99070088 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL 'a T
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL,
•}.BUILDINGIPROJECTIDENTIFICAT1ON;
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'SNAME: PHONE CONTRACTORS NAME: LIC NO:
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N/C CONTROL#
.HITECT/ENGINEER: LICNO: ADDRESS: j�.�Th ❑ ���
AILS bk,
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corvq'Acq': PHONE: } BUILDINGPERMITINFO
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❑ Consultant Fees Paid by Applicant UntuaD BLD ELECT/ PLUMB MECH
LICENSED CONTRACTORS DECLARATION QTY, f, ELECTRIC PERMIT s { �s'FEE h/(
1M1emby erfrm ltrtl licensed a p fChupter9(commencing -f ` " ). r�. }s. ]OB DESCRIPTION
woo whhsecnon�oaB).rD'-. on3..nn,Bmi .e er.res,'on.Bade arse tot hoe tree RESIDENTIAL,
woo
O_ in fall force i rd effect PERMIT ISSUANCE LYCHEE REMODEL
au'yr License cmaa Y� urs.#—A4 r�4 3A 3 ❑slvwi, 201
rFaL fn� Date Cnmme K � APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLOMNINGRE-PIPE
ARCHITECTSARCHITECTSDECLARATION El MULTI-UNIT ❑STRUCTURAL
zo�z lundesmnd my plans shall be used as public maoNs PANELS
MODIFICATION
O
UP T0200 AMPS ❑INTERIOR CHIMNEY REPAIR
❑Licensed Profeselonal 201-I003AMPS - IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER DECLARATION
I hereby alRrm that 1 out exempt from the Contractors License Law for the OVER 1000 AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
3 y F rollnwing rear....(Section 7831.5,Business and Professions Coda Any city.,,,,only [-]OTHER
SIGNS ELECTRICAL OTHER
a. which requires a permit to compact,alter,improve,demolish,or repair any ipacmre
qFq�O� prior lm nc isvuance.also requires lM1e apPliwnl for..chperminofileasigmedsmmmem SPECIAL CIRCl11T/MISC.
ti p.
that he is licensed pursuant to the provisions ofthe Contractors License Law(Chapter 9
CW AC) (commetcing with Section 9000)of Divlsian 3 riche Bt,micssnnd Professions Code)or TEMP.METER OR POLE INST COMMERCIAL
don he Is exempt therefor and Be basic for the alleged exemption Any violation of El NEW BLDG/ADIJITION El DEMOLITION
iLLCI 0. Secomm70315 by any applicant for a#omit subjects the applicanno a civil penalty of POWER DEVICES ❑TENANT ❑DEMOLITIONFOOD .
o' mol more lhnn five hundred dollars($500).
FE ed 1,as owner of the PROVEMENT
❑ property.nr my employees with wages as their sole compensmmn, SWIMMINGI'OOLELECTRIC )THF,R
Fo will da Ne work,unJ lheswdureis nal intended..r offered foreale(See.91N4,Bminess
F 3^ and Profcsslorrs Code.The Centra lea's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
F property who builds of improves thereon,and who does such work himself or Through
his own employees,provided that such improvements are not intended or moped far NEW RESIDENTIAL.ELECTR SO Ur
sale.IL however,the building or improvement is sold within one yearo!completion,the 1 lvlXMOOR IRFA E sTegy bil
owned-builder ITh thebb fp gththdl not build improvef p
f1 , JUL 3 01999
Eli, I of 1 oP a ly cramming with licensed contractor,t OTAL
votes t nM1e p jecl(Sao.?0404 4 B .'n dP f o. Cd )Th Il 1 C c - � ���
come Law does notapply( we fp perry who builds r oupi drinexam and QTY. PLUMBMG PERMTT'It ! '.it,FEE
who contracts for such Projects with a contra( os)licerojed pursuant o the Contractor s - s t
License Law.
❑ Lam exempt under Sec ,B&PPERMIT ISSUANCECbrlhisreasan -
Owner Date
ALTER-DRAIN&VENT-WATER CA) VALUATIONM
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm ander penalty of perjury one of the following declarations:
I have and will maintain a Ccrificem of Consent seleinsufe for Werker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. vim- TORIES TYPE CONSTRUCTION
scron,as provided for by Section 39W of the Labor Codo,for the performance of the
work for which this permit is issued. L FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this Permit is issued. GAS-FA,SYSTEM-I INCA OUTLETS OCC.GROUP -� /ATN
My Week s a mWu1y�swsst Lnsek�neo collierand Polu ..alis,c�ayt{g �p
Carrier l^tI.{!U Policy
No Y22`T17 ZQ : 6 GAS-EA.SYSTEM-OVER 4CA)
CERTIFICATE,OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASElINDUSTRL WASTE INTF,RCEP'TOR
(rhiesection need not be completed ifthepemit is firers,hundred dollars($100) m-tS N#Sli OARED I)11tI5r10 EVES-{VxP111
or low.) ORBASE'I'RAP
PLANCHECK FEE
1 certify Nal In the performance,the work furwnielt This the W is issued,!shall
not employ any porn..in any mmnervn unmbecamesub ed to the W.rkars'Gtm _ SEWER-SANITARY-STORM 5A 200 FT.
satian Lwoof California.Date I pen ENERGY FF.F.
ZO
Applicant WATER{{pATERW/VENgYBLECTR
PP GRADING FEE
NOTICE TO APPLICANT:If,after making this Cwthose of Exemption,you should
aheroine subject to the WorkersCompenwtion provisions of the Labor Cade,you must WATER 9YSTBM/TREATING SOILS HE
(11 forthwith comply with such pravlaons or this permit idall be deemed invoked. WATER SERVICE
a Q
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMR Sp.FT PAID
I hereby C.) Q work
my permit is
mnnswc(ian lending agency for perfonnanm of Date Receipt#
sy � the work far whichthls permit is issnN(Sec.3099,Cie CJ
WL,nde,x Name TOTAL:
Leaders Address TOTAL:
�.y fls i cerfit,but I have it this appy amen and state shot the base information rs V
Fr a correct I agree( comply with all city d county ordinances and tat Iorelating to QTY( o MECHANICAL PERMIT- I PEI:.!,
V Z. building construction,and hereby authorize representatives of this city to enter meonthe ?'tLn s
above-mcmianed property for imIcanion purposes.
(We)agree to save,indemnify and keep narmles,the City of Cupertino against PERMIT ISSUANCE
liebilities,judgments,costs and expenses which may in any way accmcngalnasaid City ALTERORADDTOMECH,
inenmequence ofthe Starting of this permit.
APPLICANT U STANDS AN COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,1100 CFM)
SOURCE $. FEEAIR HANDLING UNIT(OVHR IO,11.CFM) NTAX
gnature of Applicant/C ..tractor ate EXHAUST HOOD(W/DUCT) HOUSING MITIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE
Will lheapplicam or future building omapantilme or handle hozdnloas material HEATING UNIT(TO 100,00)BTU)
as defined by the Cupertino Municipal Coda Chapter 9.12,and the Health and Safety '
Code,Section 25532(x)^. HEATING UNIT(OVER 110,0811 BTU)
El Yes jl�No PAID
V HNTILATION FAN(SINGLE RHSID) --
Wi11 the applicant fi.nin building Occupant arc equipment ur devices which Dam Receipt q
mit hazardous air comumiinnvme as Refined by the Buy Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU)
isuiclP BOILER-COM P(OVER I( BTU) TOTAL
E]Yes ffi/tn NI,(IINIV572—
1 have read the hnwrduus materials requirements under Chapter 6,95 of the Cali- AIR CONDITIONER ISSUANCE DATE
Ibmia Health&Safety Code,Sections 25505,25533 and 25534.1 andernand in.,if me NEW RES]DENT MECH. SQ.Fq
building does..(earmonly have Incl it is my responsibility to notify No cecupxrst
oflhorc ten be, issuance of a Geri! eOfOceary.
Ownefmaulhrire agent Date TOTAL: ISSUED BY:
OFFICE