99080068 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY / O loo tO 6
CITY OF CUPERTINO BUILIi1NG-1?I,ECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/IIERMIT r1.UMRING-MECHANICAL
BUILDING PROJECr IDEN71FICATIOY
BUILDING'
,ADDRESS 5� w SANT TARV N(l. AI' .'^. DATE
OWNER'S NAME:VJ PHO ACR 'SN 'LIC NO: ^ r V
G
NIC CONTROL If
I1W VRCI I1'IEC1/ENGINEER: LIC NO: AILD E$$ 1 Vol ❑
CONTACT: PHONE: G BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG/ ELECT PLUMB MOH
LICENSED CON'TRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEEMWz
1 hereby am.that l ant licensed under p-Gor ns of chapter 9(commencing JOB DESCRIPTION
WOO thseclion 7(XX))of1 icio d)n"Basincss am It (- lot Ialyli,vr,d,, RF I
1+10 7 PERMIT ISSUANCE:
Fty� in full foriduade /Q a� / ❑SFDWL [I KITCHEN REMODEL
4$VU Ltce"''Clvsa Lica RESIDENT AL ❑ADDITION ❑PLUMBING RI;-PIPE
h6i Ume Qnnmmttr ❑MUL'rLUNH, ❑STRUCTURAL
ARCH TE, DF.CL RA N
~hZ lundcrstand my plws shall b<uscd as public cord. PANELS MODIFICATION
ZOZ�� UPT0200AMPS ❑INTERIOR ❑CHIMNEY R17PAIR
F�4t:w Licenxul Professional 201-I000AMPS IMPROVEMENT [D SWIMMING POOLS
<Yf; OWNER-BUILDER DECLARATION OVER ICIXIAMPS ❑BATH REMODEI/REPAIR ❑DEMOLITION
C C Q I hodolly affirm That 1 ton cxemm from Om Connuenor's h rcme Lnw for,he
X 1 U following minor.(Section 7031.5.Business and Profid,00ns ColAny city ar county SIGNS ELECTRICAL OT1417R
1+13 y which re9uims a permit to dansWcn,alta,improve,demolish,or repair any smucmrt
Eoo.n prior In it,v,.cncc,alenrcgcim,thcupplicat for such pant..to file"signet)statement SPECIAL CIRCUIT/MISC.
$`�y that he is licensed pursuant to the provisions of the Convanor'a License law(Chapter 9
��MC, (commencing with Section 7001 Division J f,he Business and Professions Code)a, TEMP.METER ORPOLEINST. COMMERCIAL'
d q o C Thal he is exempt morufrnm vaid the basis for the alleged uxcmpunn.Any......tion of ❑NEW BLDG/ADDIT[ON ❑DEMOLITION
W:2 Section 0031.5 by any applicant]or a Perini,subjects the upplicannn it civil penahy of POWER DEVICES ❑TENANT ❑FOOD SERVICE
not mum than Eve hundred dollars($5(10). IMPROVEM
CZO ❑ I.asa.rd,ot'didpro.Io,,army employeeswith wagesax nheirxole cnmpensutinn, SWIMMING POOL ELECTRIC 'XO
��
2r- will do lhework.lad theamniure:.cnol intendW oroliened l'orsale,(Sec.7 B¢amss Ng OTH1iR �
L 3 and Professions Code.The Communist's License law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES /` C O/ d.11 GJ✓1 f.
property who builds on nnprovsc dramor,and who docs.cuch work himself or through Ale
his awn employees.provided that such impmvenmu s am not intended or offered for NEW RESIDENTIAL 12LECIR '1'.
sale.If.however.the building or improvement is sold within one year of completion,thc SQ.FT.FLOOR AREA S/sQ.FT.
m
rnhutlder will hood the burden of proving thin be did nal build or Improve for fan,
pose of tole). ,.,y{.
I,as owner of the property,am exclusively contracting with licensed contractors to '�'V"
numce the Pmjedt(sec.7W4.Husinew and Profesciom'Cnde:)'no Contractors I,-
move
,- yI
moseTawduesnolapplymanownerol'property who builds or improves thureon.and QTY. PLUMBING PERMIT all FEE
who contracts for such projects with a commandos)licensed pursuant to the Contractor'x
hicen.%e Law. PERMIT ISSUANCE
lam exempt under Sce. ,B&P C for thomason
ALTER-DRAIN&VENT-WATER(EA) VALUA'T'ION
' )wncr Date
WORKER'S COMPENSATION DECLARATION BACK FLOW]IBMECI'.DEVICE
1 herehy.Rim under pe.try of perjury enc of the following declarations:
❑ T have and will maintain a Certificate of Con.sentto self-i"cure for Worker'.%Comped- DRAINS-FLOOR,ROOF AREA.COND. STORIES TYPE CONSTRUCf10N
muni,as pnorded for by Section 3900 of Ind Labor Craft,Int the performance ol'the
work for which this Penni,is i.med FIXTURES-PER TRAP
1 have; it will maintain Woders Campcnsntion Insurance,as required by Section
37(ksal the Lbm CWe,forlhe performance offle work forwhich this peril is:;,nod. GAS-eA.SYSTEM-I INC. OUTLETS OCC.GROUP APN
My Workers Gsuwog,iot�L di canix,rnd Policy nu W
.�
Carrier: ]V /o`F�_ Policy Nrt', GAS-EA.SYSTF,M-OVER 4(EA)
' CERTIFICATE OF EXEMPTION FROM WORKERS' GRT:ASEBNDUSTRL WASTE INTERCEPTOR
COMPF,NSA'I'ION INSURANCE BUILDING DIVISION FEES
(1'hi,waim.m ed an,ho d ideled time perit is forum hundred dnllan($100) GREASE'TRAP
or loss,) PI.ANCHECK FF.E'/ \ I
I certify that in the perfnrnunceofthe wonk forwhich this permit is issued.I shall SEWER-SANITARY-STORM EA.200 FT. /^,
non employ any iscrom in any manner an us to hccome sobject to the Worker:Compdn- ENERGY FEE
Z cation lawsof Culilinmia.Dane WATER H17ATER W/VENTIIiLECTR GRAD ME
ME e L .nn
Z Applicant .-�
.N. 11 h
NOTICE TO APPLICANT:If after making To Certificate of Exemption,you should WATER SYSTEM/TREATING SOILS FEE V V 1 o Y IJJ
a ' Jul
bean..xubJcct to the Worker's Compensation provisions.1 the Luhor Code,you must t t
H-) forthwith comply with such provisions or this petit shall M deemed revoked NATER SERVICE
5 z CONS'I'RUC'HON LENDINGAGCNCV NEW RESIDENTIALPLMB. SQ.ET. PAID —
VO I hereby notion that there is a construction lending agency fonhe perform eof ' yr Uand Reccipta
I
F ,he work for which his permit o,wand(Sac.3097,Civ,C.) TOTAL:
VLenders Nano
IcnJch AWrtss TOTAL:
W I cer ily that 1 have read this application and state that the above information is BUILDING FEE
VI conwa.I agree to c".nply win all city:rad county on maned,and,solo laws minung to QTY. MECHANICAL.PERMIT FEE SEISMIC FEE
V,Z mildingcommunion.and hereby authmix reprewomovesofths city memerupon the
slarvomcntloned props for inspection purptsee, PERMIT ISSUANCE ELECTRIC FEE
(We)"gree In e.,c,indemnify.nd keep hurmldcs the City of Cupenlno ug.imt
Iiahilities.judgmenn.emu and expenms which may in any way accme against said City AL'I ER OR ADD TO MECH. PLUMBING FEE
in um¢quenee of the granting of this permit.
CAN'I'UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0,000 CFM) MECHANICAL FEE
'OU CE REGULATIONS. /
�Z AIR HANDLING UNIT(OVF.R 10.0WCFM) CONSTRUCTION TAX
L:n
rCW,
m ofApp Cotnraclnr ate EXIIAUST HOOD(WIDULT) HOUSING MITIGATION FEE
HAZARDO • RIALS DISCLOSUREWill theupplicanl or Inland buddingocuupmt xlmm�r handle Wounlous mated.] HEATING UNIT IT0 100.00)BTU)
nW by the Cupertino MuimpW CWe,Chapter 9.12,and the Health and SafetyHEATING UNIT(OVEH IOO,OgI BTU)
Section 255321.)[
❑Yes ❑No VENTILATION PAN(SINGLE RESID) PAID
D'uld Receipts
Will the applicant or furore(wilding occupant tax equipmcnn or devices which BOILER-COMP l3HP OR 100.000 BTU)
mit homrdsus air contaminants as defined by the Buy Arca Air Q loony M.nng"I TOTAL:
01k;;e,
=R
P(OVER 100.00BBIT)
❑No
al thehuvdnua nanrials rcquimmems under Chup¢r fi.95 of the Cali- AIR CONDIIIONER ISSUANCE DATE (((''STTSafety CWe.Sections 25505,25533 and 25534.1 understand Lha Hthe NEW RESIDENTIAL MECH. SQ.pT. / (' y nrcntly hnvcnwwn,tool in lx my m.punsibila,tnnntifynheodcupom r /1,which mull ono icmage of a C,mfidaVIIdea Zyy(U TOTAL:ieuJ agent Dae ISSUED BY:
OFFICE