S 0918 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
I CITY OF CUPERTINO --- - - - - IIIILDING-ELECTRICAL PF IIT NO
BUILDING DIVISION APPLICA•1'IONIPERN11T rLUnMRNG-hn[I)FWIFIC � 0 91�
IIIIILUING PRO.IECI'IDENTIFICATION !', •4
BUILDINGADDRESS SANE 1'ARY NO APPLICAE'ION SUBMITTAL DATE
Z/�z0 '091-G.'90-4-2 4 V6
I OWNER'S NAME PHONE. CON'I RACI'OR'S✓NAME TIC NO I
�yy.11�r C�/�,aj� N,C CONTRGI.N
ARCHITE ATNGINEER: TIC NO ADDRESS. ❑
_01c.IC-GAll/C, /ovewn a/
CONTACT; PHONE: r_V�, C4 FS�Y(J HUILDING PERMIT INFO
❑ Consultant Pees Paid by Applicant(Initial) n1.DC P1`FC'I' Pit of
LICENSED CONTRACTORS DECLARATION QTY ', ELECTRIC PERhlll' •! I I PEE.!
nemny arras mill 1 am licensed amFm pow..Imms m Chapter 9("comeneing . . t. JOB DESCRIPTION
'0ZO with Sechnn'I(NX)ofD,,,umJofmhe dusine+.Land PrnfcsaonsCodgand my Lrenw is PERMIT ISSUANCE RESIDENTIAL:
�UF Lsen.cei`Ie and eden I.0 k ❑SFDWL [I KITCHEN REMODEL
U APPLIANCHS-RESIDENFIAL, ❑ADDII[ON 0 PLUh1BING R17-PIPE
TS DECLARATION ARCHITECTS DECLARATION ❑AiULTI-UNIT ❑$TRHC'I'URAI.
0+ m UP TO PANELS
y p ti� I understand my plunwb011 be Tad as pubes rccurJS MODIFICATION
UI'Ta:1111 MIL'S
h.�F'Ey
Licensed!Pro(esannal ❑IN'I'PRIOR ❑CHIhINIiY RI:I'AB
OWNER-BUILDER DECLARATION I ?111-IIXX1Ahil'S _ IMPROVEMENT SWIMMING POLLS
I hereby nntimm ttan I um 000na,from the Contra Clem+,Lax nor the OVER IWO AMPS ❑BATH REMODEL,REPAIR�EMOIATION
�qtx5 a U follows,reason. Secuon 70315.Rasmus,and Porhoos,Code:Any city ur county I SIGNS ELECTRICAL ❑OI HER
which cvymre+r pain,m condmch alte,improve,demolish,or repair any nmctum
Fnm tunv+suance.also entire,(heapphcanum+uch permnm file aslg nal,lamnunt SPECIAL CIRCI ETAUSC.
up, barrel,licensed parord m the provmmp,ol the Can...on,I......e Law OChapmr9
,e iit d,ey LaO mwnate,with herctfr ma01 her, for theallegedexemptim,rosho Come)...n( TEMR METER OR POLE INST CONIMERCIAL:
i5 E C1 NEW BLDG/ADDITION ❑UEMOLI'HON
W M Secon n 7031 S by any appheant tar a pv m(,uh lens the applicunuo v Toll penally of POWER DEVICES, ❑TENANT ❑FOOD SERVICE
I-ZY mm are man five handled dollars(SSlO) IMPROVEMENT
M ❑1,as owner of the proper,or my employees a nh wages as mar sole con ar,onon, I SWIMMING POOL ..' IC
wall dal he work,unit the Oraclure is nut micarkdorotered inr.sale(See 7044,dasoms+ ❑OTHER
and 1'mfvsnum.Code The Contractors Llccnne Law Jne+nol apply m tin owner of GO I'LETS-SWITCHES- I1RF.5
0.';.. property who holds or improves thereon,and who does such work himself or through
bass own employees,provided tact.rich Improocmenls are not Intended or interval tor NEW RESIDENTIAL ELECTR SQ PT.
sale.if.however,the hmWing onmPmvemenns sold within one year ofiontpleuon,the - SO FE FLOOR AR17A SSQ IT
builder will have the burden of pmving that he did not Muld or Impnoe for par- yL�,
saw,ufsalel CEIVED
❑I,a.owner ul the properly,ant cxalmrvdy commuting with hcen,,d oph pier,to )'1'AL. R.E
construct the protect(See ]OW,Business and Rroferanns Code)The Counselor's Li- q
cease Low does not apply man owner of property who build,or thermal,and IQ'f,Y'. • 'I'I.UMUIfJ(i .RMIT� ,• , rrr: .. NOV 131997
who"ail it,Nfol such pnycti.call a contractor lsl h.cnwal puran...t to Ibe Contractor' :t' ' . '. •
License Law
lam m
enpt under Sec PERMIT ISSUANCE. oil&P C for this re.00n 4
Owner
MITER-DRAIN&V17N'I'-WA I'IiR IEA1 �T Fµyi.vmr-
t Dal^
IL] WORKER'S COMPENSAFION DECLARATION BACK FION'I'ROT[CI'.DEVICE
I hereby affirm under penally of penury one on the following declarations
Ihave and wnlmnmmtnaCernlindeaf Gm+entlo+dt-nt.ure tar Woder',Con.per- DRAINS-FLOOR,ROOF,AREA,COND, STORIES 'I'VPIt CONS'I'RUC I ION
sauna,as pmvuled for by Section 1100 of Ilse Labor Code,far the performance of the v
work for wh ch,hw perms is Owned, FIXTURES-PER TRAP
❑ 1 bone and well maintain Walker'.Compon+abon I....ame,m nyhthd by Section
3100Ot the Labor Cade,forme perinmmnceol the work for x hsh this perm,msi+sucJ GAS-EA.SYS'I'F.M-1 INC.001/TLEBS OCC GROUP ! MIN
My Worker's Compemation Insurance tamer and Policy number are:
Carrier Policy N, GAS-EA.SI'STEM OVER 4 MA)
CERTIFICATE 017"9 EMPI']ON FROM WORKERS'
COMPENSATION INSURANCE GRIIASE/INDUSTRI.WASTE.INI ERCEPFUR
OTm,,cinnn need not be v alemdlf the peramr,nor one hundred Jol lines($100)
I III' LNG D�.'IMON FF
CRIiASE TRAP
or less l PLANCHECK I'
Loy any mmmme Inforprearce for which his pee WorkawCona hall SEWER-SANITARY-STORM I?A 20B PF
not employ any person In any manner so m m become subject the N'orkvrs'Compen- EN[RGY FE
C) 0 Applicant nl(alJnrnun Ume WA'11?R HLA'l lilt W/VIiN'f/F.hliCl It 1 \
t
OR FlII/
N NOTICE TO APPLICANT If,of c,maktug this Certificate of lixempunn,you should WATER SYSI EM,TREATING `
a �^ Inam re.ub..I to the Worker'+Coompen+mion pmmaon+of the 1.JMt Gxle,you Inlet MOTS FEE �X /
I� forthwith comply with such provis inns nr this permll+hall he JCemedrcenked WAFER SERVICE
Uz CONSTRUCTION LENDING AGENCY NEW RESIDENT[Al.PLMIi SQ FI'. PAID
U O I nereby mrrm tom mere L a construction Iemmn"agency On
me I11rb,mmame,nI I D e Recelpl rc ,
U p the work for which this permit is r sued(Sec 3897,Cmv C)
O Lender.Name r BGTAE:
Lend, AJNc+w' '1OTAI. -
�' C I cemfy that 1 have read leis application and situ thm the above ntnrman is • • BUILDING FEE
N T le—
correct,l agree to comply with all city and county ordinances indstme laws elctm,to QTV MECHANICAL PF.RMI .PEE -
U ZU building carshomna,and herchyamhorarmprwentanve.of mi+cny menmr upon mhe I! SEISMIC FEE
abnveanentened properly for inspection purpmses PERMIT ISSUANCE
(We)agree to save.Ili demo y and keep harmless the Cny or Cupertino against ELEC'T'RIC FIi13
haluddie,mignicamcnu.and expenses which nmynany wayaccme against said City AM ER OR ADD TO MITCH
top n+eyrienre of the"noun,of mI+penm0 PLUMBING ITili
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING ON]'I-(TO 10,000 CFMI MECI EANICAL FEE
SOURCE REGULATIONS
LAIR IIANDI.ING UNIT(OVER 1(1,000 CFM) IONS'I'RUCTION I'AX
Signature of AppreampCommerar Date I EXHAUST HOOD(N'/DUCT) HOUSING MITIGATION FEE
,HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant some orhandlnhazmJnus raincoat H HATING ONII'TOI OK),"B'I U)
as demand by the Cupeinno Municipal Code.Chapter 9,12,and the Health and Safety I HEAFING UNIT(OVER IlO,INN1 BTU)
Code,Section 25532W?255J2 !
❑YCS No %'EN'1'11.ATIONI'AN(SINGLERI?SID) PAID Dane ReeeiptR
Will the applicant or future building occupant use eywpmem m Jevires which t
n Imandm,au connummnms e,definnl by Ore On,Area Air QwdSy Management BOILER-COMP IJHP OR ICOMA)BTIJ)
OTAh
Distnct❑Ye-s E]No B011.liR-COMP(OV13R I(Xl,(NX)BTIJ)
A]It CONDI'I IONER
I have read the hverdous mammals requirements under Cbupeer 095 of me Cub- ISSUANCI�/ATTE
filed.I does&Safety Code Sections 255(15.is my and 2553),1 to understand mom if the NEW RESIDENTIAL MECH. SQ Fin I / ''1S /.•'
form 1 does not Safety Cat S a tenant,5501 it O my rand 255r ny to notify the dual occupant
the
of the mym ormal wbmo cowl he 11111 poor In n+riancc of a Cran lenient 011 unruly. _
Ow her or amhanzed agent lime IOfAI.: IISSUI!UBY - -
OFFICE