S 2791 - —APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY,OF CUPERTINO BUILDING-ELECTRICAL, PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. S 2791
1y BUILDING OJRCT IDENTIFICATION
iBUILDING ADDRESS: r SANITARY NU. APPLICATION SUBMgTTAL DATE
OWN NAME: PHONE'. CyIN TR ACI Ok'S MF.: LICN
3- 2od �& /099
SIC COMI'ROLM
A1111iRC /ENGINEER: LIC NO: - IADDDDR`..S ❑
Cl , ' PHONE f ILDINO PERMIT INFO
�f� V qQ(s-O/�� ❑ Consultant Fees Paid by Applicant(Initial) BID(T ELEEC/CTPLUMB N
6 ❑ 1{�' ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 M1vruby air..mal 1 am beenaw ander......ions ofChopmu 9(oommearm, JOB DESCRIPTION
�aZ thSection]000)ofDivunio.3 write Business and Rofesdnne Code,mtdmy liearec e,
y�O wl PERMIT ISSUANCE `� RESIDENTIAL:
F n full forty rind a �L ) {�
�UZV Livense Class Li- 0I � C� J JM ❑SFDWL ❑KITCHENREMODEL
yQL Dme Cnnlraa<�� APPLIANCES—RESIDENTIAL ❑ADDITION ❑PLUMBING RE-P[PE
zO❑❑yy ARCHITECPS DEC RA'r�]. ION PANELS ❑MULTI-UNIT El STRUCTURAL
NG I undersmnJmy plans shun be used as public record MODIFICATION
OZN-0 IIP T021➢JAMPS El INTERIOR El CHIMNEY REPAIR
(=.�1"; Licensed Professional 201-IOOOAMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER Hot AMPS El BATH kF,MODELIREPAIk ❑DEMOLITION
d I hereby affne that 1 aIn exempt Gam In,Comriobn'e License Law for the
a U following.,,air(Sermon]031.5.Bminess and Professions Chile:Anycity or county SIGNS ELECTRICAL El OTHER
ty m which rabores or perm;,m rosebush,alter,improve,demolish,or repair any structure
prior,o its issuance,alsorequifm lheappllan,Rostra permit to file u signed astronaut SPECIAL CIRCULDMISC.
�p. that he is licensed pursuant to the provisionsofthe Connector,Lifeco eLuw(Chapter9
Ia1[L dO (commencing with Section]DLO)wrDivision 3 of Ne Busmassind Professions Code)or TEMP.METER OR POLE INSI'. COMMERCIAL'
dTY o C that he is exempt therefrom and the hunts for the alleged exemption.Any violation of El NEW BLDG/ADDI9'IGN El DEMOLITION
evSaction"II.S by any applicant for v permitsubjee,s the applicant to a civil penulty of POWER DEVICES
y ❑TENANT ❑FOOD SERVICE
�n nal mine than five hundred dollms($500)' IMPROVEMENT
doi] 1,as owner of,hepropeny,nrmyemployees w.unceaesasthei(Set.compevxter,, SWIMMING POOL ELECTRIC
F will Jolhewers Can,The wrcia tors License La dues not apply to an Business El OTHER
and Forwarders Code:The Contractors there's License Law saes not apply himself owner of OUTLETS-SWITCHES-Is1X'NkF,S
his own who bullas or improves thereon,inti who nova re hM1 work deedo f Ihmugh
his own employees,e provided that such mens u,manta are nal intended or offered for NEW RESIDENTIAL ELECTR SQ Fr.
sole.If,hewevegthevethburden of provinlitadd thedidinare tbuild or cprova for utopur- SQ,FIR FLOOR AREA S/SQ.FT.
owent,builderofsale).will have the harden of proving,hal he did not build or Improve for par-
poem of sale).
❑ 1.as owner of the See 704 run exclusively cufessins Chs licensed emlmrr,I tu TOTAL:
construct,hep jet(Sec.Nano wner of and Professions bei❑ale:i The es thereon, Li
-
nsvLawaevsistipplymun wwnernansports whoseddrrer,in he thereon,and QTY PLUMBING PERMIT FEE
who cnmmeta For al¢hp jests with ueomrurmr(sl lieensen pursumn in he Cnnlracnn's
License Law. PERMIT ISSUANCE
I em exempt under Sec. ,B&P C for Wl,neuron r
Data ALTER—DRAT e �Wall A'rt1'ER(BAJ VALLA"fION
WORKERS COMPENSATION DECLARATION BACKF W 'RO'TE '.DEVICE
1 hand will maintain
aiunser penalty u,ofCon one of the following Worker i Cee
I have and will Forb ine Cen3700 if Consent to Code,for Cher Workmance of the DRAINS— ,ROOF RFA.' OND. STORIES TYPE CONSTRUCTION
ue provided For by Section J]00 Of 0a Libor Cone for Performance of the
work for which this maintain
is issued FIXTURES— APA\
❑ I havof
and will maintain Wo erforkra, an ed offlhi w Insurance,h respired by ashes.
3]O,IwI'Ihe Labor C�pa�le��,f��o��r,he perfonn�a.fne�e of tlm work for which this/�pennh lfdi�su�ed/.� GAS—EA.SYS � -I INC.4OUTLET' OCC.GROUP APN
Char er: !"vSTL - Imo" �(1'ol cy Nesint 000 /% GAS—EA.SYSTE -O 4
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSI'RL 'E INTERCEPTOR
(fhk scafon nerd not be completed if,he permit isforone hundred dollies($Iqq BUILDING DIVISION FEES
nr lens.) GREASE TRAP PLANCHLCK PEG
I canlfy,het irmepufwnnareenf[he work Ler which lhiepermit is issued.l shall SEWER—SANITARY—STORM EA.200 FT.
sol employ any person in any manner se as to become sahject to The Workers'Compen- ENERGY FEE -
z
an,,.Lawanf California.Date WATER HEATER WNENT/ELECTR
O O Applicant (TRADING FEE
NOTICE TO APPLICANT:If,after making this Cmniflmme of Exemption,you should WATER SYSTEMITREATING
baewmreobiect no the Worker's Coursof nliwn Pon vierun,of the Labor Cade,you most SOILS FEE
fi+rthwihh annuls wit such provisions in this permit shall he Deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENOINC AGENCY NEW RESIDENTIAL PLMB. SQ.IrC PAID
U O work
orwhich rte that isn .construction0 lending agency for the performance of Date RtteiplM
the work for which This perm;,is;saved(Sm.3119],Civ.C)
O U Lender's NameTOTA
artily L:
fLl Lender's Artifytddo,a TOTAL_'
I that I have reed this application and state Nm the above information is BUILDING P
r0. prevent,l agree to comply with all city and county ordinaneesand shale laws relatingm QTY. MECHANICAL PERMIT FEE
U Z To laingconelrua,iwn,and Turnery authorise representatives or this city to enter upon the SEISMIC FEE
alsovi, ordered pmpmy for in.genion pu,,.,as. PERMIT ISSUANCE
(We)agree m save,in lace Iy and keep harmless the City of Cappriam against ELECTRIC FE
liabllilies.jmlgmenls,costs and expenses which may in way accrue against said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBING
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
.F.REGULATIONS MECHANICAL FG
3/� AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TA
sof ApplicanVCopracmr Dnle EXHAUST HOOD(W/DUCU
HAZARDOUS MATERIALS DI I RE HOUSING MITIGATION FEE
Will the applicant or future building Ocruprm store or handle haansous materiel HEATING UNIT(TO 100,(IIHI BTU)
as defined by the Cnpad me Municipal Code,Chapter 9.12,and the Health and Sofery
Codd Section 25512(a)? HEATING UNIT(OV For 100,000 BTU)
1E]You VENTILATION FAN(SINGLE RESID) PAID -
Will,btu i licanl of future bulldia own t ucr c - merit or device,which
Data Receipt N
pp go the
qmp BOILER—COME OHP OR IB4W0 BTU)
^mil hazarJons sir conmminan,x vs defined by the Bey Area Air Quality Management )TAL.
❑older
Yes lo,"Io BOILER—COME(OVER 100,000111G)
I have mod the headedouema[mals reyuiremcros under Chnpter695 of Ne GLI- AIRCONDITIONER ISSUANCE DATE
forma Hallh&Safety Code,Sermons 25505,25533 and 25534.1 understand that if e NEW RESIDENTIAL NIECE, SQ.IT
ding ones not emormly lmvratenanl.l s myresphoubilitym notify in pint
oft ms all oras,be a id.Croupous, vcy.upon
'IsIvrTler or
t
nuthnrize age Date TOTAL ISSUED BY:
OFFICE
s
CITY OF CUPERTINO
RECEIPT
No. 1700
/SATE ", 19-m _
-. RECEIVED fK5/,
FROM GCC
O -1 �QIG
ADDRESS
CASH H MDNEY -
ORDER
DOLLAR$ CENTS
- e led
�• SDI? rn�no ��5 �I
—
e (o Maas. I oao
,.
310
i I -j
sn,, RECEIVED / 3�� J 6��
' BY J' 111
16528 CROWN BUSINESS MES.INC.-(8N)86329]5
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