99080002 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL. ER.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. - SOOOI
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS��� �. I SANI'1'AkY NO. APPLICATION SUBMITTAL DN
be.
OWNtiR'.S NAME: Pf{pNE: — CO O pk"N C:: n p
LIC NO:/
JT YTO G NIC CONTROL
CHHECI'ENGINEER: Las NO ADDRESS: ❑
0MIIACT: PHONE: BU TIDING PERMIT INTO
F�3/ 36 y-57.33 ❑ Consultant Fees Paid by ApplicaBl(Initial) BIDE ELECT PLUMB MECH
❑ ❑ ❑ ❑
LICENSED CONI RACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 herchy affirm Nat 1 am licensed code,pnwisirns of Chapter 9 harrom nAog JOB DESCRIPTION
O ds2 wish Smtiun 9lXXry nl'7 is the liwinms and Pm(ennians Code'andmylicen,vic RESIDENTIAL:
u Cc, PERMITISSUANCE ,
F�W r- i full force and effect Gr / ❑SFDWI, ❑KITCHEN REMODEI
Q,UU Ucenm Class gPPLIANCFS-RESIDENTIAL El ADDITION [I PLUMBING RE-PIPE
H a 6 Date Contractor
ARCHITECTS DECLAR 10 ❑MUl:fl-UNIT ❑Sl'RUCfURAI.
zcoz I understand my plans shall 6e used a%public records PANELS MODIFICATION
`7240 UPl1020)AMPS ❑INTERIOR ❑CHIMNHY REPAIR
F�2hW Licensed Professional 2[)I-1000AMPS IMPROVEMENT 0SWIMMING P00LS
=99,'..3I OWNER-BUILDER DECLARATION
Q hereby allinn Ihw 1 am exempt Dain the Convucmr5 License Luw for the OV17R 10)(H)AMPS ❑BATH REMODkUREPAIR C DEMOLITION
1 i U fallowing mason.(Section 9031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHH
f � .
1+13 w es which requires a permit to construct.alter.imm
prove.demolish.'it repair any swoore
HNO; prionnits iuuance,also rtyuires the apPlicam fonuch pcmiuo fileasigned uatemem SPECIAL CIRCUITIMISC.
�N Ilmtlurkiiecnxed proarear tithe pmviamns of Ne Cnmmcmr's Licenm Law lChapmr9
1'p0 (commencing with Section 7")of Division 3 of the Business and Pmfealrn.Coda)a TEMP.MEIER OR POLE INST. COMMERCIAL:
d m C that he is exempt thcrcmN
frn and the basis for e alleged exemption.Any violation of ❑NI:W BLDGIADDITION [IDEMOLITDON
1L Section 9031.5 by any applicant for a permit subjects the aMlicanuo a civil penalty of POWER DEVICES
m not mom than rive hundred dollars($500), ❑TENANT [I TOO[)SERVICEZN OTHERIMPROEMfiNT
=Q' ❑ Lothewowner k.the property,mmyemployees with eredaselei(Ser,compensation, SWIMMING POOL ELECTRIC
will Pr the work.and Nestmaumis tors Licensor Law
dos not apply to an,Business OTHER
3 m fandaro lan,who
Cole:The Contractors License dca docs not apply hi sun owner of OU'T'LETS-SWITCHES-IyXTURFS
his o ny who builds or Improvm thsuch and who docs e n tintk himself or through
his own employees,building that such mens is sold
me not intended or nutted for NEW RPSIDP,N'1'IAI,ELEC'IE SOP
sale.If.treacles,the building or improvement is sold within one ycarnf completion.the SQ.FT.FLOUR AREA SISQ.FT.
owner builder will have 11m burden of proving that he did not h mild or improve forpur04,
-
,,a of -
❑ L m.owner of the property,ora exclusively commiling with hoaried contractors m TOITL:
construct the project(See.9034,Business and Professions CWep The Contractor's Li-
c se Law does not apply to an owner of proprny who builds or improves lhcreon,and QTY. PLUMBING PERMIT FEE
who eommmsrocmch Projects with a comacmgs)licensed torwunuothe Counselors FY
��-License law. PERMII'ISSUANCE
0 1 ant exempt under Sec. .B&P C for thin reason
nni
Owner Dam ALTER-DRAW&VENT-WATER 02A) 'VALVA )
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
I hereby affirm under penalty of perjury one of the following declamtionr:
I have and will maintain a Certificate of Consent to sdLinsum for W'orke sCanner- DRAINS-FLOOR.ROOF.AREA.COM). I DRIBS TYPECONSTRI T1(
ration,ax provided for by Section 3900 of Bus Labor Code,for the perrnnnance of the
er which Nis permit is issued FIXTURES-PER TRAP
w 1 h:rvc and will maintain Worker'.Cmnpensatinn lnwmnce,a.,required by Sectio '
32(Xlof'the Lahr Cole,for Ne perfnrmanccofthe work
rrloyr which this prmaln is issued. GAS-EA.SYSTEM-I INC.3 OUT LETS OCC.GROUP AfN
My WnrkdcC ympcp hay Aay(vp apt Ril cY Nand o I chyz too GAS-EA.SYSLILI-OVER J(EA)
Carrier: /`'/9._'Ol Wig
I' r l�
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE%INUusrRL WAST It INl'ERCEFCOR
obis section mand nm be ennplened if Ne penmdn a for one hunNM dollars(Silo) BUILDING DIVISION FEES
nr Icss.3 GRI3ASE'IRAP
1'LANCHECK FEE
(certify Nat in Nearymmunccof s ,,hie utemfor.hich Nispermit isismCisopr-al[,hall SEWI3R-SANITARY-STORM F.A.200 FT
not onploy any person in any manner ae as w heconae auhlen tome Workers'Conapcn- ENERGY PEE
z ,� semen Laws of California.Data WAT12R HEATER WNII013-LECfR
0 Applicant t GRADING 197E
N
INDUCE TO APPLICANT:If,alter making this Certificate of Emmption,you should WATER SYSTEMGMEATING
PEE subject to the Workers Compensation Provisions of the Labor Calc,you must SOILS FEE
fnnhwith rurally with such provisions or this permit shallM deemed revoked WATER SERVICE
Q
7z CONSTRUGHON LENDING AGENCY NEW RESIDENT IAL PLMB. SQ.LT. ('AID
V 0 (hereby affirm that Nem is a construction lending agency for the performance of Dar Receipt
W4 Ne work for which this permit is issued(Sec,3197,Civ.C)
O F' lander,Name TOTAL'
V Lenders Arco, TOTAL:
Fr" y 1 certify Nm 1 have mud this application and state that the above information is BUILDING FEE
10 comet.I agree no unnply with all enyand county ordnances and store laws minting no QTY- MECHANICAL PERMIT FEE
U Z building construction.and hereby authorise representatives of this city to enter upon the SEISMIC FEE
aMrve-m anumal property hu m,pectiou pur ou es. PERMIT ISSUANCE,
(Wc)agree to save,indemnify and keep hornless the Cory of Cupertino against III.ECfRIC FEE
liabilities,judgments,costs and expenses which may in any way ucemc against said City AULHR OR ADD TO MHCH.
in seluenee of the granting of this pamil. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT ALR HANDLING UNIT(TO 10.0[)0CFM)
SOURCE REGULATIONS, MECHANICAL PEI.
AIR HANDLING UNIT(OVER 10,000 C171) CONS'I'RUCI'[ON'I'AX
Sigraium of ApplieaaVContma.. Date EXHAUST ROOD(W/DUCfG HOUSING MITIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or furore building occupant store or handle haoadous material HEATING UNIT ITO]00."BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safely
Code.Section 25532m)? HEATING UNIT(OVER 100.X1[)BTU)
C3Yra L,
VEN'I'ILAI']ON PAN(SINGLE RESID) PAID
Will thea applicant or future building t use a Dam Ravi M
pp gby then a Air
i
nit huutrdomss air mntuminanls as def n W by the Nay Area Air Quality Management I301LIIR-COMP 13H1'OR IIIU.UW 0'NI
)fatnct". / BOILER-COMP(OVER 100,m)(113'TO)
TQT, t
❑Yas YrnYN.
1 hove rend the hunrdm m:nerinle rc Ie under Cha n h95 of the Cnli- AIR CONDITIONER
gnircmm� pu rISSUANCE UAT'E
Damm &Saf y C k.S tions 25505.25533 and 8533.1 mmdcrsmnd Nat if Ne NEW RESIDENTIAL MECH. SQ.IT. �J lL
buil fgf see r u m yh: er¢nant,that it is my re.sporsihilitym notify the overpass L T
nnmcal is I a I set pit In anananr a Carnmeaccol OecgNsmy.
Owns a IhorDid agcm Data TOTAL: ISSUED BY:......
OFFICE