99090111 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. (j D I �PERMITNO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL
r- -'BUILDING PROJECT IDP.NTIFICATION'
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OW ERS N ME: PHONE: C rR IOR'S AME: LIC NO:
B 1_r. O /x_ N/C CONTROL It
CHITECT/ENGINEER: LIC NO: ADDRU S: l'(J ❑
(I�- vlivlcise
CONTACT: PHONE: - ,. BUILDING PERMIT INFO
�xn;e,) Monies 271-6655 1:1❑ Consultant BLDG EC PLUMB MECH
❑ ❑
LICENSED CONTRACTOR S DECLARATION QTY ,ELECTRIC PERMIT, FEE,
I Hereby affirm that I licensed a p of Chapter 9(commencing - I- i ,.. - .. JOB DESCRIPTION
OZZ 'm Secn.n 7(X10)of0'v s.n3onheemrnes oPmfovum and RESIDENTIAL:
Oo w,full forve and eff PERMIT ISSUANCE
QUU License Class MbS9b ❑SFDWL ❑KITCHEN RIiMODHL
an
nam APPLIANCES-RESIDENTIAL. L1 ADDITION ❑PLUMBING RE-PIPE
- Gomrah.r
As shall he use DECLARATION ❑MULTI-0NIT CSTRULTURAI.
H.a7vr PANELS
Z p H Z 1 understand my plans shall be used as public records MODIFICATION
CZ-0 UPT02MAMPS ❑INTERIOR CCHIMNEYREPAIR
=Iq Licensed Profesai.ml 201-1000AMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECLARATION
C ❑
Egg 1 hereby affirm thin 1 nm exempt from me Contractor's License Law for the OVER IBUB AMPS ❑BATH REMODEUREPAIR 0 DEMOLITION
613�Fm following crown.(Section 703 13Business and Profusions Code,Any city or county SIGNS ELECTRICAL [D OTHER
W O.i which reqm reclaims a permit construct,alter,improve,demolish or repair any structure
prior a tsissuance,alsorequires the applicant forsuch penton,,fileusienedsmtement SPECIAL-CIRCUIT/MISC.
Y that he is licensed pursuant to The provisions ofmc Contraemrls Eicmu.Law Chapter
CSO (commencing with Section 7000)(if Di vision 3 ofthe Business and Profession,Core)or TEM P METER OR POLP INST, COMMERCIAL:
a c C tom be is exempt therefrom and the basis for the alleged exemption.Any violation of 0 NEW BLDG/ADDITION 0 DEMOLITION
�
at Section 7031.5 by any applicant a permit subjects theapplicam to a civil penalty of POWER DEVICES y ❑TENANT ❑FOOD SERVICE
I-ZY not""ban five Hundred dolmrs(SSmI. IMPROVEMENT
=SC ❑ Lasownerofdmpropene,army employeeswithwagesmm,(Sec.compensiness SWIMMING POOL ELECTRIC
W p.,$ will dothewons Codec he Coeisnots Livens La.dotiffichad es
apply to.. Business es []OTHER
63 adProfessionswho
Code:Theoves then' License lawdoesnotapplytolf owner of OIfTLPTS-SWITCH8.5-Fl%TUR
his o nY who builds or improves thereon,i and who does such work himself or through
his own employees,provide)That such improvements are out intended or offered for N[iW RESIDENTIAL F.LECfR S
s:de,If,however,the
ve(hngorimpwvemeng stat hedid noneyeaor improve for
SQ,FT.FLOOR AREA fl/SQ 1•It
p..ne.r-builder will have the burden of proving that he did nnT build or improve[or poo
of role.).
0 I,itsr of me prapeny,an, xclusively convecting with licensed conuacmrs to TOTAL:
instruct the project(Sec 7084 Business and Profession,Code)The Contmear,Li - - ----- T . -
cemelawdoesnof apply m an owner or Property who builds or improves thereat and QTY. PLUMBING PERMIT�t iq FEE
tme '
who contract,for such projects with a conmrts)licensed pursm d to the Contractors
License Law. PERMIT ISSUANCE
0 1 am exempt under Sec. ,B&P C for this reason
)weer Doc ALTER-DRAIN&VENT-WATER(EM VALUATION
WORKER'S COM PIENSATION DF.CLARA'1'[ON RACK PLOW PROTECT.DEVICE �O
I hereby affim runder pennhy of ,uy wone of aro following deal...tions: (�J
I haveand animations oCurifimmnf Cansentm self insure liar Workers Compen- DRAINS-FLOOR,ROLE,AREA,COND. STORIES' TYPE CONSTRIJCPION
sution,as provided for by Section 3700 of the Latin,Code,for the performance of the
work for which this Permit is issued, FIXTURES-PER TRAP
0 1 have and will maintain Worker's Compensation Insurance,a,required by Section
37100ofthe labor Code,for theperfotmanceofine work forwhich Thisperrit is issues. GAS-EA.SYSTEM-I INC.4 OUTLETS OCG GROUP APN
My Worked ncpegnie vody Nnyd rw.l!n GAS<F.A.SYSTEM-OVIiR4([A)
Gorier: �° Y� 9( 2 6 33
CERTIFICATE OF EXEMPTION"I1INN
COM'fNSATION1NSUR NyyOQQ GREASDINUUSTRL WASTE INPRCEMR
tc-611 2 J BUILDINC'D VISI. yFEF.It
(Ibis udion need nm be unnplemd iDhe permit is forma huntlrrd dollars$100) - `(
ter less.) ORI3ASE TRAP PLANCHECK PGIi
I certify that in the peffonnancenfthe work forwhich this permit is issued,I shall SI7WER-SANITARY-S'FORM EA.200 FT. sj
not employ any person in any manner music become subject to the Workers'Compen- ENERGY FEE r
{Z soden Laws of CelifomiDole.Da
Z O Applicant WATER HEATER WNENT/HLHCTR GRADING FEE
V)a NOTICE TO APPLICANT,If,after making this Cenificoe of Exemption,you should ii SYSTEMi TREAFING, become subject to the Workers Compensation provisions of the la hon Code,you must SOBS FEE
forthwith comply with such prishounrm this permit shall be deemed revoked. WATER SERVICE
aQ
.7Z CONSTRUmmumm is romNLENDINGAG NCYagency NEW RESIUENTIALPLMB. SQ.FT. PAID
V Q Ihereby which thi thaun,iissued( ec.30 lending agency for The performance.F Dw ReceiptM
W F the week for which this permiT is issued(See.7097,Civ,C.)
0 U Lender's Name TOTAL:
Lenders Address TOTAL: NZk
F0. I cef ity that I has,way this appin auon and state thin he bawc iniftmashirs,isI,. BUILDING720
V] correct l agree to comply with all 'ty and county erdmncesaJ state laws relatingro QTY,, MECHANICAI.PERMIT TI '1 •FEF.
L1,� building construction,and hereby eutboriu reprwarmves of the city to enter upon me SEISMIC FEE
.1x,vememiomed property for inspection purposes.
IWe)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC
liabilities,judgments,costs and expenses which may in any way accrue against said City AITERORADDTOMECH. PLUMBINGF
in consequence of the gmmir,of this peewit.
APPLICAN UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0,0N)CPM)
SOURC :GU ATIONS. 1 MECHANICAL F i
plc cin q /Y NItHANDLING UNIT(OVER I0,INN)CNM)
/�`�' / CONSTRUC'TION T X
Sign r c of p ILI norma (late EXHAUST HOOD DODUCT) HOUSING MITIGATION PEE
ARDO S MATERIALS DISCLOSUREWill the applicant orhome building oecap.,store.,handle hcaradous marerial HEATING UNIT(TO 00.000 BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code.Section 25532(a)9 HEATING UNIT(OVER 100,0100 BTU)
❑Yes CNo VEND BATION FAN(SINGLE RESHOT PAID -
Date Receipt IT
Will the at,co applicant or future building by the B use equipment of devices which BOILER-COMP QHP,OR 100,000 BTU)
mit hueuMou,air amtuminanrs'us ddined by the Bay Aau Air Quality Mantgeanest TOTAL:
Di.a,icT I
❑Yes CNo HOT LER-COME(OVER I00j010 OTU)
I have toad the hauNous materials requimmens under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
famie Health&Safery Cede Sections.thin i 25533 and 25534.I understood!Nat if the NEW RESIDENTIAL MECH, SQ.FT.
b raiiingdce n Satin, ode.Sl have atenmommitisme reoil milbility2554.1 to notify the oe.upant
of c with most be mer priSrr to issuance of a Cenificala Z401 e c y.
�a n
rut o' ag Date TOTAL: ISSUED BY:
OFFICE