99120097 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY eel /ZI-00 ti --4--
CITY OF CUPERTINO BUILDING-ELECTRICAL. MRMI F NO.
BUILDING DIVISION APPLICATIONIPERNIFF PLUMBING-MECHANICAL
BUILDING I'RO,II+CI'IDENTIFICATION.
BUILDING'ADDRE.SS. SANI"1ARY NO. APPLICATION SUBMITTAL DATE
OWNER'S NAME 4 /59 OPKer pf(�7/G� C�?�� ME. -'T .`3 1
/LVhM ` /r�F �'/y� \/1 N/C CONTROL#
�TCHRECI'IIRNGINEER: LIC NO A�.f�k S) f,1;S ff,44 - W, J•�f ❑
CONTACT PHONE /(f• 4 •1!l L/'r .' BUILDING PERMIT INFO
•�-�-� ��Qi/ }O� ❑ consultant Fees Paid by Applicant(Initial) ij,U9. 1:1 lie 11 M}+ sifts-
LICENSED CONTNACTOWN DECLARA'T'ION _ 1
IQ •t HLECTRIC I'IiRMIT. .ii FEE /
I harehy arfimn mat 1 am licensed under,povl...ns m Chapter 9leummenrmg I - JOB DESCRIPTION
OF�WZ D m]IX0m3nh l{ lv a pres.g. - myn"men PERMIT ISSUANCE I RESIDENTIA:
moll lorcmd efrcl SFDWI,
❑KI'I Cl IEN REMODEL
aUU lacen.e a Uc#— f - APPLIANCES-RF_SIDENI'IAL
1-Z a Dale Conoennr •R•,1( 'S ❑ADDITION 0 PLUMBING RE PIPE
Fly ARCHITECI"S DECLARATION PANELS I ❑h1ULT1-UNI'i' OSI'kUCTURAI.
mZ I understand my plans%hall be used as public records MODIFICATION
CZ4r UP T02W AMPS ❑INTERIOR OCHIMNEY REPAIR
LW Licensed Pmlo-omil 201-1100AMPS IMPROVEMENT 0SWIMMING POOLS
Y�-a OWNER-BUILDER DECLARATION
-is a Q I hereby affirm that I am emoopt floor the Contractor'.License Lew for the OVER Imo AMPS ❑BATH kF:MOUIiURIiI'AIR ❑DEMOLITION
.as LU following reason (Section 7I1I5,Hronrs.and Pmtewmns Gale Any city or county SIGNS ELECTRICAL DO'THiili
1+1 I LL H which require%a perms o construct.alter.Impose,demolish,or repair any amcom
.F.LL prior to its Issuance.ran requires theeppheam forsuch prrmn ,,file mgnrJ Flo @mrnt SPECIAL CIRCUII'IMISC
K� that he n Lren.ed punu.in m the prmismn.al the Contrus.In,,Licenw law lChapta9
ad GOO tournaments with Section or Orvismn 3 ufthe liusmas and Profcutonc Code)to I TEMP METER OR MOLE INST. I COMMERCIAL:
d 6 ep4
Into hew csem,multiform and the basis for�he alleged eaampt Any viol Inuit nl 0 NEW BLDG/ADDITION ❑DEMOI.II'I(IN
iCmW Section 90315 by any applicant for a no., abed"the ap,l,csnt 1.or crud penalty of POW17R DEVICES OTENANT 0FOOD SERVICE
�..m
F'Z>. mm mare man five hundred dollars(S50in
SWIMMING POOL HLEC'I'RIC OTHERVIIDIENT
pp�6 Ol,mnwner of thepmpeny,nr my cmploycc.xath wages aahev solo congwmauon,
2 f_0 will it,,he work,and the structure is not momfoledoroflered for wle(Sol]014.Husmess OTHER
❑Q and Professions Cade.The Common,"farm,Law does not apply to an owvnn of I / OU'1'LLTS-SWITCI{ES_piXTURILS .-
63 prupeny who mild"or Improves thereon,and who doffs such work hunsulf(it hough
his own employees,provided that such nmpovement%ice not intended muttered for NEW RESIDENTIAL ELECT) k s� -
wle.ILhowner.ter huJdmg nnmpmvemennnenldwnhmnncyearufmmplmm�,the SQryT.FLOOR AREA- SS_Q,I I'
pow-hmldei will have the burden of proving shat he did no huddorimpmvelo,pm- DEC 1619'!9 U
of"ale.).
❑ 1,its owner of the pmpol,,am eselusncly contracting with httnwd commerm,u, I '
color rud the pnoen(Sec 7044,Rusmess and Pride svans Coor:I The Contomors LI"
reuse Lew does not apply to annwner cfprnpmy who bonds or impov%marron,and QTY 1, t„ ,1•PLUhI13(NG PERMI'T�ol vriE I
xhn cnntraats Lis wen Pmlem.wish a cnntramngsl Maenad pu mmt io me Conuoaon
lumense Law. "• By pERh1I'f ISSUANCE -
1 Hoch atom alder pcCOMal penury t lie nl the RoTIOg des Ore hl.reason
❑I.am esnnpt under See or
ALTHR-OItA1N&VE'N'T'-WATEk II.AI // VALCUA'I ION
O WORKER'S COMPENSATION DECLAR..ea BACK(ROW PROTECT V N _DEVICE /K S�rl
r y none / O
.I to ve and will maintain a Cemficamof Carardto"elf-ensure for Wader's Crimper. DRAINS-FLOOR,ROOF,AREA,COND 1
inn,as plus tried for by Section 3101 of the ladir Gale,for the performance of the STORIES 'T)'I'ii CONSTRUCTION
' wad no,w bid this Penult la rsued 3 NI X'I'GRES-PER TRAP
0 1 have..it will mmnom Worker's Com oscia on hAuranyccee,,a"nonpareil by Sermon olo.ol My0W ll C nCnJa fonh;Pe ePulcy'Nny�Nt✓h n• �Irn OsO� GAS-EA.SYSTEM-I INC 40VI'LETS (ICC GROUP
APE
Camcr I GAS-EA.S)'ST[M"OVLR4(EA) II`t-/�SvNIIr ✓�5
CIERTI FICATE OF EX EMNION FROM TOR KERN U y GkBASF/INOUSTRL WAS'IB IN'ILRCP.PlY1R
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thn"uetian neadnot becomplemadtne penult uformichundred doluer,S]OH,
le.,1 GREASETRAP PLANGIIIiCK FEE
Icert,destlmhe perlormunceofine-skhnwhmhmaspermtlOa Iacd'lshalll SEWER-SANITARY-STORMEA 2WFT.
not employ any person in any manner so as o became subject it)the Workers'Comoro- - F.N[RGl'Piili
O Z at to Laws of Caldnrms.Dale WATER HEAI'F,k WAIEN'UELECTR iNADINO PEE
z Q Applicant %
h NOTICE TO APPLICANT If,after making this Cemficete of Emer,o nn,you should WATER SYS'FHMGRENTING SOILS THE
become ah,,,l m the Worker's Compensamn pro Lion,of the Labor Cole,you most
(31 Forthwith comply with ooh provisions or this perms shell be deemed revoked. WATER SERVICE
Q
z Catthe is aconst LENDING AGENCY NEW RESIDENTIAL PLMH. SO I'I' PAID
U Thor 1,,,firmth enn,11 Ined(ocuonlendmg agency for he performance of Deus Rttaptp
the wnrA for whl.h this permit I"nssunl lSer 3f19],Co.C.)
II" U Lenders Nar- TOTAL
O f..l Lender's Addrt". '1 OTAI:
�•n {L1 BUILDING PEE
[ti I caddy that 1 ply real this y and coil diem that the ahmc Infnrmnuon n I
ta/I cared lagrec ctiomandhooh y cmyand repres cialoeresanJ scam eritrdaongm QTY, t ME:CHANICAI!PERA1IT PF.E"
fJ � building construction,and hereby amhanmmpo.ema6vnNfthisenymemerupnnthe ' �SIiI$hfIGFEE
nbuve"neenouned pnopery for Inspenum pmpases PERMIT ISSUANCE I We)agree o save,indemnify and keep harmks.the City of Cupertino against ELECTRIC FEE
habihues.ludgmenis.red,rnd roo,m,e.wham maym any way acemeagamst said City ALTER OR ADD IO MECH,
In conayumrse of toe grunting o1 this permit PLUMBING FBI.
APPLICANT UNDERSTANDS AND WILL COMPLYWITH ALI.NON(-POINT AIR HANDLING UNIT(TO lR"CFM) MECHANICAL FEIi
SO EQUL Te) IfINS•/� /��//.mil AIR HANDLING UNIT oovER 10.1X01 CFM) CONSTRUCTION TAX
Sngintim of APP1/BantrCome,cor r 9/ate s� EXHAUST HOOD(WIDUCT) I HOUSING Nil EGA](ON FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapphcaut infunebuddmgoompant store or handle hanelcas mu¢mil HEATING UNIT GO 100,000 BTU)
its drlined E)Ilie Cupertino Muntmpal Code,Chapter 9.12,and the Health and Safety
Cade,Section 255321+) I HEATING UNIT(OVER I)(.mO RTIA
0 Ye" Fl No (PAID
VLN'I'ILAI'ION FAN(SING 1.13 RF.SIUI Date Recelptp
Will the applicant or future building occupant use equipment or device"which 1
BOILER-COMP(7111'OR 100,000 BTU)
n M1ovWnu,ter conmmmanu as Jefned by the Roy Area Air Quality Management i IOTA 6.
liana!
Ye" ON. BOILER-COMP(OVER I00To B'1'U)
❑
I have read the hamrdm,materials myuiremem.under Chapter 6 95o the Cali- AIR CONCH TONER ISSU(NCI:DATE
fallen health N Safety Code.Sections 25505,8533 and 25534 I understand that of the NEW RESIDENTIAL MECH SO FT
bard gdoca nil cnuently hoc nnn1.maul is mymymmibda". lythe c ,anl
oft yuvenlcn wh¢h 0 pour to issuance ofa Cr
� 171
Owner in,umnonotl a gem / Onto, '1 OTAI': ISSUED BY
i. �
C. OFFICE
r