29890 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
' CITY OF CUPERTINO - BUILDING-ELECTRICAL PERMIT NO. 2989,0 9 8^O
BUILDING DIVISION APPLICATION/PERMIT • PLUMBING-MECHANICAL L VX 4J
BUILDING OJECT IDENTIFICATION
" BUILDINGADDRESS: - PRSANITARY NO. APPLICATION SUBMITTAL DATE
`17 IE7-(- lTk
OWN E 'S NAME: �LJ y PHONG: CONT CTOR'S NAME �' LIC NO:
_n_ L H -�.N/C CONTkOL#
ARC4I'TGLT/ENGINEER: LIC NO: ADDRESS: ❑ _
'6 a 3e..
CONTACT: PHONE: - - BUILDING PERMIT INFO
t ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT - PLUMB MUCH
� m,' ❑ ❑ ❑
LICENSED CONTRACTOR S DECLARATION Chapter
QTY ELECTRIC PERMIT FEE _
�C" I heehy affirm that I am licensed under provisionsof eh pt-9(commencing _ 706 DESCRIPTION `
ZO with Semon 7fXq)of Dl ' 3 fah Busi dPr feaion Cd -dray lice ' PERMIT ISSUANCE RESIDENTIAL' '
�Uff••••�: License la and effect ❑SFDWL ❑KrrCHEN REMODEL
U(�J License Class Lic.# APPLIANCES-RESIDENTIAL -
Fx•W Date Contractor- ❑AUDITION' 'PLUMBING RIS PIPE
m<as' ` ARCHITECTS DECLARATION ❑MULTI-UNIT []STRUCTURAL
[-r N PANELS
`y" 1 understood my plane shall be used ns public recoMv >•
zow� � - _ MODIFICATION
1 1. UP In 2W AMPS
fr pj 1"'1�1 Laensed Profesntnnal - - - ❑INTERIOR ❑CHIMNEY RIiPA1R
rl , 201-I0OOAMPS IMPROVEMENT -
94 OWNER-BUILDER low
OVER IWO AMPS '
6 1 hereby:(Sera that 1 am exempt from the Contractor's License Law far the ❑BATH REMODF.L/REPAIR DEMOLITION
Ia V following reason:(Section 703 L5,Business and Professions Code:Any city or,ctunty - ❑OTHER
,3 F SIGNS r M'I
W hmM1 as pe it I c t r tr ,m p e d I'h r repo y r mere -
�� Poon la issuance,
rine e4 I applicant to h permit o fl Law
(Chapter
SPECIAL CIRCUIT/MISC.p.
G� but he licensed with n Jai pro s fbeC .tad L t.e.ber Chpar9 - _ '/+�+(—^��R/y-�� loyp
(commen g with Section7W0) fD 3 illi B esv�ndP f ns Cade)n TEMP.METER OR POLE INST. COMMERCIAL' '
d c that he t,exterainfloneford suit the basis par the ll 6 d execution.A y violation of
Station 7031 5 by My anali a n for a peri t b1 rat the [I NEW BLDG/ADDITION El DEMOLITION
rnapplicant civil of POWER DEVICES
E+ p. not 1,asowne(of thprrcdiol lateyCrEl. TENANT ❑FOOD SERVICE
O ❑I,asawner of the Prupeny,ar my employees with wagesmlheir sale cnmpensminn, SWIMMING PDOL ELECTRIC IMPROVEMENT
will dt the work,and lhesmucma is out intended or affereJ for still(SIC.7041 Business ❑OTHER -
3 and Professions Code:The Ctnbncmrs License Law docs not apply to an owner of OUTLETS-SWITCHES-MCUURES '
property who builds or improves thereon,and who docs such work himself or through
his own employees,provided that such improvemems are not Immanded or offered for NEW RESIDENTIAL ELECTR SQ PT .�
-sale.If,however,the building or i mprovement is veld within one year nfoompiuien,the SQ.Ff.FLOOR'ART:Ai $/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve far par- e
Pass of,C]I). _ -
- ❑ 1,ns owner of the rmperty,am exclusively communing with licensed eminemrs to - t, TOTAL: fy1 I
consumer tae poicat(Seo.7044:Business and Professions Code:)The Comucmr'n
terse = •MAY `e 19 6
se Lave does not om anpply owner of pro'peny who builds or improves thereon,and QTY PLUMBING PERMIT FEE
who contracts for eneh projects with a amimmogs)licensed puts.......be Grmraelois
License Law. PERMITISSUANCE
M I Wr 4Ut'CII I lisic
Ll
1 am exempt under Sec. ,B&P C for this reason •4
Owner Dare ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION' BACK FLOW PROTECT.DEVICE
1 hereby officer under Penalty offorjmy one of the following declarations:
,]Ihaveand will maintain.CertiOleacmCcamenuoself-insure for Worker's Compcn- DRAINS-FLOOR,ROOF,AREA,CDND. STORIES TYPE CONSTRUCTION
statue,as provided for by Section 37W of the labor Code,for the performance of the
work for which this perntit is issued. FIXTURES-PERTRAP
❑f],.,Card will maintain Worker's Compe-Imioa Insumnce,.1 required by Section F1 NAI FD
-
3700tithe Labor Code.for the perforation ofthe work for which this Permit is issued. GAS-EA.SYSTEM-I INC.4 OUT OCC GROUP APN
My Workers Compensation umnc carrier and Policy oo yc� r�
C...ier: AA U. Policy but �"Y(_h0`6319` GAS-EA.SYSTEM-OVE"f�
CERTIFICATED EXEMPTION FROM WORKERS'
(T COMPENSATION INSURANCE / . T. GREASMNDUSTRL WASTE INTERCEPTOR
bis section need be ebmpletplifthe permit is fnrono hundrtxl dollars($lap
" •..^ 'BOfLDINC UNISION PEES .
ar less.) s CREASE TRAP PLANCHECK FEE
I certify Out in the pufomtonce()fine wmk I'or which this pwmil is issued,)shall
not em Ploy any peuoniany moaner sn nsmhrenme subjecno the Worked'Compcn-
SEWER-9ANITARV-STORM F.A.200 EI•. ENERGY FEE
,Z nation anws of Californiaa.Data
O Applicant - WATER HEATER WNUNTIF.LECTR
yy Pp GRADING FEE /
F.y NOTICE 10APPLICANT:tho Worker a aRermaking emerthis
..i,wa I of Exemption,you ynthuld WATER SYSTEM/TREATING
a become subject m the Worker's Compet,this provisions of the Labor Code you must - SOILS PEE
Lk1 forthwith comply with such provisions nr this pemtit elicit be Deemed revoked. - WATER SERVICE
0. Q
Zoo)'z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PI.MB. 4SQ.F.. , PAID 1.
Cthereby nffimt bnuhere ivnwnewcdon lending agency for the pmfon...cenf Date Receipt#
LL P the,work for ,wblch this permit Is Issued(Bee.3097,Cie CJ
o Lender's Name
-a to Lender's Address TOTAL: TOTAL:
1 ecnlfy that I have reoJ this appllcnmion and stew than the above Information is BUILDING FEE"
Fr Ln Conear.I agree to Comply with all city and earoly ordinances andsere laws relating It QTY, MECHANICAL PERMIT P66
U ,tea. building conslmnion,and heeby authorize repra,matives ofthis city to enter upon the SEISMIC ME—
above-mentioned p,Cpeny for inspection PmP i,e,
(WB)a msave indemuil ad htitheCit of gains PERMIT ISSUANCE
Gree ns p y o Pedino against ELECTRIC PGE
liabilities,judgments,c rawfi of,hissesrmit. may in any Cony accrue against said City ALTER ORADDTO MECH.
inconsequence ofthe granting of this lsrmit. PLUMBING PEE
APPLICANT 1NDE TAKES AND W COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE RF L NS ` 9 MECHANIC .
c S— AIR HANDLING UNIT(OVER IO,OOII CEM)9� CONSTRUCTIONTAX TAX
Signal of ANdicanUConuuefor Data EXHAUSTI100D(W/DUCf7 HOUSING MITIGATION PUB
HAZARDOUS MATERIALS DISCLOSURE -Will the applicant or future building occupant store or handle hazardous materiiii HEATING UNIT(TO I00,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safely - -
Code,Section 25532(:)7 HEATING UNIT(OVER I W,aIO BTU)
❑Yes No _
VENTILATION FAN(SINGLE RESID) PAID
Will thea licamt or fature huildin equipment Date ReceiIn
pp l by the Bay Aw aidy le ices when BOILER-COMP 3HP OR I W,OW BTU
mit hazardous air oomeminnms as dcl7ned by the Bey Area AigQualiiy Manngevnem ( )
)isuin? I IOTA
❑Yen_ 7No BOILER-COME(OVER IW,OW BTU)
I have read the hazardous materials requirements under Chapmrfi95 of the Call- AIR CONDITIONER -
fomla Health&Safety Code,Sections 25505,25533 and 25534.I undeuund the, ISSUANCE DATE
if the , NEW RESIDENTIAL MUCH. SQFTr
building does not surreally have a mnant,that it is my responsibility to notify the tecnpanr . . . ,
milk requirements which most be ran prior a Issuance of.Certificate ofOceupancy, -
Owner or authonzed aged Date TOTAL:
_ dSSUED BY:•
OFFICE