99070072APPLICANT -TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY q q 101 QRZ
CITY.gB CUPERTINO BUILDING - ELF.CI'RICAL
PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL
' BUILDING PROJECT IDENTIFICATION'.
BUILDING ADDRESS:
SANITARYNO.
APPLICATION SUBMITTAL DATE
?-2?- g
OWN' NAME; PHONE:
CONTRACTOR' NAME: LICK
NIC
❑
CONTROL#
'12
.Z
FIRCHITECTIENGINEER: LIC N0.-
ADDRESS:
CONTACT PHONE:
BUILDING PERMIT INFO "t
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB MUCH
El LJMB
❑ ❑
LICENSED CONTRACTOR S DECLARATION
1 hereby affirm that 1 am licensed ander previsions of chapter 9 (commencing
QTY' ELECTRIC PERMIT FEE'
JOB DESCRIPTION
with Section 7") of Division 3 of the Buenas and Professions Code. and my Been, is
in full force and effect a
Cl �Li,#
I'll, Li,
RESIDENTIAL:
❑SFDWNREMODEL
h LlLicence
❑pDDIT10N ❑ PLUMBING RE -PIPE
[I MULTI -UNIT ❑STRUCTURAL
MODIFICATION
PERMIT ISSUANCE
APPLIANCES -RF_SIDF,NTIAI.
ARCHITECTS DECIARATION
1 understand my plans shall he used as public mcrnds
PANELS
UP TO 200 AMPS
[_1 INTERIOR ❑CHIMNEYREPAIR
IMPROVEMENT LJSWIMMING POOLS
❑ BATH REMODEUREPAIR El DEMOLITION
❑ GTHER
Licensed Pmfcs,i.n.l
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License law for the
fallowing person, (Section 7031.5. Business and Pnsfes,iatn Code: Any city or county
201-1000AMPS
OVER HXXIAMPS
SIGNS ELECTRICAL
which require a permit to consater alter, improve, demolish, .r repair any sun core
SPECIAL CIRCUI'DMISC.
prior to its isxuance. also requires lheappicant Casted permit et file u signed statement
IF Iry fir --
that he is licensed pursuant to the provisions of she Contractors License Low (Chapter 9
(commencing with Section TIDO) of Division 3 of the Business and Professions Codh or
TEMP. METER OR POLE INST.
COMMERCIAL'
that he is exempt therefrom and the basis for the alleged exemption. Any violmion of
❑ NEW BLDGIADDITION ❑ DEMOLITION'
Seen 7031.5 by trey upp,ud tin apshou, mbjed,the applicant,. a civil pcnalry Of
wit more than five hundred dollars ($500).IitgoF
L as owner of the property, or my employees with wages as their sole compensation,
willdathe work, aniline swnure isnot inteadedoroRemd forsale(See.7044, Business
POWER DEVICES
❑TENANT El FOOD SERVIOE
IMPROVEMENTFl
❑ HER
SWIMMING POOL ELECTRIC
and Professions Cale: The Contractor's License Low docs not apply to an owner of
OUTLETS -SWITCHES - FIXTURES
proMny who buil(, or improves thereon, nnJ who does inch work hinisell art thm.gh
his own employees, provided that such improvements are not intended or offcmd for
NEW RESIDENTIAL. ELECTS SO FT.
SO. FT. FLOOR AREA $/SQ. FT.
/ .
�tIJI ......
1 n
f st Y+
(� � q n I).
VAI. r'
sale. If.however. the building or improvement issold within one year ofcompletion. the
owneolhunder will base the burden f movingthat hdid notbuild or improvefor Pur
pore 1 )
❑ I, as Owner ofth properly win exclurively coutrainingwith en.edc mractorim
constructun project (See. 7R41B:' and Professions Contractor'sCrd)The L
wLa d t ppirt an fp Penr n null: procto ane
whoconswes for rch Thaveces with ocontractods) licensedpamuant tothe Contractors
E] Ia Law.
❑ am exempt under Sec. ,li&PCtnr thio reason
TOTAL:
QTY PLUMBING PERMIT FEE
, PERMIT ISSUANCE
ALTER - DRAIN R VENT -W'A'TER TEA)
�"` ncr Dmc
W'ORKER'S COMPENSATION DECLARAI ION
BACK FLOW PROTECT DEVICE
I heathy rl'fam under penalty of perjuryone of the following dedamtlore.
❑ I rose and wit l tnaiamin a Ceniliewe Of Consent towlf-insure for Workers Cnmpcn-
cation, as provided for by Section 37W of the Labor Cade, for the Nrfmmance of the
DRAINS- FLOOR, ROOF, AREA, COND.
STORIES'!`�,.
TYPE NSTRUCTION
work for which this permit i, I ... Ind.
FIXTURES - PER TRAP
❑ 1 have and will maintain Workcr's Compensmlon Insurance, us required by Stdion
3700 of the Labor Code, for the perl'ormanecolthe work for which this, In, itis i¢ued.
My Warks C,¢ pr � e ,)as erprtiewnd Policy nuypcy/r 251, -
Carrier. S I /�%� a�`lh (% Policy Nn: 'ilO fbC fO
GAS-EA.SYS1EM-I INC,40UrLE'FS
OCC. CROUP
PN
./ O
1
GAS -G.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
}
GREASFIINDUSTRL WASTF,,INTERCEPTOR
BUILDING DIVISION FEES
(I'his. Yio.reeda., berotnpleted it tbepennit is Throne hundred dollar, ($100)
or le".) (I
GREASE'FRAP
_
PEE
I certify that in the perforromacchhe work for which his —it is isuvat. 1,1.11
not waples any Person in any manner so as m became subject to the Workers' Compen-
SEWER - SANITARY - STORM PA. 2W FT
ENERGY FEC '
WATER HEATER WIVENTIELECTR
cation Laws of Colifirmie, (late
Appllc:tm
GRADING ITT;
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
ncasme suhjed to flee works(', Comiximodlon pnrvisions of the labor Cade, you most
WATER SYSTF.MUREATING
SOILS FEE
WATER SERVICE
forthwith comply with such prosmions or mi, permit shall be deemed revoked.
CONS' 1' RUCPION LENDING AGENCY
I hereby affirm that there is a conswction lending agency far the performance of
NEW RESIDENTIAL PLMB. SQ, ET
])ate Re :pt#
the work for which this permit is issued Xg 3197, Cir. C.)
Lender's Name
TOTAL:
Lenders Address
TOTAL:
DING FEC
f.Al,.LD
I cenify net 1 havcrerd this �pplicati�a..ad once that the above information is
QTY. MECHANICAL PERMIT I FEE
IC FEE
rzect.l agree m comply with all cies and ... ties mainenees and state Inws reclining m
building construction. and hereby outhouse mprcwor ran ex of this city m enter upon the
PERMI'i' ISSUANCE
TRIC FP,C
a a,vormntomed property for inxpcction parpn,cs.
(We) agree et save, indviandy and keep hurnes, the City of Cupertino against
AUFER ORADDTOMF,OH.in
PLUMBING PT:C
lethilitle,mliments,c.st, and exp.n,a which may in any way acerae ugninxt suit City
,.sequence of the granting ofthis permit.
AIR HANDLING UNIT (rO IO.IKK) CEM)
as
MECHANICAL FEE
APPLICANT DERSTANDS AND WILL COMPLY WITH AL1. NON -POINT
AP1.IC. 1LDERST.
AIR HANDLING UNIT (OVER 0,000CFM)
CONSTRUCTION TAX
Signa ic
umul'ApplienfitsCompacilrE Dam
HAZARDOUS MATERIALS DISCLOSURE:
EXHAUST HOOD (W/DUCT)
HOUSING MITIGATION FEE
HEATING UNIT (TO 100.000 RT U)
Will the applicant or future building occupant store or handle hrmNoos material
as 60 ed by the Cupertino Municipal Code, Chapter 9.12, and the Ilenith and Safety
Cade, Socom 25534(a)'!
HEATING UNIT (OVER 10(1,0(X1 B'TU)
Yes No
PAID --
Darn Recciptp
VIiNTILATION PAN(SINGLE RESID)
Will the applicant.. v t or lulu., nuildied by In. n use exPArea Air Qm art Marta which
t mit humnlovs ter ec.nmminnnnx u.v defined nes the Bay Any Air Qmllry Management
DidrsdI
❑Yes ONO
BOIL(?R-COMP CHPOR I01,000 BTU)
Tun •
BOILER IOO.IMID BTU)
AIR CONDITIONER
I have read the hatpokav mmedWs requimmcnts under Chapter 6,95 of the Cali-
ISSUANCE DATE
NEW RESIDENTIAL MUCH. %17..
forma [Icahn & Saldy Code Suchen, 25505, 25533 and 25594.1 media,': t hold the
buildingdm currently have. Icahn. that it is yrap.mlbilay to nmifythe occupant
of the mcroswhlchmust prioIt.oveof.ce"Ificacrif 0c cy�
ISSUED BY.
TOTAL:
Owtiunn a.mmie agent DateG�
OFFICE