S 2962 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDINGAIIDRESS: SANITARY NO. APPLICATION SUBMI ITAL DATE
jg7S2 QiX pnvG dose,
O)yNER'S NA t PHONE'. COST RACTOR'S NAME: LIC NO:
CK' NIC CUNTROLp
`
ARCHITECUENRUNCEIC LIC NO: ADDRESS: ❑
CONTACT': PHONE:
INFO
g�^ 5(7-5377 BE PERMIT B
- JCO IW DJ Consultant Fees Pail by Applicant(Initial) BLDG ELECT Pwme MECH
LICENSED CONTRACFOR DECLARATION EJ ❑ ii, 1:1QTY. ELECTRIC PERMIT FEE
®n' a nereny tderm mw t am licensed colder provisbans m chapter 9 cmrroense I, JOB DESCRIPTION
Z with Secncemad pecDivision3 nflhc ltusinees and l'mfewions code,and mYlicettso is
PERMIT ISSUANCE RESIDENTIAL
�F W in full force end dice[. [:1 STOW], 0 KITCHEN REMODEL
UzU License Class hlca
h6W Dam Comrcuu APPLIANCES-RESIDENTIAL. []ADDITION [_1 PLUMBING RE-PIPE
ARCHITECTS DECLARATION PANELS
o) ❑MULTI-UNIT - ❑STRUCTURAL
zc� I understand my plans sM1ull nc ueul ax pubhc rc<nnls MODIPICAT'ION
O.Z. La UP TO 200 AMPS
C C.,I=W 4censed Proln.annA El INTERIOR ❑CHIMNEY REPAIR
OWNERBUILDERDECLARATION 201=1000AMPS %B
I,MPROVEMENT E]SWIMMING POOLS
W Q 1 herby affiant Im m h 1 aexemptm frothe Centaur,..License Law mime %
OVER 1000 AMPS BATH REMODEUREPAIR ❑DEMOLITION
O hadnwmg reason.(Section 90315,Busidas,and Professions Code:Any city or county SIGNS ELECTRICAL OOTHP.R
W 31L y which royutrex a perms to mnmrm,alte,improve,datndien.nr mpdir any arvcmre -
F_u'y0a prior to its-e6uaneq also requires the applicant for such pandit In filermaedoilement SPECIAL CIRCUIDMISC.
that be is licensed pursuant o the provisions oflne Cormdn',License Law(Chapter 9
Cam (condnancing with Section 90110)of Division 3(iflhe Businessland Polessiens Code)or TEMP.METER OR POLEINST. COMMERCIAL'
d p m a that he is exempt therefrom and the basis for the alleged exemption.Any violation of [I NEW BLDG/AUDITION ❑DEMOLITION
.+y
Second 7T31.5 by any applicant for a permitsudect,Ec. licvnt rod civil Penally of POWER DEVICES
F Z S+ t1mora Nan Five hundred dollars(ISM). 0 THNANT El FOOD SERVICE
dO I1,as owner of the property,or my employees with wages as their sole compensalion, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and(hcswcmre iv not intended a offered farad,(Sec.9044,Ratio... [:]OTHER
m unit Profession,Code:The Comments License Law does not apply In an owner of OUTLETS-
SWITCHES-FIX'I'URGS 41
property won milds or Improves thereon,and who does such wnrk himself or Through
his own emPlnyces,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTI2 SQ Pp. - \�-
Isle BEbwxever.Ihemilding or inTowemenlis,old within ane year ofeonydetinn.the IS FI'FINER AR�i $ISQ.frl.
er-builder will have the burden al that he did not build or improve /
proving PreveCwpur-
poso of sale). (
I
❑ 1,as owner of the Proparty,am exduslVCly eenlmoting with licensed ennnneters In TOTAL: �I'/ APR
2 1 1999
can...a"the pngect(Sic 7044,Business and Profexeions Coda:)The Contractor,Li- I� H
cense Law does not apply to ad owner of property who meds or improves thereon,and QTY PLUMBING PERMIT FEE IJ
who cmmraas fmauch projmlx with v conwdor(s711censcdp�rsuant(.the Contmcmrs
License Law. PERMIT ISSUANCE r
❑ l am cx/t under-See I ,B&PCfor this reason n)/
C]
�j ALTER-TRAIN&VENT-WA'ftlR(GA)
OWi2i it „^' _n,,.. VALUATION
WORKER'S COMPENSATION DECLARATION BACK PLOW PROTECT DEVICE
I hereby aff ral under penalty of perjury one of the following declaration,: D
❑
I have and will maintain a Cerlificale afConsent1 It'nsr for Worker's CompenDRAINS-FLOOR,ROLE AREA,COND.
sation,as provided f r by Sodden 37M III tire Labor C ed bar the parfieranance of the STORI S TYPE CORUCTION
work for M1 , his perm, dFIXTURES-PGR TRAP , 2 O
L] I M1 d ll ainl W k Contp -t Insnca q 1 by Section C/
3700 of the Labor Gude,for the performance of the work for which this permit is issued, GAS-EA.SYSTEM-I INC 4 OUTLETS OCCGROUP
My Workers Compensation Insurance carrier and Policy mm
ther ad, CC f IC
Carrie, Policy Na: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMFI'ION PROM WORKERS'
COMPENSATION INSURANCE GREASEJUkDUSTRL WAS'1 E INTERCEPTOR
(This scalion need not rte cnaddried ifthe perlil k for one hundred dollars($HID) BUILDING DIVISION FEES
unless.) GREASE TRAP
PLANCHP,QK L=EE
I certify the' n lheperformnocent durvank ferwhichthi,permit i,issued,Iana11 SEWER-SANITARY-STORM EA.20017..
not enlpley any person in any manner m m m mm�mu,object m Ihn Wndirrk Ciampeo- ENERGY PEE
Oz nation Law,of Callforma.Date WATER HEATER W/VENT/ELECTR
O A,pla, I GRADING FEE
NOTICE TO APPLICAN'It If,after making this CCrlificate of Exemption,you-should WATER SYSTENYTREA'1'INC
O- hernmcsuomly the Werh di Ooons or tis prvisiens nr the Labor Gxle,you must SOILS FEB
IaZI ” becomebbject ,with such divisions Connsorthis pennitnas rthecmedr Coe,
Q WATER SERVICE
zv) CONSTRUCTION LENDING AGENCY
U 0 1 mads alum that there is a conamclime lending for he performance t NEW RESIDENTIAL PLM,. SQ.PI'. PAID Recei UI
U O Y g agency p r ormunec n p
W F~-I the work for which this penal is issued(Sce.30D,Civ.C.)
C Lender's Name TOTAL:
W Lender'x Address
�.t 1.coif%[tint l hove read This appllCminn anJ scale lhdl Ole shove infommlion is BUILDI iE
F-t V) correct.I agree to comply with all city and county crimina s and sure laws relating to QTY, MECHANICAL PERMIT FEE
UZ building conslrodion,and hi authorize reprexanlWises of this say In enter upon the SEISMIC E
above-mentioned pmpeny for inspection Impose, -
(We)agree m Gave,indemnify and keep hamdux the City,I Cupertino aguin,l PERMIT ISSUANCE ELECT41 FEE
Iinbilities,judgmcnls costs and expenses which may In any wiry accrue against said City ALTER OR ADD TO MECff.
an ,sequence of the coming of this peanut PLUMBING 'pG
70
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AI R HANDLING UNIT(TO I BJHhI CPM)
SOURC- FELLATIO S. MECHANICAL F,'
AIR HANDLING UNIT LOVER I(I,INHI CFM) CONSTRUCTION TAX
Sigigstife of AppllcvnVCnmuctor Dale EXHAUSTHOOD 1 W/DUC19 HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fins,health ng oecupanl senor handle hmnniontrame,il HEATING UNIT CI'01 W,0IXI BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532(u)9 — / HEATING UNIT(OVER 100,0[X1 BTU) is ��
Yes alfa PAID
VENTILATION IAN(SINGLE RES ID) Dale Recei,d#
•
Will the i,co um or fuwre defi ia8 by the nl are o Air Qu or devices which
emit hw.ardoue uirmmmnmanls as defined by the Bey A.Air Quality Managonlad BOILI'.R-COMP(311POR 00,00OBTU)
Dt dmOYes � BOILER-COMP(OVER I WINDS)BTU)
I have mad the hazaNnus materials requirements under Chapin 6.95 of the Cali- AIR CONDITIONER /// ISSUANCE DATE
forma Health&Safely Code,Seclinna 255115,25533 and 25534.1 marinated Loin it the NEW RESIDENTIAL MECH. SQ.Irl'.
building does nnleurrendy have a tenant,that it i,my responsibility to notify themrapunl /r-7 /
of tit iRmenl6W IC Y61 Yprinr t0�'saadec of a Ciniflcne of DCVM
pey.
rmationaldagent True TOTAL: ISSUED BY. lam/
OFFICE