99120018 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 4�.�OI 41/ /1
CITY OF CUPF,RTINO BUII,DING.ELECTRICAL.
BUILDING DIVISION APPI,ICATION/PERMIT PLUMB INI:-MECHANICAL
BUILDING PROJECT IDHFIF'ICATION
BUILDING ADD.&SS SANII'ARYNO, APPLICATION SU9MI'1'1'AL ONE
1 v V. k r whc -- 2 -` ,?
AlIMWNER'$NAME: 1'HONIi: )NTA OR'SN f:: LIC NO NIC CONTROL#
O QI ❑
CIIITfiCI'/IiNGINEER: LIC NO: ADDRL$$.�� 1 Pr 1-4 n
W11,
CONTACT PHONE. SS 1L/LL BUILDING PERMIT INFO
❑ Gonsultara Fces Paid by Applicant(Initial) BLDG 17111= PLUU�MI It// MRC"
I.ICIlNSHD CONTRACTOR SDECLARA'I'ON QTY. 19LECI'RIC PERMIT FEE JOB DESCRIPTION
I Imrisy afRrttl tha 1 inn Hcemed miner pmvhimI,mf Chapter')(conttnea ia,
MaIZ Ih Section 9(XXpol'Division 3 of the Bminess and PromotionsCo;le,und myh«nscis RESIDENTIAL:
won wt PERMIT ISSUANCIi
C1= mI HE rcc and clfal. ��6 / ❑SR)WI. ❑KITCHI?N RIiMOOI?I.
aUO Licrnsc ClvSs Lic.N APPLIANCES-BILtiIDIiN"I'IAI. ❑AIJDI'1]ON QP�k!MIBING BIi-PITC
rFn6a D've ll1f-FI Commctor ❑MULTI.UNEP ❑STRUCTURAL.
F]m ARCHITECTS DECLARATION PANELS
w Z I understand my plans shall he used re public records h10DIFICATION
OZND UP TO NIO AMPS ❑IN'EFRIOR E3 CHIMNEY REPAIR
[=yHW Licensed Professional 201-IIKKIAMPS IMPROVEMENT SWIMMING 1'OOIS
C yX OWNB lEmu ❑BATH R
iMODEIRFPAIR ❑DEMOLITION
OVER OWAMIS
WQ 1 hereby uffirrpt thtI amem# from Comnm's License law fur me ❑OI {IB
16 folloing mumu. ,Business and i.m, Any city foamy SIGNS ELECTRICAL
1+13 tl h which requires a permit m construct.alter,imprme,demolish or repair any.weure,
o; pr art t 1: 1 e me applicant fsuch permit file g dstatement SPECIALCIRCUITIM ISC.
}
unatheis liverscalpaosmurn to thepm,,,ions ofthe Contractor's LL (Chapter 9 COMMERCIAL,
i^yob� That he is exempt lhcman9m101 of Drvislon3o lob B :' q JI f:.' mCsdel ser TEMP NI?'iT3H ON IN)1.1?INST.
a KQ� (wnnnsrnin nth Stu
yy from and the bans for the alleged exemption.Any,"Italian al' ❑NI?W BLDG/ADDITION DEMOLITION
51Y Section 911315h an applicant faro permit,ahmv11 the appllcam m u civil penally of POWER DEVICES ❑THNAN'I' ❑FOODSERVICE
nouns,thin fee hundred Jnllam lSSW1.
SSCI.avawncrot the n SWIMMING POOhlihf:C,1,R Ih11BOV1iM1iN'I'
❑ #rope y,or my mnpinyceswithwdgumthelrrnm c0n:pcmeb°' ❑O'I'Hiilt
will do the work,and lhcamcwrc is nm mrended an:Rcrcd for sole lSa.11slq,Bmincss
W�w and 1'ndes.ions Cade:The Comractnr's License Law does nm apply hs;In owner of OUTLC'1'S,_SWITCHES-F TURD,
d property who hard,m improve,thereon,and who does such work hinsself or through
his own employee.,.....oc l that such impmvemcros arc not intended or olicred for NEW RESIDENTIAL I!LICTR SQ F .
sale.If.however.the building or impovemem issold within one yearnfenmpletion.'he SQ.19'.FLUOR AREA SISQ.FP.
owmcnhuiide,will have the funded of moving that he did am build or improve for par
rysu oLwluk TOTAL
❑1,as owner of the property,am exclusively connoting with licensed contmcmn m
constrain the pmjce(Sec.9814,Business and Professions Code:l'Me Contractors Li-
saLow does nnlapply,.an owners.f property who builds r impmvcs thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such poicas with a conabacor(s)licensed pursuant to the Contractor's
License Law. PERMIT ISSUANCE
❑1 am exempt under Sm. .R k 1'C far this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Dal[
WORKER'S COMPENSATION DECLARNf10N BACK FLOW I'RCECL DEVICE
I herebyallirm under#coollyof perjury ane of the following declara nim:
� Ihavuunsl will tnnintainaCcnifiwm ofComenun sclGin,urelnr Worker's Contpcn- DRAINS-FLOOR,HOOP,ARIA.COND. SIORIPS TYPE CONS'I'R LICI ION
,mien,to pro.soled far by Section 3900 of the labor Cole.lid Ili,perl,a too,al'he
work for which this lermil i,issued. PI XTURI'.S-PEIi'fRAI'
❑ 1 faces,end will ani main Worker's Compensadan[manatee,m acquired by Section
37W(it Lithnr�Ceode,for the perfamonceof the work lin which
t flus#conit:,issued. GAS-EA,SYSTBM-I INC.4 OU)'I.ETS Occ.GROUT' �('T A�
Cm`cvk��<'fY— ;,Zara c camartedPoliPolicy
N' s Q7_1 • GAS-FA.SYS ERM.OVIR 4(EA) YI
CHRE
DFICATE OP EKMPI'ION FROM WORKERS GRF.ASUINDUSTRL WAS It INTERCEVIFOR O
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not be completed Raw permit is formic hundred dollars(411X)) GRE, SETRAP
PIANCHIiCK P19!
nr less)
I rectify Pratinthe anyornrom,romewmrkfurwbji,cl I.the Wrmbis,'ued. shall SEWER-SANITARY-ST ORM IiA.2W FT.
not employ any person in any manner so as to Mc.nte suM1jecno the Wnrken'Co.,.-CoENERGY FEE
Z arm Lawnof Califomia.Dae WATER BEAT'ER W/VENT/ELFCfR GRADING FEE
z C) Apphcam I
NOTICE TO APPLICANT:If,after making this Ccnificam of Hsempenn,you should WATER SYSTENVI'BEATING SOILS PEE
rd" Income sobject n the Workers Compensation provisions of the Latoo Cost,.you must
Fes,: forthwith coy with such provisions or this permit shall he deemed revoked. WATER SERVICE
Q CONSTRUCTION LENDING AGENCY NEW RESIDIiN'I'IAL PLMB. SQ.IT. PAID
g agency' per \IL^�.Rereipf#
V p Ihcrvl nfli rn: forrcrelssuen(Set.30lcndin for the Ibnnuna of s
Q. the work Ire which this pcnnit is issued(Set.3097,Civ.Cd \ 11 11 t
Q U IxnJcr'.Name 'r OTAL
r LEI Lender's Address BUIhD FHL:
I s,eml',shut I have restedmi,a,hovaia,uad stat that IM ebo.c infor n monis21999
6. mem ca .l agree comply with all city and county ordinances and state laws mlmingto QTY. MECHANICAL PERMIT FEE I- Slil. ''E
U Z building consm¢lion.and hereby auuffim,,c reprmenmtnesofthi.,citymenmrman he
nMrumenhoned property far inspection Purpose' PERMIT ISSUANCE 1]LCI'RIC PER
(Wel ogre to save,indemnify and kap harmless the City of Cupertirm against
Iiahilities.judgments,corm and expenses which may in my way accrue against.said City ALTER OR ADDTO MECH. I E'PLUMBING FEE
in consequence of the gillarting of this permit. -
API'LICANTI" DP STANDS NO WILL COMPLY WITH ALL NON.POINT AIR HANDLING UNIT(TO 10.000CFNU MECIIANICAI,FEE
SOURCP L ONS//_
AIR HANDLING UNIT(OVER I0.0(I()CPM) CONS'I'RUCTION'1'AX
Slgnu
re of ApplicanUCommnor Dine EXHAUST HOOD(W/DUCO HOUSING MITIGATION FEE
f{AlARDOUS s RIALS DISCLOSURE
Will the uppliwm on furore baildin :wcupvm store or handle hmallommmerial HEATING UNIT(To 100,000 BTU)
as defnal by Om Cupcniao MnNc"pul Cade,Chopin 9.12,and the Hashh and Safety
Code,Sadun 255321u]? HENCING I1NI'I'(GYI!R 03,000BTU)
❑Yes ° VEN'I'1 I.NDON PAN SINGLE RESIDE PAID
_D It, Rcccipt#
Will the applicant or folam building mania n,me equipment ,,dcviay.which BOILER-COMP(311POR 100,000 BTU)
mit humaloo,air contaminants as defined by the Bay Arca Air Quality Management
Uirricf! BOILER-COMP(OVER 100.0001ITU)
E3 Yr, IZlgn /
11havereadihchuraN.7o''s"materials rquiremems umler Chdpmr6v5 of the Cali- AIR CONDII'IONIM ISSUANCE DATE
forma Hullh Such
Codc.Scon s 25505.25533 and 3534 1 umk nd that if the NEW RP_SIDEbT[Al.MECH. SQ.FT. /
huildingili ore my have mad,that it is my responsibility it)no0fy the moment 2-
of.I of hich t met missuameofaCrnitica pot iscupki
(Inner nr vmhnriceJ ager Uva TOTAL: ISSUED BY:
OFFICE