99090118 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY O I
CITY OF O BUT]DING-ELECTRICAL PE MI
BUILDING DIVISIONAPPLICATION/PERMIT rlUmalrvc-MECHANICAL
r;.IfUILDING PROAECT IDNNTIFICATION',tiY%OJ Y'If
BUILDING ADDRESS.. SANITARY NO. APPLICATION SUBMIITTrA�LpDATE
,4'2 1 2O 1 b To y\,;l Qq It W U 2.^ L,.C70— 2�0 9l�6 7 9
OWN 'S NAMyq /') � PHONE: CON9RAC1'O 'S NAME: LIC NO:
i LVJC'h_/Jl G/-La NIC. CCdONTROL# ///���AR TP '/v GINEHR: LIC NO'. ADDRESS: 1:1 / al/
CONTACT; PHONE: r r1../1i,:q„rBU11.UING'PERMIT IINPO ,',".'
6 _ ^�^ ❑ Consultant Fees Paid by Applicant(Initial) BLDGELECTzPLUM El MF,CH
In
LICEN )CONTRACTOR DFCIARATION r ' Ir n- l.; LCJ
QTY •'r „ ELECTRIC PERMIT, 'r
1 hereby affirm m t 1 am 1«read!under p f Chapter 9(commencing i. - r +IY tJr " �i'FFF+/r.�'t LOB DESCRIPTION
wooZ9Z mS, m70ffo D , m3ofmclEome :n1 r R E�m and n,r arc xn,
woo
in a Of end Rca. 6 PERMIT ISSUANCE ,PDWI. T - ❑KITCHEN REMODEL
aZV Date Chs Lie .64 APPLIANCES-RESIDESDIAL []ADDITION ❑PLUMBINGRF_PIPE
N6y Dam GSDw
,I',Ca T'S DECLA 1 ❑MULTI-UNIT ❑STRUCTURAL,
Z p v=z 1 understand my plum shall he used as public moods PANELS MODIFICATION
p'2,.-0 UPTO200AMPS ❑INTP,RIOR El CHIMNEY REPAIR
64 fXLicensed Professicnal 201.0"AMPS IMPROVEMENT C]SWIMMING POOLS
OWNERDECLARA'I ION
rY 04 G -BUILDER I hereby affirm that 1 am exempt from the Contractor's License Law for the OVER ILXXIAMPS El BATH REMODL'VREPAIR ❑DEMOLITION
X 3 c., following reason.(Section 7031.5,nusiness and Profi sslons Code:Any city or rummy SIGNS I LEC'I'LOCAL [I OTHER
which requires a permit to constnmt,cher,improve,demolish,or repair any smucturc
F�-O poor wits 6,mtr cake rcgmiresthcapplicam for nuehpermino fileasigammineseen SPECIAL CIRCUIT'/MISC.
mut he is licensed pursuant o the provisions of the Contractors License Law(Chapter 9
�L'�� (commencing wit Section 7okoof Division 3 of the Business and Professions Code)or TEMP.MET1311 oft M)LE INST. COMMERCIAL:
d c rG mat he is exempt merefmm and the basin for the alleged exemption.Any Anlaticn of ❑NEW BLDG/ADDITION ❑DEMOLITION
�m Section 9031.5 byvnlapplicant fora permit subjenn the applicant too civil penahy of POWER DEVICES ❑T NANT ❑FOOD SERVICE
nor more than live handed dollars($5(X1). PROVBMENT
=A DLas ownerof the progeny,or my empinyas with wages as theirxole n,mpennation, SWIMMING POOL ELECTRIC
h.. will dorhewotk,and rhestmctere is not intended croffacJ forsale(Sce.7044,Businces 'rHER
t�i1-'� and Professions Code:'ILc Contractor§Licemve Law does not apply m an owner n( OU'ILE'I'S-SWI HES-FI%TIJItES
a'a.. property who builds or Irnpmves thereon,and who does such work himself or through
his own employees,provided that such improvements am not intended or offered for NEW RHSIDHN IAL E• CTR SQ NT.
sale.If,however,the building orimpromossal In sold within one year ofannplmlun,the SQ.FT.FLOOR AREA $/SQ.F..
rymer-builder will have the burden of proving that he did not build improve for pur-
sar e f s e) G r), (/0
1 f tit p pent d . IY t i 6 with licensed ministers oomrt to TOTAL _l Y G
construct be project(S 7(94 Business ad Pudr. C J;)I he Com 't IJ-
Ame Law does not apply tf property who huildi or initiativesthereon,and TY -( J.PLUMBINGP rr FI F�ii�/
who t t f hp )ern with venntre na(s)Imenved pu. n 11eConw t r:
`7
ElI am exempt under Sea ,R B P C for this reason P17RMI'I ISSUANCE I
•
Owner Dale
ALTER-DRAIN A,VENT-WATER(EA) _ VALUATION 2R 1
Wmunder;PCOMPHNSAIy on DECLARATION PACK FLOW PNfITECr.DEVICE S •
1 heathy affirm under penalty Iaperjury one of the imnoc or declarations:Co
❑ Ihavc and will nforbi Section
n37M of the Svm InLabor
Self-Cosensur the Worker'sCn of the DRAINS-p1.00H,ROOF,AREA.COND.
smian,as pnrviJeA for by Scaion 3]00 of rite LaWr Calc!m the performance of the STORMS TYPE CONSTRUCTION
work for which this permit is issued, FIXTURES-PER'T RAP
❑1 have and will maintain Workers Compensation Imumnee,av required by Section
3700 el LubarCodeIforth,perlorm nceefthc work lorwhirhthispa ' ire s.vucA. GAS-IiA.SYS'rI?M-I INCA OU'I'LETS OCC.GROUP APE
My Wadi se"1112 tion!near trees crier Policy num re r
Carrier il' MS-EA.SYSTEMOVERJ(EA)
tract 1 P M ORKERS' GItEASP./INDUSTRI.WASTE INTERCEPTOR
COf'MPPEN�SAT'IOUUap BUILDING DIVISION NESS
nr le'v)This mo �(7I /till fnry a undyed dollars 100) GREASETRAP
fpf- - 66 tit G, f PLANCHECK FEB
I cert that m the fomta cc if a rk ter hich this permit is issued l shall SEW employ any person in any instance so as m hecome subject to the Workers'Compen- STORM EA.21X1 Ff. ENERGY FEE
zZ ertimt Laws of Califnmi°'Data WATER HEATER WNENT/ELECTR
O Applicata GRADING PEE
y NOTICE TO APPLICANT.ll;aper making This Certificate of Exemption,you should WATER SYSTEMGKHATING
abecome subject m me Woder's Compensation pmvisions of the Inbar Code,you most SOILS VHE
A tnrhwlth,imply with web pmvisions or Nis mooil,h.11 he deemed revoked. WATER SERVICE ,
7 z CONST ROC'I')ON].ENDING AGENCY NEW WiSIDIiNI'IAL IUMB SQ.IT. PAID
i:_JO l hereby affirm Thai them isaconswaio.tending agency fnnheperfommnceof One Receipt If
the work for which this penult is i,v.cd(Sec.3097,Civ.U) •--�,
ULeaders Narne r-_S ^"�•+ 'TOTAL:
Isnder's Address TOTAL ' 1 ' ^
yi 1 molly that I have J this application d state that theM i f ti s - -]-- M BUIIiDING,ITE 1 1
h street lagrce to comply 'm II 'ry a ry rd' - eat I t goo QTY. ,_MECIIANICAI PHRMI'F tl '' .BI.,'
U Z huildngconstmcton ndh reby:nthorize eprescntati es fth:xdtyt enterup nhe / SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
It(We)ngruc to auvq indemnify mJ keep hamrlexs tha City of Cupertino aguinn - C .Ii 9
liebilitiev.judgments.coxa and expenses which may in any way accrue against said Cnv ALTEHORADDTOMECH.
in cit yuance of the graming of this Ix-reit. PLUMBING FEE
APP I ANT UNDERSTANDS AND WILL COMPLY WITH ALL NON- INT AIR HANDLING INS III 10,(100CPM) (3
E`EGULATIONS. _. __ MECHANICAL FEE
k. AIR HANDLING ON]Y(OVER 1....)CFM) 'A' CONST__RUCTNT
w ppli scour D. c RXHAUST DOUG W/DUCD
{AZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building occupant store or handle hazardous mammal HEATING UNIT(TO 100,000 BTU)
as defined by me Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Scrano 25532(,)9 HEATING UNIT(OVER 100,000 BTU)
❑Yes VENTILATION FAN(SINGLE RMID) PAID
,• 001 BTU
RP OR 100
COMP G , )
Will the applicant or et vbuifined occupant use equipment or devices which Date Receipthazardousmit hazardous air conmminums uv defined by the Hay Arur Air Quality Management BOILER- TOTAL:
District'
❑Ycv ryf1 BOILER_COM P(OVER IW.O(MI BTU)
tild,
ave read tlm haz:mden,nwte.ials rs under Cha ter 6.95 ufthe Cab- AIR CONDITIONERISSUANCE DATE,rcuircmen plth&Safety Calc.Sections 25505,M533 and 25531.1 indentJthatifthe NEW RESIDENTIAL MECH. SQ Lp.cexnarurenll nlemm�,Thal lr is rnyrcspensihility nn0rd thenmupunl
met prmto isnuance of i1 ( yrrrtttKn dL, Otte TOTAL: ISSUED BY:
OFFICE