S 3999 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MECHANICAL S 3 - 00
BUILDING PROJECT BEEN'I IFICATION
BUILDINGADDRFSS: SANITARY NO. APPLICATION SUBMITTAL PAT
RtMRas� lel� N - 2—
OWN NAME: PHONE: C NT ltlgZ . LICNO'
[KoliCrIda / Ii - ♦/8,(/lfo 17 NIC CONTROL#
�CHITEC'I AiNGG I NEER: LIC NO. V AUIIRE Sear Gr #' ZSTT q�-(p� 0 �' S 29
CONTACT PHONE: S BUILDING PERMIT INFO
�/Q L 6A IZC(Ii (�rl���f71 P3 d D E] Consultant Fccs Paid by Applicant(Initial) BLDG ELECT PLUMB MIiCH
Do—
LICENSED CON'fRACTOR:S DECLARATION QTY ELECTRIC PERMIT FEE
1 hemby.frrnt than 1 an,reenned ender pm,t,mrs of Chapter 9(sommemlmg JOB DESCRIPTION
Daft with of Division 3 ofthe Business and Profexxions Code.and my littnseis RESIDENTIAL:
slop wt PERMIT ISSUANCE.
Fgg= infret)force and effect /1_ Ir.3.io 2C� ❑SFDWh ❑KITCHEN REMODEL
�UU Liccnsc Clans _ D�Lic.# aY APPLIANCES-RESIDF.N'HAL [I ADDITION ❑PLUMBING RE-PIPE
yG Uum Glrlrlle
F�m ARCHITECPS DECLARATIONPANELS ❑MULTI-UNIT' ❑STRUCTURAL
y
ZOZ (understand my phos shall bea .
used as public UPTOMPS MODIFICATION
pZ�� 2WA ❑INTERIOR ❑ IM
p+�H,fy hlnmsed l'rnfcsvionOl 201-Ilxx)AMPS IMPROVEMENTSSWIMMING
POOLS S
G w-: OWNER-BUILDER rd he minartN BATH REMODEIaoREPAIR [I DEMOLITION
C OVER I(MM)AMPS
C{go.Q I naso aRrm ohm 1 am exempt fmm the Cession,Co e:Amy,cense Law far the
G U following ream..(Section 7031.5.n.nine, vnd Professions Code:Any city or eouory' SIGNS ELECTRICAL OTHER
Y13 LL vFi w1irM1 its issu a penni(nr conmrocn alter.improve,h Inion.t or repair any a men,
�ei poor to issuance.also requires the applicant for sane]pcnniuofle esigned rtalamcm SPECIAL CIRCUI'UMISC.
�' p- Nat he is licenxd pumuanuu Ne provisions of the Contractor's License Inw(CM1upmr 9
��a� (commencing with Section 7000)tot Division 3 of the Bu,iness and Professions Code)Or TEMP.METER OR POLE INST. COMMERCIAL:
d d o rL that he is ucnrpt morreffonr and the ha.is for Ne alle,ol c,,am,a ni.Any v,thilin.Of ❑NEW BLDG/ADDITION ❑DEMOI.ITION
�y
Section 7031.5by unyapplicant fill.permit subjects the applicam to a civil Penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
m more than five hundred dolhrt(SSWL IMPROVEMENT
FSS ❑ I,us owner of the pro,o or my employees with wages as their vole compensmion, SWIMMING POOL ELECT RIC
g. willdolhcwnrk.mal Ncaniti eiv not mu,ndedoroffned finade(Sce.70M.Buxinco ❑OTHER
13 in arW Professions Code:The Conn.,.,.License Law does nor apply n an owner 0 LRS- 'WI'T'CHES-FIXTURES
property who builds or implores thereon,and who does such work himself or thmug
hi.own anpinyces,pnwiJeJ Nm such improvements are not intended or oBcrcJ f0 NE rR ENTIAI1. .
sale.IL however,the building nr inrpruvcnmm lx sold whhin one year Of compleliun,th SQ.FT.FLOOR AREA VSQ.FT.
cr-builder will have the burden of posting that he did not build or improve for par t �>: t
Prse of sale.). �,
❑ I,a.v.enol of the proK.,,ant racltssivcly contracting with licensed covvucurrx t
construct the project(Set.7044,lm,bexa road Profession,Cnde:)'Ibc Coovacbris 1, .,,�#
cense Law deas not apply r an owner of property who builds or impmtex Ncreon,en L BING I E I 1
IL
whocontracts forsuch p,.jec.with.counsel b,)licensed pursuant Inthe Comnctm's
Liccme Law. PERMIT ISSUANCE
❑1 nm axenpt under See. .B&PC for this rcuson
ALTER-DRAIN&VF 1'-WATER(HA) VALUATION
Ower Date D Ob
WORade,p CIIMPfiNSAT1ON DE Ce ollowON RACK FhOWP
I bendy intoe under Curdy to perjuryone of Nc fn%mefor Jmlaer's .
(have and anill far by Sein a tion 37M of the self
sore n,gerf ortu re,atBeCosenza- pRA1NS-FLOU ST RIES TYF'Ii CONSTRyEf1OP
auon,as Providedti fur by Section 3]W of the WMr Cssle,for the ledomunce of th
Fork forwhichNis maintain
is orker PIXNRLS-PER AP
afoot "o
Ej 1 have and will ode.fon Worker's Cume ofth w rkfor ce.which
h required by Sssuion
3](Ml of the labor Cole.4a the performance of the work for which Nixpemrit is issued. GAS-[A.SYSTIiM-1 INC. (ICC.GRUUPb//
My Work is Insulpkace canier unJ Policy. bel i9Q9 GAS-EA.SYSTEM-OVER4UA) 3 WO
C.rier:.S("T1Y( row rAM r Pnhcy No.:�.11- rL3-L[1—
CERI'IFICATF,OFEXEMI'I'IONPROM E S' GRE 17 COMPENSATION INSURANCE BUIL DING DIVISION FEES _�—
Olds.metlon need not he completed ifthe permit is forombandreddollan(SIW) GRGSE TRAP
Or le") PLANC14ECK HE
Ieenify that in fire perfmmunce of Ne work for which his pennil is owed,(shall SEWER-SANITARY-SI ORM EA.20C,FT.
not employ any person in any runner so u,in become subject o the Workers Compen- ENERGY FEE toU
Z vmlon Luws of California.Dale Vo HEATER WIVENTTLECTR
Z O Applicant GRADING FEE
Z
NNHCI?'IY)APPLICANT:If,atter making Nis Ceirmemc Of F,.aanplion,You should WAIPR SYS'I 17MO REATING
..r O50145 FEE
F ]orae subject y a Wo res mon,or this er mit steal of the Imedr Code.you must
Cakl � forthwith comply with such prmieinnx or this permit shall be deemed revoked. WATIiR SERVICE
a CONS'1'RUC'1'ION LENDING AGENCY NEW BESIDES I'IAL PLM B. SQ I9l PAID IT ne Receipt
V p l hereby union that there is a construnion lending agency forthe performance of
LLUm
the work!ar which Nis permit is issued(Sec.3097.Civ.C.)
p Lender's Nae / TOTAL:
} TOl'A /
Lender's Address
L 1 certify Nat 1 have read this application and ,are that Ne.hove banrrawm is BUILUI FT'
ti N
correct.I agree to comply with all city and connordinances and state[a...cle ingm QTY. MECHANICAL PERMIT FEE
tySEISMIC PEE
U z milliing eoRgmcno.,and herchy m..It... reane,,,mull...of th'wcit,ovir ter upon the
aMwe-menioned properly,ber inslnelien putimo s. PIiBMIT ISSUANCE
(We)agree ,,vve,indemnify and keep hartnles. be City of Cupertino against Ii1.ECfRIC PEE rtoo 9
liabi lilies,judgment,costs and expenses which may in any say boree-gains]said City ALTER OR ADD TO MECH. PLUMBING FEE
in ttquence of me gnming of this Permit.
APPLICANT UNDERSTANDS ANU 'l1.L COMP LY WITH ALL NON-POINT AIR HANDLING UNIT Tf0 IO,gM)CFM) MECHANICAL FEF
SOURC 1GULATIONS.
j.- 7f-Q9 AIR HANDLING UNIT(OVER[Do"CFM) CONSTRUCTION TAX
Signa] ver 1p nOVC, ram lil..OV I� DHnn 1 I EXHAUST IIOOU(w/DUC'q HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future buildingoccupentsnnc or handle hazardous mmenal HEATING UNIT(TO I00.000 BTU)
as defined by the Cupertino Municipal COde.Chapter 9.12,and the Health and Sarc]y
COde.Seclinn 25532(.)7HEATING UNIT(OVER 100LW)RTU)El Yes Yo VENTILATION FAN(SINGLE RF_SID) PAID
Date Receipt It
Will heupPliena or forum hmildmgoccupant ass rum,unt er de,iccs which BPILL'R-CIJMP(3HP ON IW,IXMI ETU)hazardous air confirmations as defined by the Buy Arca Air Quality Management
mlrcC
El yea �y�/Nu BOILER-CONP(OVER IW.00U BTU)
1 have read thehazardous materials requirement.under Chapter 695 ofIM1e Cali. AIR CONDITIONER / ISSUANCE DNYE
fomia Health&Safety Code,Sections 25505,25533 and 25534.1 uodeonand unroof In, NEW RESIDF.N'I'IAL MECI{. SQVT
building does not comonly have
net tenant,that it is my msprmsibiliryw notify the Occuprom (Jf IIOO
nn the ogmnm l bib masprier to iscu-nccnC
f o Ccniti ,,to upuncy
B /f . -est-y9
Own t ...cJot.1m b Date TOTAL: ISSUED IIY:
OFFICE