
Code.Scction 25532(0)^ 1 HEATING UNIT(OVER Ilk,"BTU)
❑Vita �!.'o VENTILATION PAN(SINGLE RESID) PAID
Will the applicant or future Building occupant use equipment or devices which Dae Ree pt p
it hazardous air contaminants as defined by the[lay Area Air Quality Management BOILER-COMP(3HP OR I WWII BTU)
tsuim'
❑Vcs BOILER-COM P(OVER IWWO BTU)
y(No '
Ihave real the .atlas crials AIR CONDITIONER
req ' nu under Chapter of the Cali- ISSUANCE DATE
fomin Health&Sr _ ,mit) 255115,25 3 and 1 understand mut If the NEW RESIDENTIAL MECH. SQ.FT. ,n
buildingJceS no aveat thatili n Birymnntifytheaccuprm J( .� `�_
of me nts� must et pr trt are enFZ ifimmufOccua Y.
6Z4
Ow oraul oozed ant Dam TOTAL:
ISSUED BY: �b
OFFICE