99080055 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO I ' I BUILDING-EI,F.CTRICAL t PeR 1444
APPLI CATION/PERMIT PLUMBING-MECHANICAL O
RUILhING DIVISION ( UILDING PROJECT IDENTIFICATION `5000
JR
BUILDING AIIIIRES SANITARY NO APPLICATION SUBMI ITAL DATE
Los lJ( II uxL 1 PH f/J�^� COFJ 'OR'S N/AMI' I.IC NO I N/C CONTROL It -
CHITECTILNGINP, . LIC NO� ADDRESS ❑
coNTACT PHONE ['' BUILDING PERMIT INFO
- 72G�_�'�� ❑ Consultant Fees Paid by Applicant(Initial) 61.uC. ELECI PLUMB nI u
LICENSED CONT'RACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby Dlfinn Thal Ism seemed wider pm.rcum.of Cha ice,9(commencing
C Fq Z, with Sent r7G00lm Dianton lot he Returns.and Progesmn;Cnd_ee,addd,.,been ,, ` !� \ RESIDENTIAL
F,p or all farcergd ery�t.p'1N 1^'ll/W�S011�[/� 1 PERMIT ISSUANCE ,JJ SI-�I El SFDWL ❑KITCHEN REMODEL
F_UW OaLeme Class lA/`—,-i/V �"M# tor�I� G APPLIANCES-RESIDENTIAL I OADDITION [_1 PLUMBING RE-PIPE
FlyCHITECCS DECLARATION PANELS OMULTI-UNIT C:1 STRUCTURAL
Zpy2, I understand my plai,doll be used mpublac barred, I UP TO 200 AMPS 25.5DI _ MODIFICATION
OZ^0 ❑INTERIOR ❑CHIMNEY REPAIR
Licensed Proficoumal 201-IOMANIPS I IMPROVEMENT OSWIMMING POOLS
OWNER-BUILDER DECLARATION
yg , OVER Paid AMPS O BATH REMODEUR' AIR ❑DEM1IDI ITION,
6 I hereby off rat that 1 am exempt from the Conlmcmr,Lac6 c Law for the
Dot L U following reason (Section 70315,Business and Professions Code Any uty or coumY SIGNS ELECTRICAL OTH
F u..•Cn ynoorturFoaar.nonrequire%(he applicant for wch peuohlto filt.,gned statement , SPECIAL CIRCUIT/MISC
r{/��,>Ni (hat nenbaemcd pursuant 700)of Dismn. 3 oft he Business Law(Chapter9 /�I �o �� UP
lcnmmenemeds Ingraham and ofDnu,nfr the the exemptoPoets.Ax«nsCMe)our TLM1IP NF:'fER OR POLL IN51' l!i M I
that an is exempt tang applicant li and the Pere for Ibe subjects the ewmptmn,Asp violation of IF ❑NEW BLDG/ADDITION ❑FOOD DEMOLTI E ION
tivCl ti• Seamn]UIISby any uppscem fora perms suhlectc the appscumma cis d pewlly of POWER DEVICES � TENANT [I FOOD SERVICE,
^y not more than five hundred dolla,S500)
ZY 'IMPROVEMENT
��.0 ❑ Las owner of the Progeny,or my employees wnh wages as lbev sole compensation, SWIMMING POOL ELECTRIC ,
Mp.o will do the work,and the sesame is notintended oroffered for sale(See](4W.Rnanesc OTH-
^m and Professions Code The Connector's L(cewe Law does nrn apply to an owner of OU'T'LETS'-SWITCHES-FIXTURES
^ Property who build,in tmprevus thereon,and who days such work bmc)If or chmugh F
ho awn employees,provided that such tmpmvements are not m¢nded nr offered for NEW RESIDENTIAL ELECTR SQ PT -
sale IL hoxae a the brdtlmg rnmpnrvemenc is sold wnh(n one yemof complemn,the SQ IT FLOOR AREA SISQ FT
nerhu(Ider w(11 have Ibe burden of proving Ihm he did nor hudd or miprme far pur-
pree of sale.).
1,as owner of the property,em exilic>ncly contwdmg,nth licensed comran70n In TOTAL
omare t the project(Sec 7M4,Business and Pofessions Code)The Contractor's L(-
i
cause Law does not apply to an ownerof progeny who holds or improves theiam,and (QTY.' " PLUMBINO PERMIT FEE
whin contracts for such projects with a mntrac70rh)licensed pursuant the Commerce, Q
Lncm,Law PERMIT ISSUANCE, JS -SO
❑1 am exempt under Sec. .B&PC for this reason
ALTER-DRAIN&VENT-WATER(EA) � � VALUATION
Der Date � � _ O
WORKERS COMPENSATION DECLARATION RACK FLOW PROTECT DF.VIC _
I hereby affirm under Penalty of perjury one of the following dichinu nnc
Ihme end willmamm(n nCemfcem of Consenuo.elfancurc for Worker's Cnmpen- l DRAINS-FLOOR,RO tARLA,CO 8 •5a STORIES TYPE,CONSTRUCI ION
,noon,a,Provided for by Section 3700 of the Labor Code,far Ise performance of the r
k for sameb t is perms n issued FIXTURES-PER MAP
/4}�1 have and will mandon Worker's Compem2tion Insurance,u,required by Scene 1
J J]Dl of the Lan9n(rnFG�i"de.�fargt�hye�up�e�rfommnce of the work for wpheh this pemOin is issued GAS-EA SYS FNFI INC 40U'I LETS OCC GROUP ?APN
Cayrnr,'a1 \T'`hii��i c Pnlcy No y\ nb_a1'Sfo�7i Oq GAS-EA.SYSTEM-OVER4,(F.AI - 7 G
CERTIFICATE OF EXEMPTION FROM WORKERS' GREA51%INDUSTRL WASTE IN'1'ERCEPTOR '�
COMPENSATION INSURANCE TIES
(This section need not be completed d theperma n forms,hundred dollar,($1W) rrr'^JJJ`... R 1�
on less.) SEWER-SANITARY p NE CI,µEI�I
Toy any Person in Performance as for which this pet mdnns'Counhm1 SEWER-Si\NITARY-STORM EA.2101 FT lll� "�/L" E 1111101
not employ any Person m any manner ac m become subject to the Workers'Crmpen- b R, AEG
z arms c of Calibration Dore WATER HEATER W/VENTIELECTR I R � 'LL
Applicant g 1999
h NOTICE TO APPLICANT If,after making this Certificate of Exemption,you should WATER SYSTEMRREATING rl�la1 1lFM"
(~ heu m
tne subject to the Worker's Compemun provisions of the Labor Code,you must OILS E
Wforthwith comply with such provisions or(hr,permit slmll be deemed revoked WAI ER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB SQ.PI'. PAID
U '0 1 hereby affirm that there a com m
trucn lending agency for the permanence of �� Receipt#
U O me wmrk tar wlmn m(>petal)(t ittned(scar 3897,e(v,C) 'I
4' ULender's Nam-o W ' TOTAL � TOLL
Lenders Adil
BUILDING FEE
Ll+^" p, 1 scarf,that I have reed iho apph,anion and sate that the above mountains,
h correct I agree to comply with all city and county ordinances and stale laws relating m QTY. MECHANICAL PERMIT FEE
U ,Z bwldingron....unit,and hereby amhonze representatives of lhncdy ,,muerupon the QTY. FEE
ahnve-mcmmned propeny for inspection purposes ` PERMIT ISSUANCE ✓' •SU�ELECI RIC PEE
(Wm agree to sure,indemnify and keep harmless the Cry of Cupemmn again �10 •i0
Iiefulims,ludgmenls,costs and expenses which may in any x ry accme against said City ALMS OR ADD TO MECH
in consequence of the granur,ol'this permit PLUMBING FEE
APPLICANT Usl 'RSTANDS AN D WILL COM PLY W1 ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM I MECHANICAL FEE fog,
SOURC EGUI rDpa. h,)461
AIR HANDLING UNI'1'(OVER jQBBB GFMI CONS'I'RUCTION TAX
Signa Apphcait Contractor Man EXHAUST HOOD(WMUCTI HOUSING MITIGATION The
HAZARDOUS MATERIALS DISCLOSURE O�
Will lheappi«ant rrfgme budding occupant name nrhmdle Noredoes neutral , HEAPING UNIT G70 wo,00O R'rU( ��. l-
ac defend by the Cupemm.Mune,n]Code,Chapter 9 12,and the Health and Safely
Code,Section 255327017 ` ' HEATING UNIT(OVER 100,00( BTU)
❑Yes `yQNo VENTILATION FAN(SINGLE RESIDI (PAID
/ , Dace Recept#
Will the applicants or future building occupant use equipment or devices which BOILER-COMPl1HP OR IfN1,OfN1 BTU(
i_.nazanks,mr corTina ants as defined by the Bay Area Air Quality Management TOTAL (/�/Vr'� /•j
Disysta X BOILER-COME(OVER 1111,010 BTU) / 91r / 9
t
El Yes I
1 L� )) L
1 have read the armadas matenalc requirements under Chapter 6 9 of she Cal(- ` AIR CONDITIONER ��1 •J O I ISSUANCE DATE:
forms,Health An Safety Code,Sections 25505,25513 and 25534 1 understand bald the NEW RESIDENTIAL MECH SQ,PT
budding do nr n0y hover«wet,chat it Is my oapon,iality to marifJJ'he an g^ J
nit warn moat ne met prim Im iscuacan of a eemr,w iijrcylep p �/'q j �
f/�//oDNan,- - TOTAL: 'q/ ,(/�J ISSUED BY / I� >
ti y OFFICE r,~