99170004 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILUING-ELEC'I'R{C'AI. P
BUILDING DIVISION APPLICATIONIPF.RMIT PLUMBING-MECHANICAL
BUILDING PROJECT IIIENTIFICATION
dlII1
I UILDING ADURCSS: SANITARY NO. APPLICATION SUBMITTAL DA'I
IO �R:S NAME' 'f1(INE: CO TRACTOR'S NAMH: q�Uk L�O�Ol S NIC CONT OLp
l fYl COb� 0. ` I i 16 (�(
ARCI{TTI:CTIENGINF.I:R: LIC NO: AUDRE.SS:�Vr I 1 V -1 J Ii-L ❑
CONTACT: PHONE: CLf U BUILDING PERMIT INFO
' ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ [ ❑
LICENSED CONTRACTOR'S DECLARATION Q'TY ELECTRICPERMIT FEE
I hereby ulimn data 1 am licenced under provisions of Chapter 9(commencing JOB DESCRIPTION
Te, with Section]qXp ill vaumBnf the ltu,inmv and Profen'xioiu'CnJe.and my Gcensc lx RESIDENTIAL,
m O O PERMIT ISSUANCT:
W Ug In full forc a qr z q ❑SFDWh ❑KITCHEN REMODEL
Rub License Clan, S--J hicM APPLIANCIS-RESIUEN ITAL ❑ADDITION 1) BINGRE-PIPE
N z w Dwe Contractor-
ARCIIITIiCI"S UECh RAI R) ❑MUITI-UNIT [I STRUCTURAL
z p'n z I undersmnd my plans shall be meJ as public otcools PANELS MODIFICATION
O z=`-C Oil 1021X)AMPS ❑INTERIOR ❑CHIMNEY REPAIR
I=.4Fu1 Licensed Pone,maril 2111-II011AMPS IA1PROVEMENT SWIMMING POOLS
�gf�� OWNER-BUILDER DECLARATION OVER 100)AMPS ❑HAI'11 REMODEI/REI'AIR EJ DEMOLITION
b
m z a 1 ereny afar m
that I am exempt Earn he Cnorm
s Lurew Law rnr me
W 3 LL F following reason.(Section]1131 S,Business and Profession,Cbdc:Any city or,,Iran SIGNS ELECTRICAL []OTHER
Ha which requires a Permit to construct,eller,improve,demolish,or repair any mmmure
oil
priorto itsalso e9 dicapplicardI ch hunit lefile,a signed st temem SPECIAL CIRCUIT/MI.
N
�Gf
that he licensed p :n a m p fn Contractor L L Rhaprcr9 COMMERCIAL:
W�00 (commencing with Section 7000)of Division 3 of the Business ndlrnfirs n.Code)it TEMP.MIiTIfR OR LE INSI'.
a ty e C Lha he is exempt tbcrtfmm amt the oris for the alleged exemption.Any violation of ❑NEW BLDGIADVIle" DEMOLITION
acMSection]n315 by any applicant for a permit subjects the applicant to a civil penally of POWER DEVI SOTIiNAN9C3 FOOD
oat mom then five hundred dollars SNX)1.
p.zY IMPROVF�.1- T
�=0 01,asownerof the propcny.army employees with wngecas their sole cona'asanion, SWIMMI POOL ELECTRIC R/
F willdatnewark,andthe suucmreisnot intendednrnRered forsale(Sce,WI44.Busiress ❑OTHIi
23 mand Professions Code:The Commoner's License Law does not apply to m nwner of OUTLETS-SWITCHES-FIXTURES
prnpcny,who builds or Improves thereon,and who down such work himself or through
his own amployewn.provided shot m,la im,rowemems ane oat intended nr offroed for NEW RESIDENTIAI.ELECTR SQ IT.
sale.If,however,the building or improvement is cold within one yeorofcomplctian,the SQ.IT.I'L(XIRABEr SQ.FT.
ownertrudder will have the burden of proving that he did not build of improve for pur-
puce o'cnle.).
D I,1 nwner of the prnpcny,mit exdueively cnnuuwting with licensed rotational,m ttmmnrs TOTAL:
onsuua the project(Sec.70LL Bribes and PmE,sions Cod J'ITcC a aloa I J.,
cense Law does not apply to an owner of progeny who builds or improves thereon.and QTY PLUMBING PERMIT FEE
0hit enmmets for such projects with a contortions)nations)licensed pursuantn the Contractors
se Law. PERMIT ISSUANCE
0 I bin nxempt under Sec. .B&P C fm Ihi,,-caro
Owner Doc ALTER-DRAIN&VENT-WATER IIA) VALUA'f10N
WO unIer penally COM PBNSATION UE Ce following
olio Ing BACK FLOW PR(TTECT.D13VICE sa"� 570
IherebyalRnntain acan,of Conaneoself-usam ingJmlker'sCx: J l.J til
Dir ac and will for hynaCenihcac of the Labor
Code,mrefnr Workersce of th- DRAWS-FLOOR,ROOF.ARIiA.WND. STORIES TVPIi CONS'I'RIJC'I'R
wtinn,m provided for by Section 3]W of tM1w Labor Code,for the performance of the
k for which this permit is issued FIXTURES-PER TRAP
'5_<1 have and will maintain Worker's Cnmpcmaino r% mace,as required by Section
37M of the labor Codc,for the performance of the work for which this permit in issued. GAS-EA.SYS]EM-I INC.4 OUI IT.I'S OCC,GROUP 1'
My Wnr�c+ Comgry{1y n Ln .ince carer and Polity JI j j' •r/I
Cartier:l—V1'(l r Xl"t?'� Policy No: LJ h�I� GAS-FA.SYSTEM OVER Il m
CERTHICATE OF EXEMPT ION FROM WORKERS' v /
COMPENSATION INSURANCE GRIASEIINUUSTRI,WASTE INTERCEFIDR
(Thi,section ncalnm lwmmple¢d irthe .it is fomite hundred dollars(FI(q) BUILDING DIVISION VEEl
,it less.) GREASE'TRAP PLANCHECK FEE
Icenifymm mile pelfummocenl 0eworkforw0ichthis,ormad is i...oc.],ledl SEWER-SANITARY-STORM EA.2101sT.
n
bill employ eny persoto any manner sa a,m hemme,uhject,,the Workers'C,,.Nn- ENERGY IFI?
Z cation Law,of Califomia.Data
z 2 Applicant
WATER HEATER WNENT/ELEC R
GRADING PF,Ii
y NOTICE TO APP LICANT:If:alter making Thir Cisionsf of l Labor iodyoushould WATER SYSTIiM?RIiATING
Frei ;
became_aun top y the Worker's Cam1'wnxmiis provisions of the lads Cale,you nmm SOILS FF.Ii
forthwith comply with such pmvi,iom onhi.c permit nM1xll he dcomwA revoked. WATER SERVICE:
c.
= z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL I'LMB. Sp,IT PAID
U Q Ther which iiohm there is..ed See.30 lcnCioagency for the Pur(otmmcc of F�-�Dme�.LRoxciPlq
LL F the work for which this permit is isnueJ(See.Jfn].Co..C.) A A
O V lenders Name Ill \ Tf)TAI.: n
j- LenJer'.eerily
s '1'OTA h
I
:
I" y that I have real Thi,apPlicatinn and state that the ahwc ma
inhntinn i, RUIL{)ING FEE II
rail correct.I agree tocomply with all city and conmy ordinances and slam laws relating to QTY. MECHANICAL PERMIT FEE
V Z building construction,and hereby authorize repreacnmtives of this city to enter upon the SE1S1 CF
vhwe-mentioned property lar hi etion pugatscs. PERMIT ISSUANCE
(We)agree it)save,indemnify and keep harmless the City of Cupertino ugaimt III 1C FEE
linbiliti,,judgmcnls,cnas andcapenses whichmay item'way accricagainxlsaid City ALTER OR ADD TO MECH.
in onscnce of quegraining of this permit. PI NHING FEE
APPLICAN 'RSTANDS AND WILL COMPLY WITH ALL NONPOINT
T AIR HANDLING UNI'I'(q'O 11).gp CPA11
50 IRC A
_ MECHANICAL FEE
q)
AIR HANDLING UNIT(OVER IB, OCO ) CONSTRUMIONTAX
Sig mreaf A,heauc Comraa utc EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAJARDOUS MATERIALS DISCLOSURE
Willthehau pplicam or future milling occupant store or handle hazardous internal HEATING UNIT(TO IBgf))B U)
defined by TCaocaza
prin Municipal Cole.Clmpmr 9.12,and the health and Safety
�st,Section 25532D)1 HIIAUNG UNI'I'(OVER I,IXRB'UJ)
E]Yes ONo PAID
VENTILATION FA :WGLF.RESIDI Date Receipt#
mit
Will the applicant or future by the he use equipment or device which
ehorrendous air conmmin:mts ns refined by Bay Arca Air Quality Management BOILER-COM (lHl'OR Ig1,W11 B'I'U)
Minim] IXUAL:
D Yes [3 No BOILER P(OVF.R 100,00))RTU)
I have read the hwnnlnux materialsa under Chapter of lhu Call- AIR CONDITIONER
ngmrnaen p- ISSUANCE DATE
fomia Healtb&4 ty Csde,Sa:tions 2s5o5.25531 and 25514.I undcm:md that if the NEW RLSIUENTIAh MECH. SQ.FT.
builJingd toren that mace of
ibilirymnotify NcoKcup;lm
aflh mnpriomo is my responsibility
espon Cc4ii�amo notify
or autM1nriec agent u / Due TOTAL: ISSUED BY.
OFFICE