99090030 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI'T'Y OF CUPERTINO BUILDING-ELECTRICAL 1'
APPLICATIOWPERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PRfIJECT IIIEN'1'IFICATION
BUILDI1,16ADDRESS: SANITARY NOPPLICAT12sl'ITAL DATE
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OWSZB:SNA E THO NA LIC NO:
NIC CONTROLp
'HITI:CT/LFGINGER: .-. LIC NO: A /S�:
6f.
CON'IACI': PHONE: B ILDING PERMIT INFO
❑ Consult. Fees Paid by Applicant(Initial) B ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 he.ny a n nlat I son h¢II,W ntmnr prwi,i.as.r coop.,9 m..mmencins JOB DESCRIPTION
�xZ •th Section] fD'if4i ofthe Businersa fessinnsc c mylicenuis T IA
OO tun pC� PERMIT ISSUANCE
F nl'u II RnICCt del
xwr ❑ FDWL ❑KITCHEN REMODEL
U Uce
n. t s Lic,p
APPLIANCES t. Uea Co a o []ADDITION CI PLUMBING RE-PIPE
ARCHITECT. N ❑MULTI-UNIT ❑STRUCTURAL
Z p N Z_ I .&,,,.ad my plan.shall be.awed as public record, PANELS DIFICATION
O Z- UP TO 200 AMPS
I=n f O Licensed Ymfcsxional ❑INTERIOR IMNEY REPAIR
Q 201-11100 AMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECLARATION pyBR I(N10AMP5 ❑BATH REMODEIIREPA R ❑DEMOLITION
x x Q I hereby affirm that 1 am exempt Rolando,Contractor's License Law for the
X3 2 F following rets..(Scoimt 7011.5,Business an.1 Pr..fnsions Code:Any city-county SIGNS ELECTRICAL ❑OTHER
u1 ti y which requires a permit to construct,alter,improve,Jm
enlisn,or.pair any stmat
a
nprinno its issmance,also reyuins the applicant fur such permit o file a signed statement SPECIAL CIRCUIT/MISC.
E Y that he is licetned porsuam to the provisions of the Contac,',License law(Chapter 9
�C11C, (commencing with Seutinn)000)uf Division Sof the Besinesvand Professibr,CMe)or TEMP.METER OR POLE[NST COMMERCIAL:
=E., that he is exempt therefrom and the basis for the alleged eocarro on.Any violation of ❑NEW BLDG/ADDIT]ON ❑DEMOLITION
X m P. Seetiou 7031.5 by my appllutm far a pc..nit,al the applicant tea civil penalty of POWER DEVICES
W^w m more than five hundred dollars(551101. ❑TENANT ❑FOOD SERVICE
X2071 Las owner of the property or my employees with wages as their sole compenvotion. SWIMMING POOL ELECTRIC IMPROVEMENT
F will do the work,and Im,bareme,tum intendedoroRcred for ide(Scc.7(Wq Booties, OTHER
a3 m and Professions CWe:The Contractors License Law dates not apply to an owner of OUTLETS-SWITCHES-FIXTURES
progeny who builds or improves there...,and whit dos such work himself or through
his own employees.provided that such improvemenn arc not intended or offered for NEN'RESIDENTIAL ELECTR SQ FT.
.sale,If.however.tne huildingorimpmvemcnt lssold whom nneyearnfrompl,ron.the OR AREA LSQ.PT.
r-builder will have be moven of proving that he did net Wild or improve for pur-
n 1 of coded.
1,as owner of the pmpeny,am exclusively ttmtrm;ting with licensed c...rectors to TOTAL:
.shod the Is Nv,(Sec.7044,B-mel,and Nu eaion,Coal,s e Coon—v I Li-
contest,Law does not apply to an owner of propeny who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
wed contracts for such projects wrib u aommemr(s)licensed pursuant to the Contractor's
License Law, PERMIT ISSUANCE
1 ant exempt under Sec .B&P C for this reason
ALT17R-PRA IN&VENT-WATER(EA) VgLUAT
tuner Date �f/'(y)
10N
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE �
I hereby affirm under penalty of perjury one of the following declarations:
I 1he,,and will maintain a Ceni fica.of Consennn self.in sure for Worker,Compe.- DRAINS-FLOOR.ROOF,ARIA,CON DSTORIES ;TYPECONSTRUCTION
suuo s provided for by Section 370J of the LaboPerformance Code.for the per[bnnee of mer f.rwM1ich this permit is iasacJ. IIXBURF.S-1'ER'1'RAP
o but and will maintain Workers Compensation Insurance,as required by Section
,a
y_
uWr Cndcv jurrr• � :y Nttk fit iiyp� i GAS-EA.SYS9'EM-I INC40UTLETS OCC.GROUP APN
y War �fq.VS Policy mer. /
/ GAS
-GA.SYSTEM OVER 4(l'A) �a�0 �r�
CERTIFICATE OF EX ENPfION FROM WORKERS' d
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR
(Thissectioo need not be completed irthcpctmit isf bmu mbEct dollars($100) BUILDING DIVISION FEES
nr ler,.) GRGASE'IRAP
PLANCHECK FEE
Toy any thatinthe cuormarreany
w)fthe ecomesork for ubje phis the W ikes Contain. SEWER-SANTI'ARY-SFORM EA. 1?.
not employ any person in any nunnenn as m Wcnme mbjcct m the Workers Contain. ENERGY FEE
Z sation laws of California.Date --- _
Z � Applicant WATIiR IIIiATBR W/VEMT/ELECTR GRADING FM
n
y NOTICE TO APPLICANT:ILtfter banking this Comfienle of licerption.you should WATER SYSTEM?BEATING
a ; become subject to the worker's Compcnvatinn provisions of the Labor Code,you must 11 1
fnnnwitM1 cnnply with such promvnnv nr thin pennh,hull be dcamW revoked. WATER SERVICE I 1
= z CONSTRI1CfION LIiN'DING AGENCY NEW RESIDENTIAL I'LMB. SQ.FT —��
U0 1hereby affirm that then is construction lending agency for the performance of Dafe RA
{S. r. the work for which this pcnnit is I,ted Sec.3097,Civ.C)
0 U Lenders Name TOTAL:
Lender's Add.... TOTAL:
Fy I cenify that I have.ad this application tad,tate that the.hove iafonnutlou is AIJ32
N correct.I agree.comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEF,
(..) Z buildi.gen..aaaiun,and hereby amhorim mpresenmtis'es of this city nmnterepobthc SEISMIC FEE
above-nuademed propcny for inspection purposes.
(We)agree to save.indemnify and keep hannle,the City of Cupersino against PERMIT ISSUANCE F.LECI'RIC FEE
inconsequudgments,ensuing of this eswoich may many way acweagainnt said City ALTER OR ADU'TO AtECIi.
consequence of the Ranting or this D WI PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I R(B0 CFM)
SOURCE REGULATIONS. AIR FEE _
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TA%
Signature of ApplivenitContracmr Date EX HAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MAI'P,RIALS DISCLOSEJR17
Will the applicant or future Wilding occroad.store or handle henarsoti,material HEATING UNIT TO 100.000 BTU)
nv
defined by the Cupcnin0 Mis a 'Me,Chapter 9,12.and the Health and Safety
Code.Swim,2553213)7 HEATING UNIT(OVER 100,000 BTU)
❑Yo PAID
VENTILATION FAN(SINGLE RESID) Da. Rec th
N'ol the applicant or f wre Wilding occupant use equipment or devices which
nit meruN.us airc.nlaminnn¢n d by the gay Area Air Quality Mnnugan.nt BOILER-COMP(3Hp OR IOO.OINI BTU)
Dsuicll e tie T L
[3 yes. BOILER-COMP(OVER IIXI,gX)BTU)
I have read the It, Anus :nerial.s rnryibenicnu under Ch 1 6.95 of Is Cali- AIR CONDITIONER ISSUANCE DATE
f aHeal Safer e.S X505,25533 and'_5534 Ira .nand at iftbe NI7W RESIDENTIAL MUCH, SQ.EL (//f'/►�
ui Wingd •alcuma,dall reayonv���yBd//////yt dryte or
re eh est tprserronsa. of if of
water or archon J agent r Dam TOTAL: ISSUED BY: r /
OFFICE