S 234208
Amt CANTTO alt I M INFORMAMN w[Tu1N RFn I INFS - IISF BALL POINT PEN ONLY
CITY OF CUPIiRTINO BUILDING - ELECTRICAL
WILDING DIVISION APPLICA'1'I0N[PF.RM[IT PLUMBING -MECHANICAL
[WILDING PROJECT IDENTIFICATION
PERM] T NO.
S 2342
BUILDING ADDRESS:
/99/6 Beekman Place Cu ekt►no, GA 9s0/`F
SANITARY NO.
APPLICXRON SUBMITTAL DATE
/o 7Z_�' r 76
O E'S AME: PHONE:
Qliia1 2 _DZH/
LIC NO:
CO AC'UH4S NAME:it
rs
NIC CONK l,p
❑
ARCHII'LCI'/IiNGiNEER: EJC NO:
A DRESS:
CONB'nCT: PHONE.
BUILDING PERMITINF
Sh kola kat X863-is8d
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB MECH
❑ ❑ c!I--
LICUNSEUCONTRACTORSDIiC1.ARATION
I hereby m6nn mat 1 am licensed rude r ...... lmlt it Chalner v Rommaamrg
QTY. ELFCTRIC PERMIT PF13
JOB DESCRIPTION
�J
P13RAil I' ISSUANCIi .i r
winh Sation 9a)n)nf Division)of theeusines. unci Profe.xinn, Gde, and my license is
in full force send Clicct.
RESIDENTIAL
❑SFDWL ❑ KITCHIZN REMODEL
APPLIANCES - RESIDENTIAL
j License Class Lica
I Da¢ Cmntmceor
El ADDITION El PLUMBING REPIPE
MODIF❑h1ULT1-UNIT El STRUCTURAL
ATION
CHIMNEY
L1 INTERIOR ❑CHIMNEY REPAIR
ARCHITECTS DECLARATION
1 understand my plans%hall be used as public records
PANELS
UY T021XIAMI'S
I Licensed Prom,ional
NII-IIXXIAMPS
IMPROVEMENT C]SWIMMING POOLS
OWNER -BUILDER DF.CLARA'I [ON
1 hereby affirm that I am exempt from the Cormi License Law for the
following mavin. (Section 703 1.5, Business and Nofessions Code: Any city or county
❑ BATH REMODEL/REPAIR ❑DEMOLITION
(] OTHER
OVER UMAMPS
SIGNS ELECTRICAL
3 which requires a permit to construct, alter, improve, demolish, or repair any structure
SPECIAL CIRCUIT/MISC.
I pno in its Issuance, also requires the applicant for such permifto File u signed statement
(bat he ix license[ purmanuo dna provisions of the Cnnutieor's License Lnw (Chnpter9
(con nn an escar,th Section it ad Irmc,ofrtheale,ed es. and l'm Air, ns Code) or
that he is exempt iherefnmt and the basis for the allcgcA exenlptlun. Any vinlmion of
T[MP. MIi'I'EIi ON POLE INST
COMMERCIAL,
❑ NEW BLDG/ADDITION ❑ OIiMO1,IT10N
' Section 9031.5 by any applicant far a permit subjects the upplicannn a civil Penalty of
al amu than live hundred dollars (S5IXp.
�7Lna nwncndlM1epmmeny, ormycmplmyeeswilb wages a+lheir.olecompensation,
will Jo the work, and themcmre is not intended ornfferd fiorvale(Sec. 914.1, Business
m
POWER DEVICI3S
[]TENANT ❑ POOD SERVICE
IMPROVEMENT
El OTHER
SWIMMINGIYADLELFCTRIC
i and Professions Code: The Contractors License Law Jmex not apply to an manor of
progeny who builds or ini,mes thereon, and who docs such weak himself or through
his awn empinyres, provided that such impmvemcros am not intended or offered for
sale. If. harasser. the building orimpmvement is sold within line year ufmmpletiun,me
owner builder will have the Farren of moving that he did not Wild or improve for put-
OUTLETS - SWITCHES - FIXTURES
NEW RISIDEISTIAL ELECTS SQ FT.
,aA SQ FT FLUOR AREA
QSQ. FT.
pox nLmlene r of the y, am exclusively Profess ng with licensed amtmmmI m
T AL' T
® V
Site 7
mecum the protect 9DLL Business dad
who bu -111;J Lo' Contmemrs
coma LmactstnatapplYtoaa ny and
apply Pnspenywccused sorimpmvhe
QTY PLUMBING PERMIT FF:F.
aof
Comon,and
who comnmts rata such PmJed. with n wmmmogs) licensal purxunnt m ten Cmmommrs
with
FERMI l' ISSUANCE
License Law ♦�, H&PC forums reason
El lam anent lu c
N:I13it-DRAINh VI?NT-WA'T'ER (F,A)
VALUADON
, 6/61 t
O�Owner lam
1, WIIRKderp COMPENSATION DIiCe
BACK FLOW 1'Ii(YfIiLT. DEVICE
Jolla ing
rade penallyofperjuryone mfthe Wllowmg reductions:
hand
will maintain 3700 of Co Latton od.toytPor Workers Compen-
El [have and will for Section 39a of the LoMsr CtMe, for the performance of the
- lin n, as provided Toa
DRAINS - (LOON, ROOF.AREA, COND.
STORIES
TYI'Ii CONSTRUCTION
work forwhich this mi is issued.
Pl%TURES-I'IiR TRAP
I have and will maintain Workers Compensation Insurance,as require) by Section
maintain
whiaM1 this permit is issued .
t]IXl of the labor Cole. for the performance of the work forrwhich
OCC. GROUP
APN
GAS - En.SYSTEhf-I INC 40UTLETS
My Workers Compensation Insurance carrier and Policy number art:
Cartier: Policy Nos.:
I GAS - PA. SYSTE M"(EVER 4 (FA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREAMIINOUSTRL WASTE INTERCEPTOR
BUILDING DIVISION PERS
IThisxaion needwt be completed iOhe Permit is formal, hundred dollars(Stan)
lir Ic".)
GREASETRAP
PLANCHP,CK FEE
SEWER -SANITARY -STORM EA. 200 FT
ENERGY PEE
I certify[hal in the performance of the work for which this permit is issued, l shall
not employ any persam m tiny manner m a, to became soveet m the Worker,' Con.Peo-
WAI'Elt HEAD R W/VENT'/HI.ECTR
GRADING FEE
,edam law, of Callfmntim. Dale
A,,heant
NO)ICHTO APPLICANT: If, ufternaking This Cenilwan of Exempting yon should
beemnn sit m me Worker. Cm,a mdmn proskimo lir dm Labor Code. rota mml
WAIIIR SYS I'I1Ml'kl?APING
sons FEE
WA117R SERVICE
fenM1withemmply with such provlslonsorthis mroashall bedectued revoked,
CONSTRUCTIONisxcisLENDINOAGENCY
I herewymhmtthatmit them is se ed(See. 3( leading agency Br the performanccof
the work Nor which this permit is issued (Sec. )091. Cir. CJ
� Ianaers Name
PAID
Date Receipts
NEW RESIUENI'IAL PCMB. SQ. IT'
Tcrrnl.:
Lendre,AJdres
LDING FEE
J 1 certify but I have read this application and .mte the the abeve information is
] correct. l agree to comply withal[ city and county oninonccs and state laws relating to
building consumption, and hereby authorize representatives of this city to emerupam the
QTY. MECIIANICA
. MIT FF:
S 'MIC FEE
above-mcmioned progeny for inspection proposes,
(We) ugme m save, indemnify and keep hamdess the City of Cupertino against
PERMI'TISSUANCE
CI'RIC PEE O O
ALTER OR ADD TO MUCH
Pt. MNINGF
Iiahihlic.,jud,ment,cost. and expenses which may in any way same against said City
SthNDWit,
of UNDERhe STANDS
in APPLICANT
/sl URC17 RE ULATIONS. DS AND WILL COMPLY WI"fli ALL NON -POINT
S(NRCE REGULATIONS. '
o
Alli HANDLING IINI'1'(I'O BPp1�CF�i ]__
- HANICAL FEF.
AIR I IANDLING UNI '(OVER I0,000CFM)
CONSTRUCTION TAX
Signamm,dA,PHe'am/Cimmaa Date
EXIIA OS', 1,,U(W/Dl1CT)
HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO I W.000 BTU)
Will the applicant or fumre building occupant%lure or handle haaardous material
as defined by the Cupertino Municipal Cade, Chapter 9.12, and the Health and Safety
Cole, Section 15532a):'
HEATING UNIT (OVER 100,000 BTU)
VENTILATION PAN (SINGLE RESID)
C] Yea C3 No
PAID Date Receipt
Will the applicant or future building occupant me equipment or devices which
aous air contaminants as defined by the Bay Arca Air Quality Management
emit hazrr
I
POILF.R-COhtl'pHl'OR 100,1%p BTU)
OTA.
ROILER-COMP (OVER 100.(100 BTIII
District!
❑ Yes FIN.
have octad the huzallouv materiels requirements nndcr Chapter fi.95 of Lha Cali-
Iirmia 11calm A Safely Calc, Sections 255115, 25573 mad 25514. 1 and eramnd that if the
,ittildingdnavnouumich a,, bean kar,apuponrihnitrrteofymppm.Y'm
AIR COND[UONIR
ISSUANCE DATE
O
-! a
NEW RESI1lIN HAL MECH. SQ Irl'.
ser Lha regahemeam wltmn amt be met odor m I9xnaeCe nfnt eeranene or fk<mmaacy.
dux to
[$SOLD BY: n Q
AL:
Owner lir authorized agent Dote
OFFICE