99090174 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY V .
CITY OF CUPERTINO BUILDING-ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLU$IBIN'G-MECIIANTCAL
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS (� SANITARY NO. APPLICATION SUBMITTAL DATE
Lbq L v R_clqfiuz-hvo - .2 `L,
OW;VER' M h'AMF.:PHONE: COY)R'S I
`NAME NIC CONTROL
A CHITECDENGINEER: LIC NO: AuDgIRtISS: Gk ❑
I'
CONTACT; PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG LE PLUMB MECH
❑ � ❑ . ❑
LICENSED CONTRACTOR S DECLARATION ofChap QTY ELECTRIC CTRIC PERMIT FEF,
Ihermby ))of that licensed d p rcnapmf9Oi,hnarmg _ :,.. . ]OB DESCRIPTION
oaz mse<mmn Taxp mrDi
m3 ofthu Bus ndlr fusionsCdc tend my l'wnscis RESIDENTIAL:
Fpp nlfull force and effc I'CRhfIT ISSUANCE
CSF- _ -!D ❑$FOWL [I KITCHEN REMODEL
aUU Date Class Lic.N APPLIANCES-RESIDENTIAL ❑ADDFFION El PLUMBING RE-PIPE
aAdC1'IT,i SDECLA ATION ❑h1ULTI-UNff ❑STRUCfURAL
Z C,to Z I understand ter plans shall W used as public rewrdR ` PANELS MODIFICATION
__ —ar UPT0200AMPS El INTERIOR ❑CHIMNEY REPAIR
W Licensed Nole,iomd 201-I0Ix0AMPS IMPROVEMENT E]SWIMMING POOLS
C ¢ 1 hereby affirm hat I am exempt fomE Ne G Contractor's License Law for the OVER 1000AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
3 LLF following ri(Section TUE$.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
W which requires a permit to construct.alrer,improve,demolish,or repair any sweurc i.
F'�pQ prior to its issuance.ulsr requires me applieam prince permitm Cleasignedsmmmcm SPECIAL CIRCUIT/MISC.
that he is licensed lnrsuam to the provisions of the Commnor's License haw(Chnpter9
Waap (commencing with Scction 9L`00)of Uiviaiw}ofthc Busincsa and Prmfnsions CnJe)mr TIiMP.MGFEft OR POLB INST. R IAL:
C.�,0 af that he is exempt therefrom and the basis for Ne alleged exemption.Any violation of NBW BLDG/ADDITION ❑DEMOLITION
X^� Section IDiLS M1y any applicam fm v permit mnjects the applicanuo a civil penalty of POWER DEVICES
y not more than rive hundred dollars($500). ❑TFiNANT ❑FOODSERVICE
IMPROVEMENT
S6 wi Lasownere(the pmpeny,structure is employees with wagesas their Sole compensation. SWIMMING POOL ELECTRIC
�(..p will Jm fa,,,i I,and TheCommeaot intended License Law dJ s or apply to a4.n Business ❑OTHER
3 m
and Professions Core:The ConOhereo Licence do dome not apply m an owner of OUTLETS-SWI'TCIIES-FIXTURES
his
property who builds
yea,or improves tneram,and who does such work ndedI l'or through
his own em to pmvemnn - NEW RESIDES r1AL ELECTR 5
p r,the provided or
,men me is are not year of or n coon,for Q .Fr.FLOOR ARBA LS .FT.
sale IT however,the building or improvement is sold within one year of completion,the �Q Q
ow,builder 'ITh the burden fp provingthat l J'J tbuild - p fPar-
,overrode.)
ar
pe f. Ie), S
Fl 1. f theproperty, t exclusively contracting rth licensed t t . to T
st tin I j tlS ]04411 .' dP ( :Code)ThC t'ct Li- _ . .
cerise Law fires notapplyt r of property who builds or p ves Ncreonand QTY. PLUMBING PERMIT P
who contracts for such projects with v contractor(s)licensed pursuant o the Contactors
License Law. PERMIT ISSUANCE
m
1 aexempt under Sec. ,B&P C for this reason
CoNsirm
Owner Dalu ALTER-DRAIN&VENT-WATER(EA) / VA L O.
WORKER'S COMPENSATION DECLARATION BACK FLOW TRUE ECT.DEVICE
1 hereby at'tirm under penalty(if Perjury one of the following declamJons.
I have and will maintain a Cenifncale of Consent o sell-insvm for Worker's Com,.- DRAINS-FLOOR,ROOF,AREA,COND. E -TYP ON UCTION
suitas provided for by Section 3]110 of the Lm or Axle,for the Performance of the
work for which this permit is issued. FIXTURES-PER TRAP
E3 I have and will maintain Worker's Compensation Insurance,as required by Section
3000 of the Labor Code,for the perfommnce of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP �! APN�
My Worker's Caniecorma1 mmnurr
accier and Policy nunnher are: (e
Currier: Policy No.: GAS-EA.SYS'I'BM-OV F:R 4(EA)
CATE OF EXEMPTION FROM WORKERS1- O
COMPENSATION INSURANCE GREASETNDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This sectim freed not be ciand"cd if the permit is furore hundred d.11 (S 100) GREASETRAP
or[as,.) PLANCHECK FEE
Ioyany that inthe aperformance ny
Nework for which this the W rkersued'Calc]shall SEWER-SANITARY-STORM EA.2(x)I'1'.
not employ any person in any manner so as m become Ruhject m the Workers'Cmmpen- ENERGY PCB
Z sation Laws of California.Dam WATER HEATER W/VENTIELEC'I'R
Z 2 Applicant I GRADING FEE
NOTICE lO APPLICANT:IL ager making Nis Ceniliea¢of Exemption,roe Nould WATER SYSTEMITRENTING
F•' , Isco w subject m the Werkcr',Compcnsaeon provisions mf the Labor Crde,you most SOILS FEE
Wfommoth Comply WIN such Provisions or this permit shall M1e deemed revoked. WATER SERVICE
aQ
CONSTRUE-I'ION LENDING AGENCY NI!N'RESIDENTIAI.PLMR. SQ.FT. PAID
� rZ Date- Nleelptk�
UO Inerwyrhnn that Hare is aemnatmeimnnndmsasemrterdoe lxnamrmm�ae of 1.-J ._
the work for which Nis Permit Is issue)(See.309].Clv.C.) i• --��
CTtU LandnR Name 'tt�� /r_�70TAL: 1 rZ
'
U LenJeh Address I
TOTAL: J '^I I
r Ell I cenif that I have read this application and state that Ne above information is BUILDING FEE 1 r
1.., a r I _
rn correa.lagree comply and withallcity and county ordinances and,al,tolaws tnmtiza a Ql'Y. MECHANICAL PERMIT FEE, .J Z O .IQ ID
U Z nmJJimg eansomdmn mod hereby amdtmdre repmaennndvaa m[mLc atrmemernpm mm SEISM IC FEe OL, O
xbovo-maminned nopeoY for in,anion Ourposms' PERMIT ISSUANCEELEC'BI'C7
(We)agree m save,indemnify and kap hamilesx Ne City of Cupeninn against FEE
liabilities,jed,annal,msts and expenses which may foamy way acerae against said City ALTER OR ADD TO MECH.
as asequence of he 6anfng of this permit. PLUMBING FEE_ `
APPLIC/kaVT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT AIR HANDLING UNIT ITO 10.000 CFM)
SOUR�V1�FF UULLARONC`. MECHANICAL FEE
lIC/ AIR HANDLING UNIT(OVER 10.001 CFM) CONSTRUCTION TAX
Slgnaum oy{A gnV`tm/TT-ofi/rData EXHAUST HOOD(WIDUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding oecupin store or handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Cod,Chapter 9.12,and Nc Health and Safety
Ctde,Section 25532(.)? HEATING UNIT(OVER 100,000 BTU)
Ye No
VENT LATION IAN(SINGLE RESIDE PAID Date Receipt M
Will rd the applicant m future building t,w H use equipment.Aor devices Management
mit hazardous air conuminanu as defined M1y NC Buy Area Air Quality Management BOILER-COhtl'IJHP OR I00,(Xx)fit U1 TO
Div.,,? BOILER-COMP(OVER DR.000 BTU)
E)ye, ❑Nn
AIR CONDITIONER
Ib rad the hazardous 2555, c d Chapter 6.95 rthc Cale � _ IS$l1E DATJ%7 /S
tom Health& oSalary Cal S f 2550525511 1255141 J tM1 t'1 the NHW RCSIDF.N'I'IAI.MECH. SQ.FT- 7- 1
Y /l-J
buildingd rturtentlyh at nLNtt y 1 bltyt City tl �ulpan_t
of lie mutant,�.fjl�k�yThich ��{p 1 ,poo t ...rec of a Cc n a¢n ) auP
Owner.,am...9 egcmtiplill ne TOTAL ISSUED BY: Is O
OFFICE