99090044 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY p9 Q
CITY OF CUPERTINO BUILDING.ELECTRICAL PE
BUILDING DIVISION APPLICATIONWERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDP:NUFICATION
RUILDINCADDRESS, SANITARY NO. APPLICATION SUBMI'1'1'AL DATE
LV e ti 0 � � q_
W, NA P: PHON is 'lotCONTRACTORS NAMC: LIC NO'.
NIC CONTROL
'CHITECU'UNGINEER: LIC NO: 1( ADDRESS: ❑
L'ONTACT: PHONE BUILDING PERMIT INFO
ED Consultant Fees Paid by Applicant(Initial) BLDG ELECT P,IT MUCH
❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPT ON
0C)Z with Section 7000)of Division 3 of the Business and Professions Code.and my license is RESIDENTIAL:
Fop in full force andf
effect. PERMIT ISSUANCE
4l ElSIUWL ❑KITCHEN REMODEL
aUZU L Date hiccnsa Clas Lick Connector APPLIANCT;S-RIiS1UEN1'IAI. []ADDITION [I PIP
PLUMBING RC- E
v 6
ARCHITECTS DECLARATION []MULTI-UNIT [I STRUCTURAL
F 7 ren PANELS
Z O m Z 1 understand my plans shall tc rood as public records MODIFICATION
OZ yQ UP TO 200 AMPS [I INTERIOR [I CHIMNEY REPAIR
F4LW Licensed Professional 201-1001JAMPS IMPROVEMENT )]SWIMMING POOLS
�W OWNER-BUILDER DECLARATION OVER I0f0AMPS 0BATH REMODELREPAIR C1 DEMOLITION
C C Q I M1 tuft,aflimt that 1 me esempd Irnm the Co nowuns License Law for the
3 W U+ following ratsomB
.(Section 70315. tsincss and Nefcvvions Coda Any city m county SIGNS IiLECTRICAL
F ❑OTHHR
A¢ which fegmrer a permit ht construct,alter,improve.demnikn or repair any stm,ame
P OJ poor to its issuance.also regnires the applicant for such Pennitto file a signed statement SPECIAL CIRCUITIMISC.
yNat he is licensed pursuant to,the pmvixlons of the Camcorder's License Law(Chapter 9
u+='00 (commencing with Sermon 7")of Division 3 of the Business and Professions Cole)or TEMP.METER OR POL COMMERCIAL'
a a c C that he is exempt thernfmm and The basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
�'w Section 7031.5 by any applicant btra Permit subjects Nc applicant to Penalty of POWER UIiV]CPS ❑TfiNANT ❑FOOD SERVICE
not more than five hundred dollars(SSW).
^Z Y IMPROVEMENT
❑ Lmmo,,ralthe pmpcny,mnnyanntender...Noned arifle(Ser.ntmpcmrtion, SWIMMING I'OOLF LTR
FS- will dntbe work,ande. she Core is rods Licenseed Law does not apply to
owner
of
O0'1'HfiH
LL3 m and 1'rofrsions Rede The Contractor's License law dues not apply to an owner of OUTLETS-SWIq'CHES-Po
his own employee,or impmvea such
i and who does such work deed or of though
his own employees,provided That such impr is sold s are nm intended or plleered for NEW RISIUCNTIAL ELECfR .Q
F14,F
sale.IL however,the building m ori.1 nmmrt is old within one year of completion,N- ESQ'
ET
proncrbuilder will have the brother of proving thud he did nm bidder impose for prof- I1., M
"o,vJ. lJ u
1,are owne,nl the pntpmY,am cxdnrivdy cnnvvming with Ilrn.ved nmtruclnm to TOTAL.
n the protect(Ser.7014,Business and Professions C den The Contractor's Li-
serve Law does nodapply to an nwnerof property who builds or improves front and QTY, PLUMBING PERMIT FEC ' 7 199
who contracts for such projects with a rnmmetud%)licensed Pursuant to the Conuacmr's 9
License Law. PERMIT ISSUANCE
1 am exempt under Sec.
n B&P C for this mason
F) f - A ALTER-DRAIN&VENT-WATBR(EA)
VALUATION
wa, l _ _
OIKEBS COMI XI'ION DECLARATION
BACK FLAW PROTECT.DEVICE
1 hereby nlfien under penalty of perjuryone of the following declamtuatV
IM1me and will animism a Cenlficote of Consent wsclf-Insure for Workers Compete DRAINS-FLOOR,ROOF,AREA.COND.
tion.as provided for by Section 3701 of the Labor Code,for the performance of me STORIES TYPE CONSTRUCTION
work for which this pcnrif is issued, FIXTURES-PER TRAP
Fl 1 have and will nu intum Workers Compensation Insumnre,os required by Section
3700 of the LUAU Cock.for the Performance of the work for which this pandit is issued GAS-EA.SYS'TEM-I INC.4OUTLETS OCC.GROUP APN
My Worker's Compcnxminn Insurance currier and Policy number are:
Currier: Policy No.: GAS-EA.SYSIPM-0VER 4(EA) 13021
CERT /IFICATE 01;EXEMPT FROM WORKERS' )
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INIBRCEPTOR BUILDING DIVISION FES
(This section need not be,coinpind if the Permit is for one hundred dollars(S 100) GREASETRAI'
or Icvs.) PLANCHECK FEE
I certify that in the Performance of the workforwhich this Permit is issued,I shall SEWER-SANITARY-STORM EA.210 FT
rot employ any Person in uny manner no mut hecome sub od to the Workers'Cnmpen- ENERGY FEE
OZ anion Law,of Cold....ia Dare WATER HHA'1'ER W/VENT/ELECTR GRADING FEE O A,,111.111
NONCE TO APPLICANT If,atter making his Certificate of Exemption,you should WATER SYS'I'FOREATING SOILS PEFi
became subject m theWerkers Compensmime Pno iomi,of the labor Code,you tear
{SI Emhw'idh comply with,ah provisions or this Permit shall be deemed revoked. WATER SERVICE
0
72. CONSTRUCTION LENDING AGENCY NEW RESIDIiNTIALPLMB. SQ.FT. PAID Date Rrcciptk
U O Inereny arErrr mauhereisarmtstmaien lending agemry forme pednrmance ere
me work for wfidt this prrmirs towed fSee,30,17,Co,.C.)
0 U lade,,Name TOTAL:
> [ Lender's Address TOTAL: BUILDING FEE
1 I certify that 1 have rad Nis application and nate that the ahtsrc infmmmion is
F' 0 cori l agree to romply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U Z building combustion.and hereby araedm representatives of this city to enter upon the SEISMIC FEE
UMwe-mentioned property for inspection pia mses. PERMIT ISSUANCE
(Wel agree rot save,indemnify and kccp harmless the City of Cupenlno uguinst ELECTRIC FEC
Iiuhilile,Joifi mama coax and exl'<nvrolud—my inuny wry nrcruragaiol,mcl City ALT BR OR AT)])TO MECH. PLUMBING FEE
in consequence or the glaring r it porion,
APPLICANT UNDERSTANI S r NO WILL COMPLY WITH ALI,NON-POINT AIR HANDLING UNIT(TO IH,(XX)CFM) MECHANICALFEE
CF .GUI � IONS.
nto �-. — AIR HANDLING UNIT(OVER 10.00)CFM) CONSTRUCTION TAX
. t of ppl11'C'oncannr Date E%HnUSI'IIOOD(W/UUCP HOUSING MITIGATION FEE
HAZARDOUS MAT17RIAM DISCLOSURE
Wil the npplicum or fwnm hnilJing nuvpam mnrc or hnndlu h:caNnus nnnoriul HEATING UNIT(D 10a),W)FITU)
;is defect by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cala Sectio 259321a)I HEATING UNIT(OVER 100,00(BIG)
❑Yes 0 N VENTILATION FAN(SINGLE RESID) PAI[)
Dam Receipt M
Will the applicant nr future building occupant use equipment or devices which
it harardnus air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP CHP OR IW,(Xp BTU)
TO
sedna", BOILER-COMP(OVER 101,000 H'IU)
❑Yrs ❑Ne
I havemad the arnNous omen rcyuimmcros under Cidned,695 of the Cali. AIR CONU IT IONER ISSUANCE DATE
forma",
e &Sof Ctdc.Sections 2S5 5,25513 arvd 25571 I understand Nat if Nc NEW RESIDENTIAL.MECH. SQ.FL
'di,does ore havearran6Na aismyresponsibilitylonotifv Neovc
of th quiet a met pt o m issuance of a Ce ora of up: c
Owner or authnry W ngumum TOTAL: ISSUED BY:
OFFICE