21999 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pmied Ideraficatlort PERMIT NO.
Budding Address: P 21 9 9 9
LZ7�,o 4c_CA/%DC /7-1)
.weer.Name:fx 11 - aenone: AI'1'Ln_A11Unbi.aM111AL0AU:
tlZ-Ilr�l PJR-U 7n1,/.f CITY OF CUPERTINO-BUILDING DIVISION G /
c°ntrachn'.Nname: rap p Lic.No APPLICATION / PERMIT
rG Wf[�x'I I�FUINN COQ p ],(4,Z BUILDINGELECTRICAL.PLUMBING-MECHANICAL CATEGORY CONTROLM
Architect/Engineer. LIc.N.;' - L.
LE 1, r.. ` td, • :',BUILDING PERMIT INFO'
� Q7Y ' ' ' ELECTRIC PERMIT, �• 'd FEET �' '� 'i -I
Address. ` I ' PERMITISSUANCE /z�O�/ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby of@ mthat l am licensed under provlslonsof Chapter9(commencl APPLIANCESRESIDENTIAL I JOB DESCRIPTION
ingwlth Sodion7000)of Dlvlsim 3 ofthe Businemand Profe,e..Code,and my -
Date is iryn Pfy3—f 1—d efect. (- /1/', PANELS
LI.c eC LCK
Contractor T. &ReWN
CON t)f, UP T0200AMPS
I ARCHITECI•S DECLARATION �'201.10DOAMPS
OVFA l000 AMPS C SQ.FT.FLOOR AREA 5/SQ.FT.
O e sederstaedmy playa shalt be used as public records - r 1IN A L E D '•I t..
SIGNS ELECTRICAL Licensed Pmfeavlowl /� � /7 g''� I
�EF� OWNERexempt DECLARATION ( II I,\/� Y f � E
SPECIALCIRCUIT/MLSC tlaJC Y V 7 V
t.., !hereby a(Rrm that lam exemptfromthe Cant rador'.Llrxnse law(or th•
pp following resson.(Section 7031.5,Bu.messand Profession.Cede:Mycityor \\,,II xx
F'yti TEMP.METES OR POLE INST. -. U
county whlch regeto It permromcoorequialter, apmvgdemolth,armit to
anyntmdumpammentlhat he Is also licensed pursuant t the por.uehpermlt - ! •G
Pl ca file a signed statement that he Is Brensed punuant to the provlilov of th^ ��R DEVICE' D TE
3w Contractor.License Law(Chapter 9(mmnrncing with Section 7000)of Dlvi- VALUATION
SOS sion3ofthe Buelnenand Professioea Code)orthathetexempttherefmmvN !SWIMMING POOL ELECTRIC .
6 5 the basis for the alleged exemption. Any violation of Section 70315 by any m OUTLETSSWITCHESFIXTURES
O
applicant for a permit subjects the applicant to a civil penalty of not ore than I
five hundred dollars($500). SQ.FT. STOfOFS. •TYPE CONS'f12UCTION
�n ❑I,as owner of the property,or my employees with wages r there sot-
NEW RESIDENTIAL ELPITR
compensation,Business awork,andthes,Code:The not Intended or offered foil N
O .ale(Sec.apply Business and f propelora Code The Contractors harem Lad
eS
does whorl tepplytorkhi n rorth pgtywho builds oyim.,pv ldhdth n.and
whodoesmchworkhimself orthmugh hleownemplayees,pmvlded that...' - _ � � OCC.CROIIIs RES.UNITS
improvements are not intended orofferet for sale.If,however,thebuildlegor I TOTAL:LZQ OV
Improvementtsoldwithlnoneyearof completion,theodvner-builderwlllha t,
the rden of proving that he did not build or improve for purpose of sala.) QTY.! n�'PLUMBING PERMIT„� '• tFEL -FLOOD ZONE APN
UI,as owner of the pmpeny,am exclusively contracting with Ilmnsa PERMIT ISSUANCE, I-.
contractors to mratrutt the project(See,7074,Business and Professions Code: '
The Contractor's Limese Taw does not apply to an owner of property wh_ ALTER-DRAIN&VENT-WATER(F1J ”
builds or Improves thereon,and who contracts for such ptajem with a FEE SUMMARY
cgR(p dor(s)Bcensed punuant to the Contractor'.Llanm Law. d,
LI BACK FLOW PROTECT.DEVICE
f see exempt under Sec. B k P C for this moon t gnrcgjj;,PF1a i
I _
Hate — DRAIN&FLOORRcKir AREA,COND. I SANITARY RECEIPTM
/ Own•• _ __
WORKMAN COMPENSATION DECLARATION FlXTI1RF_S PER TRAP �SCHOOLTAX RECEIPT It
I
01 hereby affirm that I have a eenlRote of consent to self-Insure,or a
certifinte of Workem'Cmmpemaatlorynituurance oramrtifled copy thereo((Se<. GAS EA.SYSTEM-1 INCAOUTLETS I PARK rM, Y N
3500,Lab C.)O5, c 4, Y0 9 2.6 I RECEIPT p
I liryq O GAS EA.SYSTEM-OVER
Co v I I BUILDING DIVISION FECS
CerHRM copy t hereby famished.the I CREASE/INDUSTRL WASTE INTERCEPTOR I PLANCI-IECK FEE
❑Certified copy tilled with tM city Impaction division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP I PAID
INSURAN SEWER-SAMTARY-STORM EA.2mFr. Date Receipt# '
Hhissedbn need not M completed if the permit t forone hundred dollars
(g100)ane.s.) WATECHEATERW/VENT/ELECTR ENERGYFEE Y N
I reni(y that he the performanceof the work for which thla perrlt is esomet l
I shall not employ any person in any manner sa a to become abject to the WATER SYS[EM/TRGTING PAID
Worken'Compensatlon taws of California.Date ..
Ct NEW RESIDENTIAL PLMB. ,
Z Z Appllca•d
0 NOTICE TO APPLICANT:Ifaftermuking thea Certificaleo(Exemption,you SQ.FT Date Receipt#
l- 'should become sub)cd to the Workers Compensation provl,loma o(the Labor I TOTAL: I
N Code,you most forthwith comply with such provtlons or this permit NallM
� j deemed revoked. I BUILDING FEE I
W C CONSTRUCTION LENDING AGENCY SEISMIC FEE
d Iherebyafflrmthatthemis construction lending agency for the perform,� ELEGTRIG FEE .0/f
O ance of the wruNcir which thispermit is Issued(Sec.3097,Cle.C.) „ TOTAL:! PLUMBING FEE
L) Lender'sNaer-
H Loodere Addrea. !QTY. . MECHANICAL PERMIT
LL - -_- PEE I MECHANICAL FEE
U Imnify that l have mail this appBratlonand gatethat the above information -j�
O 1 umrrect.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE I !FEE PAI 61t(n 1
} N relating to building constmdlun,and hereby authodze representatives of this
(— U) city to enter upon the above-mentioned property for Impact purpasn. ALTERORADDTOMECH.
— ,(We)agree to save,indemnify and keep harmless the City of Cupertino Date ReCe)Fat# -
againstliabilities,Judgment,cost aand expenses which may In any way seeme AIR HANDLING UNIT(TO 10,000 CFM) I I SUBTOTAL:
agauat said City In consequ once of the grant ing of this permit
' AIR HANDENGIATT(OVER I0,000CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHALSTHOOD(W/DUCT I CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) ( Date . Receipt#
material a.defined by the Cupertino Municipal Code,Chapter 912,and the
Healthand Safety Cade Smtion25532(a)2 HEATING UNIT(OVER 100,000 BTU) I I TOTAL: v�
0 Yea M No
W111 the applicant orfutum building occupant use equlpmentor devices VENTILATION FAN(SINGLE REBID) .I I$$GM��6epATE
whichemit hazardous air contaminants as defined by the Bay Area Alr �6i�U ,
,S Quality Management Distrid7 !BOILER-COMP OHP OIt 100,000 BTU) - A (�ai li
4heve read the haze..,material,regWremenmiunder Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) v APR '7199 -
the California Health k Safely Code,Sedlom 2550.5,5533 and 25537. I
understand that if the building does not currently have a tenant,that it is my NEW RLSIDENTIAL M[CH. SQ.FT
responvbllitym notify the occupant of the mquiremorm which st b et fllDse rt/yasseall
prior to Issuance of a Certificate of Occu anq. wW W wseYm T•
Owner or authorized agent Dote I TOTAL: (ISSUED BY: �x KfC, ,e/,/
OFFICE COPY