99070063 l�.APPCICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
iCITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDETSHTFICATION
BUILDINGADURESS: - SANITARY NO. APPLICATION SUBMITTAL DAT:
rsoo no 17
R NAME: ` r SNE: � C ACTQR'S NAME: I LIC NO'. (
_k hL�J� 1 NIC CONTROL#
IT•CTI INTER: L NO'. A DRES,$S (1_ ��� ❑
CCOON'1'AC` // PHONE: Il 1V �J\ BUILDING PERMIT INFO
1 l �, j\/1C ` �Q��42_1q_ �k I ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
1/ —\ �J `ill ` ` ❑ N'SJ ❑
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby arum that I am licensed under provisions of chapter 9(commencing JOB DESCRIPTION
oaZ with Section]0W)ofUlvision 3 ofthe Business and Professions Code,and my license is
Won ' PERMIT ISSUANCE RESIDENTIAL,
F'= amu force Bact
aUU Liceysc Class Lic.p s 'DWL C KITCHEN REMODEL
y44 Da¢ Conuamor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
f-,Dm ARCHITEC ,,DECLARArrs MODIFICATION ON PANELS ❑MULTI-UNH' ❑STRUCTURAL
ZO�j?, I undersand my plan.%shall be used as public ren
OZ..q UPT02MAMPS El INTERIOR CCHIMNEY REPAIR
�too F7, Licensed Professional 201-1000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION El SWIMMING POOLS
C ..l I hereby affirm that 1 am exempt from the Contractor's License Law for tiro OVER 1000AMPS ❑BATH R 1 D'IAREPAIR ❑DEM ION T
a vS
t1 0.V following reason.(Section Omarp Business and p Professions Code:Any city m mumY SIGNS ELF,C'I'kICAL O HER b _.Q.>_1-y
tL y which requirce a permit to concoct,idler,improve,demolish,nr repmr any swuure
F,..�6 prior to i Is issuance,also requires the applicant for such permit to file a signedsalement SPECIAL Cl RCUIT/MISC.
that he is licensed pursram lm the provisions mf the Connector,License Law(Chupter9
�ap0 (commmci ng wish Section 7001 Di,r,mr 3 of the Businnss and Professions Ccde)or TEMP.METER OR POLE.INST. OMM -R IAL'
t1 m¢r that he is exempt merchant and the basis for the alleged esempliom Any violation of C NEW BLUGIADDITION C DEMOLITION
IL Sectma7031.5 by any applicant fora permit subjects the applicant to a civil penaltyolPOWER DEVICES
❑TENANT El FOOD SERVICE
not morethanEve hundred dollars(empl. IMPROVEMENT
❑I,avCvank,ahe property,or my emntended with motional
miracle(Spic.
compcusntion, SWIMMING POOL ELECTRIC
p. will do The work,and the stmctureis not intended oroRereJ for sale(See]IW4,Business0'fHER
mand Professions Code:The Comments License Law does not apply In an owner of OUTLETS-SWITCHES-PIXI'URBS
properly who builds or improves there...,and who Anes such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RF,SIDEN HAL ELECI SQ EL
.sale.It,however,the building or Improvement issold within one year of completion,the SQ.mr..FLOOR AREA $/SQ.FT.
owner-builder will have the barren of proving that he did not build or improve far prr-
E]1Oa¢own JUL 2 81999
❑ 1,as owner of the properly,am exclusively contracting with:)The
mntraors i- TOTAL:
construct the pmjut(Su.7044,Business and Profescians Culex)The Conoadors Li-
cense Law does not apply toanowner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEF,
who contracts for such projects with a contractor's)licensed pursuant to the Contractors
P License Law. PERMIT ISSUANCE 1.]A
❑1 am exempt under Sec. ,B&P C for reason
Date ALTER-DRAIN&VENT-WATER(EA) VALUATION
comer
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE w
I hereby affirm under penally of perjary one of the following declarations:
C l have and will maintain aCerilicam Cf Comenunself lnsurefs-Worker's ComNO
DRAINS-FLOOR,ROOP,AREA,COND. STORIES TYPE CONSTRUCTION
cation,us musician for by Section 37M of the Labor Cowde,far the pradompanof the
work for which this permit is issued. FIXTURES-PER TRAP
1 have and will nminmin Worker's Compensation Inmrance,as required by Section
3700 Cf IM1e Labor Code,for performance ofthe work for which this permit is issued GAS-EA.SYSTEM-I INC.40U'1'LETS, OCC.GROUp
M Com as a or ace earn red Policy F r'
CarID.�uy trey No.:� � GAS-BA.SYS'fEM-OVER4(EA) (/
CEER�I'IFICA E OF E) 'M N FROM W RKERS'
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR
(Tare section need not becomplab d ifthe permit is for onelmndred dollars($100) BUILDING DIVISION FEES
nor less.) GRF,ASETRAP PLANCHECK FEE
I certify that in the performance nfthe work for which this permit is issued,Ishall SEWER-SANITARY-STORM EA.2UU FT.
not employ any person in any manner so as n concerns,ee subjecto the Workers Copper- - ENERGY FEE
O Z cation Laws of Galat iu.Data WATER HEATER W/VENTIHLECTR
z O Applicant' GRADING FEE
t-r ti NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM?kTATING
become subject to the Workers Compensation previsions of the Labor Code,you must SOILS PEE
III forthwith comply withsuch provisions or this permit shall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION isoconLENDINGAGENCY NEW RESIDENTIAL PLMB. $Q.F1'. PAID
I hereby rte thatthere lsacomSee.30 len ding agency for the perfommnec C( Data Receipt#
W � the work for which Ihie pcnnit is issued(See.3097,Civ.C.)
C) Lenders Nunn TOTAL;
{U Lenders Address TOTAL:
1 certify that I have mad this application and state that The above information is BUILDING FEE
o's r�jy mrmt.I agree to comply with all city and county ordinances and state laws relating m QTY_ MFAHANICAL PERMIT FEE
U building construction,and Tandy amhon,a representatives Oil city to enteruponthe SEISMIC FEE
above-mentioned property for inspection purposes PERMIT ISSUANCE
(We)agree save,indemni y and keep harmless the City of Cupertino against ELECTRIC PEE
liabilllies.judgme s.costs ander 'msec hich may in any way creme againa,and City ALTER OR ADD'TO MECIi.
ic
ansequene b the gaming hiep mit. PLUMBING FEE
APPLICANT UGft���'''JJJ'''AN AN WILL COMPLY WITH ALL NON-POIT AIR HANDLING UNI'I'GO Mutual CFM) MECHANICAL FEE
SOUR
AIR HANDLING UNIT(OVER I0,00%1 CFM) CONSTRUCTION TAX
( Signature of Applicant/Contractor Da EXHAUST ROOD(W/DUCT) .HOUSING MITIGAI'IUN IrEE
HAZARDOUS MATERIALS DISCLOSURE
Will heapplicanl..r future madingaccupanlsare..r handle M1amacres malarial HEATING UNIT('1'0101,W0 IT I'OR
ae dentist Thyme Cape,,..Municipal Code,Chapter 9.12,and the Health and Safely
Code,Section 25532nd? HEATING,UNIT(OVER BOTTOM BTU) --
❑Yes ❑No PAID
VENTILATION PAN(SINGLE,RESID) Date Reuelpl#WId ill the air cortrr m furore building by the Bt use ea Air mor device which
miticts us air contaminants as defined by IM1e Hay Arca Air Quality Management ROTI-ER-COME(3HP OR IW,WB BTU)
Districts TOTAL:
Cl Yes E]No BOILER-COMP(OVER IIXI,IXO BTU)
"a real kuearJam maar ncn14 under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DA•1'E
Iarms Health&CC y Calc,Smlion. 5 U 255'1'and 25534.1 understood that if that I
buildingducs , rrenllyha ten t. It is my responsibility to oto f' o urea-ant NEW RE5IUGNTIAL MECH. SQ.FT. 2 `•r
Cfthe Swhlehl 51 1 r to Issuance of a Canape ..
- Ow v ten vd agent Di I TOTAL: ISSUED BY;
OFFICE