99080060APPLICANTTO FILL INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTI O BUILDING - ELEC'rR
6UILDINCI)I V ISION APPLICATION/PERMITPLUMBING. MECIIA!
0
OFFICE
ECHITECI" GINEER: LIC NO:
ADYRE, S:�
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'ON'TACT. PHONE.
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
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LICFNSI!D CONTRACTORS DECLARATION
1 hachy editor mat loon licen.ed i n lef pinvi.ionx m Clort 9 h,mmcncing
w s
IimSecn.....a0olD lon3nnncBnma.. ane Prolesxi,Raemm, an n.y Gacnxck
dull tierce n..J c' v
nseC Lick
Datc Cnna.mor
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL'
❑ SPDWL [D KIT REMOUEh
El ADDITION ❑PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCTURAL.
MOD114CATION
❑INTERIOR 0 CHIMNEY REPAIR
IMPROVEMENT r] SWIMMING POOLS
El REMODEIIREPAIR ❑ DEMOLITION
[]OTHER
PERMI P ISSUANCE
APPLIANCES—RESIDENTIAL
All 'ill l'ECI':S IIECL 1
I enJemand my plan. shall he used as public record.
PANELS
UP TO 200 AMPS
Licensed PmfaWonal
OWNER -BUILDER DECLARATION
I hereby .!firm that 1 em exempt from the Contractor's License Law for the
mason. (Section 7031.5. Business and Professions Cuda: Any oily or county
which respires a permil or conswa, altar, improve, demolish, or repair any slructom
prior to it issuance. also requires theapplicom for such permit to rile a signed statement
mal he is licensed pursuamm the provisions ofthe Contractors License Use (Chapter 9
(commencing with Section 7(M) of Division 3ofthe Bonen and Profusions Curie) or
mat he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civ
t mora than live hundred dollars (55(0).
L as owner ofthe propvny. or my employees with wages ax theirsole compemmi,n,
will do the work, and the.amaum is net intended oroRercd for sale(See904,1. Business
and Professions Lets The Comreeuo's License Law does net aPply to an owner of
201-1000AMPS
OVER IlgO AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
_
TEMP. METER OR POLE INST.
COMMERCIAL,
❑ NEW BLDG/ADDITION Cl DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ HER
00
SWIMMING POOL ELECTRIC
OUTLETS—SWITCHES—FIXTVRfS
a,3
prnpeny who builds or nnproves thereon, and who does such work himself or mmugh
m
his own moployees, provided that such improvements are not intended or olicrcd file
sale. If, h thehmildingor inproveramet is sold within one year of completion. the
NEW RESIDENTIAL ELEC IR SQ Ff.
FT. TIbR)R, EA I Q. Er.
will l' (hehN fp bth to d'd Ihold p I to or- owner-holderf1'D�'^I.:
❑ 1 e III property, IYcontracting with licensed t 'tors In
UG 1 0 1999
D
[13y—j
QTY. PLUMBING PERMIT FEE
wastrue, the pr p,,l (Sec ]M4 Bus areas,: d P fusions Code) Ire C t t r'x I,i-
seLaw &oes not apply to an owner of property who NoW or improves theme,and
who commas far such pmjce s with a cent le,G) licensed pumeam m the Contractor's
,
License Law.
PERMIT ISSUANCE
❑ Iam exempt trader Sec. . B & P C for 'his .,an
ALTER — DRAIN & VENT— WATER (EA)
VALUATION
Owner Data
/"
^0n
WORKERS COMPENSATION DECLARATION'
BACK FLOW PROTECT DEVICE
.�-^�
1 hereby affirm under penalty of perjury one of the following &eclamtirow:
I have and will maintain a Cenificae of Consent o w1binsure for Workers Compere
%tion, as Provided for by Section 37M of the Labor Code, for the is----, of the
w A for which this permit is issued.
.J
DRAINS—FLOOR. ROOF.A .GOND.
STORIES
'
TYPE CONSTRUCTION
FACURES—PER TRAP
1 have and will Reason. Workees Cumpcnsatien Insurance, as respired by Section
00 or the Labor Code, liar the performanceof the work for which this Permit is issued.
GAS — EA. SYSTEM -I INC. 4 OUTLETS
OCC GROUP
YN
GAS—PA. SYSTEM -OVER 4(EA)
My Wor Coln atln ,.tones Gamer and Polic'nu q
CamiccLL Policy No !
s '
GRF.ASE/INDUSTRL WASTE INTERCEPTOR
CI!RTIFCA IEOF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
BUILDING DIVISION FEES
0 ,7,
Z O
ti
abahwithourpy
W 0
V 0
H. F'
ULenJds
(lristtctinn need not beenmplcuedif the permit is foram¢ hundred dollars 1$ 100)
ur le"')
Irani ly mat Ines pert romance of thewofk for, hick this pumul is issued, l shall
Cpun-
aid ....ploy tory pemsm in my amore,... as m become subject, the Worker,'nin
.mien Laws of Cublotoie. We
Applin t
GREASETRAP
PLANCHECK PEE
S17WER— SAND ARY—STORM FA. 200 FT
ENERGY FEE
WATER HEAT17R WNEISTIFLECI
GRADING FEE
NUI ICE TO A PLICAN'1'. 11, almr making this Crabbers, of Exemption, You should
the Wmkorsenmpcnsamn provisionsofthemed woke, you must
InnM1wim amtply with inch pnrvsinns or permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
orance of
l hereby affirm thathem is a construction lending agency for perfm
the work fill which oris permit is issue (See 3097, Civ. C.)
Name
WATER SYSTEM/IREAs'ING
SOILS IEE
WArEN SERVICE
PAID
Dam Raeiptp
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
TOTAL:
G
F' N
U z
Lendcfs Address
BUILDING FEE
thbo
I acetify that I have mad this epplicmilm and seta at the ave information is
carmen. l agree m comply with all city and county ordinances and state laws nelaing to
building canswctlon. and hereby authorize representatives of this city to enter upon the
advise -mentioned propcety for inspection purprss.
(We) agree ur save, indemnify and keep bamless the City of Cupertino against
liohilities,judgments.crisis and expenses which may in may way accrue against said City
in asequence of the grunting of this permit.
APPLICANTU ERSTANDS AND WILL COMPLY WITH AI NON -POINT
QTY MECHANICAL PERMIT FEE
SEISMIC FEE
PERMITISSUANCE -15rc2
ALTERORADDTOMECH.
ELECTRIC FEE
PLUMBING FEE
AIR HANDLING UNIT (TO lRdan CFM)
MECHANICAL FEE
SOURCE! RCG�F}/PfTIy�S.
IROS)
AIR HANDLING UNIT(OVER IROS) CFM)
CONSTRUCTION TAX -
rX �i�
Sign,", ot Alrylictrnr/Coupe.'' I— ])am
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the uppli,r or'umra huildingaceupnrr stere or handle hnrtrNous nonaxial
HEA D NC ON IT TO 100,000 B' 1' U)
its defined by the Cupcnino Municipal Coda, Chapter 9.12, and Ile Health and SAuty
Cxje. Scehon 255320)°
E3 Yes qNn
HEALING UNIT (OVER I00.00(i B TU)
r
PAD
Dae Receipt p ......///
VENTILATION PAN (SINGLE RESID)
Will the applicant or fume building norep ird use equipment or devices which
'n hwardous air contumitems as defined by the Bay Arca Air Quality Manuga ianl
BOILER—COMP (3HP OR I W.IXXI BTUI
TOTAL:
(OVER 100.000 B'T it
n rict4BOILER-COMP
❑ Yet 116h,
AIR CONDITIONER
I base mail the haeaduus mamr.ils requirements uMer Chile, 6,95 of the Cali
ISSUANCE DATE
NEW RESIDENTIAL MIC", SQ. FT.
Ischia Health & fcry CnAe. Section 25505, 25533 and 25534. 1 undcntmJ that if the
building doesn Or r y have a tenant, mat it is my ms prow, tywpppppp tify t44ata prem
ofthe a is must be met pro........ ce of a CW yf (l(Cyy�
llliiiiii G/Dste
TOTAL:
ISSUEDBY;
t�t 'rW agent
OFFICE