B 0618 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUH'DwG-RLECTRICAI. Q wr:B�H�o. L V U 1
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.-MECHANICAL rO0 O
-. , .�IIUII.DIN'PROJECT-
IDENTIFICATION
BUILDINGADDRESS: SANI'fARV NO. APPLICATION SUBMITTAL IIAfI
IjkS7]3'9/�e S.A/2nj 14A2T AUS., �� 2 F
C. /x7/N.�p/L-1 �ANll7 SU�
PHONE: GOryTRA(�7f1R$ - E. fJ..or/NG LIC/`✓/ 9/
M GG r/f/1�9 /RI FAV N/C CON of a
ARCfi1TECf/ENGI IiE LIC NO ADDRESS: — El
NocD t 1 gC!l�Sg�o Aar 5T 51z
CON'TAC'E PHONE: «I ' . B1.111-DING PE RMI NNFO '
+ ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
0' ❑ El- ❑
LIC ENn In.liCONTRACTORS DCCmicof [ON QTY ELECTRIC PERMIT ',ll I FEE'
1 nemby amrm Jot 1 licensed d le ...... .mfChapter9 femoro 'ng 1 JOB DESCRIPTION
with Satlon](NNBnf DilownM1 f he Business dP f s,m C d ndmy lactate RESIDENTIAL:
�U p PERMI ISSUANCE
PG,_ ,full Leeman IYut ❑SPDWL ❑KI'ICIII3N REMODI31,
aU�j Licens'Cnxs Lica APPLIANCES-RESIDEN'T'IAL []ADDITION ❑PLUMBING RE-PIPE
hQ1 Dele Cnnlrndn
'Doo PANELS PANUS ❑h1ULT1-UNIT ❑STRUCTURAL.
Z I undcn,and my clans shall M1c nsd as puMi<rccnrds MOIIIPICATION
OZ—O UPIO2hAMPS El INTERIOR ❑CHIMNEY REPAIR
I=.�F J Licensed Prom,,ional - 2M d(NX)AMPS IMPROVEMENT SWIMMING POOLS
4+�
OWNER t BUILDER r, be CoAI IONlaillo 'OVER ISNIAMPS ❑BATH HEAR) 2EPAIR DEMOLITION
�aJJ WL 1 Fera..off ton 1ant1.5 uBa,un train be e,lion, o License I.,Iw for me
O L CO following rwa n.(Section)031 5, alcor,',and Ptofmsions CUJc Any airy nr county SIGNS I!LEC'I'RICAL ❑OTHER
�LLy whichreq ' r1 tt 'I 11' r e nrepair' any structure O
FU OI poor to its': reartims thepph h Nnint to File a vignedTmemmot SPECIALCIRCUIT/MISC.
RM that he licensed p ,f Chep ki n.of file Contractor.L La (Chapter9
W�CO (commencing with Section 700h)of Division 3 mine Bus'Ossa and Profession, TEMP.MIiTEROR FOI.17 INS!". COMMERCIAL:
d o y that he is exact,therefrom and the nnsi.for the alleged exemption.Any vials, of ❑NEW BLDG,, )Ul'1'ION ❑DEMOhITION
^ Sot more thu1u51 vc hundmpl ndnll cc(%$pilon subjects the nPFliennnradvll punulty of POWER DEVICES ❑'TENANT ❑FOODSERVICE
h
FZ)+ " OTHER
aa
S 6 ❑Lo the work,Nepropeny.or mycntptendec wi effeed..a.Inei(See 0,LLB sines SWIMMING IKIOL ELEC'1'HIC
a�O will doh s,mas o the he rnmeCom IsaaOnocs intended Law
dJ s not apply to 4J,amt os ❑OTHER
W 3� and Prnfec«innc Ctdc:The Contramor.License law Jtcz not apply m an avnmr of OUTLIi1;S-SWITCHES-FIX'IURE' -
property who builds or itnpowec thereon,and who Joes such work h,mself or through `N
his own employee.,provided that'nuch improvements are not intended or offered file NEW RESIDENTIAL IdAICIR
sale.If however,the building orimprovericnt is sold within one yearnfcompletion,the Q.PI. .00R EA z- Q,PP.
,whir-tiuildcr will eme the madco of,I...a,that he did not hudd or improve fnr pnr-
puser ole, JUN 2 4 1999
❑1,m,wner of the proneri,a exclusively contracting with licensed contractors to T'O'TAL:
construct the project(Sec TOO,Business and Profession,CtdcJ The Contractor'0li-
censeLawJm.nm a pplymalloscOrd,roper,wh,build,orintprocesthereon.and QTY, ' ' r PLUMBING PERMIT,t 1 FEE
who contracts for such porects with u commands)licensed parsuunt to the Contractor x - 1
License Law. I'likbll'I'ISSUANCE By
1 am exempt order Sec. .B&P C fnr this rt,4 m 1
Al Iii-DRAIN&VENT'-WATER(EA) VALUATION
Owner ])am ////////
WORKERS COMPENSATION DECLARAl10N BACK FLOW I'ROTECI'.DEVICE / K
it IhudwillT roe under mall)rf of Comeneoftlf-iso nwingdeelori Ch: Y
❑ move enJwiedfor by
yection300ficam of Ge Labor pace,
the Wmrker.a Compem DRAINS-FLOOR,ROOI,AREA,COND. STORIES TVI'Ii CONS'IRIICIIOh
workas pmvidW for by Section 3]IXI of the Labor Ctda,for the perfonnanee of the
work forwInch this permit is issued. FIX'I URES-PERI RAI'
❑ I hale Imd will maintain Worker's Come of
n work
irumhi h a,permit
by flection
3]IXl of lbs h�nor6de,for li,rnuumcof the work fnr which this tis lnstmd CAS-IiA..SYSTF.M-I IN44011TLET5
per permi OCC GIt0111'
y Worstas"Dieu
lncurunec curierand Policy31/
mer. Vl1CM Policy No.., n � CAS-13A.SYSTEM-OVER 4EA)
GiRTIFICATE OF EXEMPTION FROM WORKERS' 10
COMPENSATION INSURANCE GREASI9INDUSTRL WAS HE INTERCEPI OR
BUILDING DIVISION IiiE5
(Thissmtion need not necnn,rlmalif the permit&fnr one hundred dollars(b1f10) GREASETRAP
nr less.) PLANCHECK FEE
wnit'yflatintheperforionceul lie work for which thin pc,mit i«ust¢J,I shall SHOVER-SANITARY-SrBdRM EA.200FI'.
not employ any action in any manner to as to hecome anbjcct m the Wnrkm, mnnpen-C17NERGY FEE D
OZ smile.Law.of Cuffomia.Date WATER HHAT£R WIVE N'1'/[LIiLTR
Z Applicant T GRADING PEE
ti NOTICE TO APPLICANT:If,after making this Certificate of Exemption,You should WATER SYSITIVIGKEATING
t•-' hecome subject or the Worker's Comrynsa,ion pmvisioa,of the Labor Cale,you most SOILS FEE
fnrthwithcmnply with such provisions rr this perrnil,hall bedeented revnked. WAI'IiR SERVICE
Q
z CONS'1'12UC'I'ION LENDING AGENCY NEW RESIDENTIAL ELM B. SO,EL PAID I tie Receipt It
U p l herehy affirm that the.,, lendingagcncy Ga the perforuenee of
the work for which this permit is issued(Sec.309].Co.C.)
0 U lenders Name TOTAL:
V LenJcls Address TOTAL:
I}' gl' I certify that lM1 ad thisapplication nd.t, Ih nth M 'stimulation s I{DECD GFFi
h
coneo.Iag ply with all city and counly ondurvances and:tt laws relatingo, QTY MECHANICAL PERMIT kFEE
U hulld ,c ,.,.Ilan,and horohy,t Nnr m,nesermi fti it,m emu 11-11,'lSLISMIC f
above-rush, ed property fc,inspection purpose,. PER MI'T ISSUANCE
(Wc)ugmc to save,indemnify and A-up hinnies rho City of Cupertino ugainat i[IJtC'TRI PIiE
Iinalitax,judgmentc.costs and a,schaw.c which may in anyway aecme against said City ALIIiRURADDTOMECII.
in consequence,of the granting of this Permit. PLUMB FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLI NO UNIT(TO I0.(IW CFM)
SOURCE.REG 'LATIONS. MECHANIC L Ilili
AIR HANDLING UNH(OVER Ifund CFM) CO NSTRUCTION'1'AX
Signatme of Appllcun mdrachh Data EXHAUSF HOOD(W/DUC'T) HOUSING MITIGATION FEE
HA9 RDOUS MATERIALS DISCLOSURE
Will the applicant m future building ocaapant score or handle moradnus material I11iATI NO UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal CMe.Chapmr 9.12,and the Health and Safety
Cafe,Section 25532(a)] HEN ING UNIT(OVER 100.000 BTU)
E]yes ❑No - PAID
VIiMfILA'rl(IN PAN(SINGLE RLSIIp Dum Receipt
Will the applicant or future budding occupant u,c attainment or devices which BOILER OHP OR Ipo,f1U0 ETU)
emit hazardous vie contaminants an defined!by the Bay Area Air Quality Manugemem
District] BOILER-COMP LOVER 100.000 B GO
❑Yes El No
I have read the hazardous neneriuls requirements under Chapter 695 of the Cali- AIR CONDITIONER ISSUANCE DATE
femia Ilenhn&Sahay Cade,Sections 25505,25533 aid 25534.1 ondmsmnd that If the NEW RESIDENTIAL MECH. SQ.FI'.
building does art nimmoy have a imemt,that it is my roc,n wihllity to notify the ovnpnnt
methe mgmr t,wh' utnmt nnni. eofuCcnifeme of(xevauney.
her mr amhuizale m Due TOTAL: ISSUED BY:
OFFICE