99080118 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL P >
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
(, BUILDING PROJECT IDEM1TIFICATION J C .I
BUILDING ADDRESS: SANITARY NO. APPLICATION SU L DATE
Za6e13 cher 1OT%NO / (�
OWNER'S NAME: PHONE: CO RACIOR'S NAME: LIC NO:
�Mt � IN al.ne �k �/a��f� L1.Z LY! NIC CONTROL
'# ARC'H,IT,(C1/+ GINEE�_L`» LIC NO: ADDRESS: O/ A w+7fOJ T ❑
{f/l it y 21f, /fAMIL76jv ly
CONTACT: ,,(, PHONE lee '� ' `BUILDING PERMIT INFO
//1� • T-/"an i 267-7&033
El Consultant Fees Paid by Applicant(Initial) BLDG i ELECT PLUMB MECH
�Y vii rL�W/ ❑ ❑ ❑
LICENSED CONTRACTORS Dc QTY - 1 F,LECTRICPERMIT t ' l - FEE
1 herehy mlina tht 1 ahnaaa.neer nrov a ons or enapmr v mann,, g -. __ �t; _ ,10B DESCRIPTION
{vQ agZ Lh Scel'0170om of Dis A the Ousioess unJ Profeaa ens G+dc mJ my l ce :e'
F OO w full force u M r. F PERMIT ISSUANCE.
ul '" SFDWI, L1 KITCHEN REMODEL
FNu License�Lic.» APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
N Q 6 Dae Cslntmcan
ARCf11TECT5 DECL ❑MULTI-UNIT [I STRUCTURAL
[.7 ti PANELS
ZOr'�Z Iundersnnd my plans shall he used as public rem MODIFICATION
OZ—Q UPT0200AMPS El INTERIOR El CHIMNEY REPAIR
Licensed Professional 201-100SAMPS IMPROVEMENT EISWIMMINGPOOIS
OWNI:R-BUILDER DECLARATION
W ,Q I hereby human that 1 am exempt from the Contractor's License Law for the OVER I(NMIAMPS ❑BATIi RIiMODEUREPAIR ❑DEhfOLIT10N
K�6 V following reason,(Section 703IS,Business mad Professions Code:Any city or county SIGNS GL[CIRICAL ❑OTHER
LLl�+u.� which te,aires a pe.1 to construct,hoer,inpmse,demolish,or r<pan any structure �^}
0�' primmits Issuance,also requires the applicam for auchpmitm lerife a signad'amement SPECIAL CIRCDIUMISC. 'y hal ✓J �t
y that he is licensedpursuant,,the"asi'mr,of the Cemraeba,License Law(Chapter 9 VVV 6L/sF
u1�00 (commencing with Section 7(0))of Division 3 of the Business and Professions Code)or TEMP. MR OR POLE INST. COMMERCIAL:
A a e a that he is exnnpt therefrom and the oasis for the alleged exempiiun.Any vioI b of ❑NEW BLDG/ADDITION ❑DEMOLITION
QL
-w Section 7031.5 by any applicant fmi
ar a Fr t subj,ex the applicant to a civil penally of POWER DEVICES O TENANT ElFOOD SERVICE
5pnot moa!line rise hundad dollars($500). IMPROVEMENT Fl Las ownerof the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
~ will do the wink,and the sma,hma isnotintended nndlered forsale(Sce.7044,Business []OTHER
Y m and Prolesslons Gide:The C"..actor',,Limns,,Isw does not apply m un owner of OUTLETS-SWITCHES-FIXTURES qW 40"
property who builds or improve Ihcreon,and who docs such work himself or through
his own employees,providW that such improvements ha not intendW or offered for NEW RESIDENIT1AL FLEC 1t SQ 1'f.
sale.IL him asset.the building or imprvvenen kind within one yearofmmpletion NeDSQ.IT. AREA Q.FT.
owner-milder will have the hunden of proving that he did not build or improve for put-n oD
pef sale.)
❑I,as owner of the pn F,,y.am exclusively mnmmlin6 with licensed earmictom ho 'TOPA L:
a,navam the pro;ecl($ec.7 4.Brain a and Prelb tens Cade,'H a Centrnete:a Li- AUG 17 1999
cerw does not apply to an owner of property who builds or improves mereoe,and 'QTY. PL'U'MBING'PFRMIT ' FEE.; '
who contracts for such projects with a contmcmr(s)licensed pursuant m the Contracture -
License Law. PERMIT ISSUANCE
El Ianexnnptunder Sec ,B&PCforthisreason B
Owner Dam ALTER-D AIN&VENT-WA'I'ER(EA7
WORKER'S COMPENSATION DECLARATION BACK PLO TEC'L DEVICE
I hereby affirm under Penalty ofperjury one of Ne following declinations:
I havemd will adonis.Carificmeof Consent no self-insure for Workers Co.,.- DRAINS j E.R.ROOF.AREA,COND. STORIES TYPE CONSTRUCTION
chive,as provided for by Section 37M of the Labor Cede,for the performance of the
work far which this permit is issued, FIXTU S- AP
E] 1 have and will maintain Workerls Compensation Insurance,as required by Section
3700of the Lata Code,for lheperfmmunccof the work for whichdii,permit is issued. GAS-EA.SYS'H.;M- NC.4 f-S OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number arc: GAS-FA.SYSTGMOVEk ) J /
Came,, Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' �J
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE IN CEPTOR
(Thissemionneednor hecompleled iflhepermil is fmcne unfired Jollars($100) GREASE TRAP PL„ AY a BUILDING DIVISION:FBES
tar kssJ ANCfIIiCK FEE
Icenify that in the ped....mnceofthev ark! whi is pe mit is s all SEWER-SANITARY-STORM EA.2110 FT.
not employ any person in any manner so r yv telWryl su Com n ENERGY FEE
O Z .lion Laws dC.hhunih Data WATER HEATER W)VENT/IzLECfR
Z Applicant GRADING FTSE
y NOTICE TO APPLICANT:If,after making this Cri ifica f emplio you s u WATER SYSTENUT BEATING
a ? become suh rel moan Worker's Cnntpeniauon previsions + her C must SOILS Ml
fenbwith comply with suetr provisums ar this pennil shall he a neA avnked. WATER SERVICE
0 et
CONSTRUCTION LENDING AGENCY NEWRPSIDENTIALPLMB. SQ.FT. PAID
V O (hereby affirm that them is a construction lending agency forme performance of Dam Receipt»
{I. the work for which this permit is issued(Sec.3097,Civ,C.)
C)
U Lenders Name TOTAL:
LSI Lender's Address TOTAL:
1 cenlfy rem 1 have rend Ibis application and start that the above information is -,.1 - t,. BUILDING ITE
N correctJagrecto complywilhall raymmi ommayordinancesend state laws relating h+ QTY. MECHANICAL PERMIT
V Z building construction,and hereby ingforim representatives of this city to enter upon the SEISMIC FEE
above-start aed Pro rty forimpectionpumoscs. PERMIT ISSUANCE
(Wel agrte ,inde fy and keep hamdess Ne City of Cupertino against ELECTRIC ITE '
liubilitles,judgm ,costs a nes wti may
inr, ayaccmoagainstsuid City ALTER OR ADD TO MECH.
in nsequcncn eB tinBo hissPar PLUMBING IgiG
APPLICANT D STAN ND COMPLY WITH ALL NON-MINT AIR HANDLING UNIT(TO 10,11(10 CFM) MECHANICAL FEE
SOURCE RF.( LA IONS.
/ff AIR HANDLING UNIT(OVER 10,0110 CFM) CONSTRUCTION TAX
Signature at Applicata oaoanor ate EXHAUST HOODOMMUCT) HOUSING MITIGA9'ION FEF.
HA E IAL. DISCLOSURE
W.111heuppliwnlnrd'u imllding oouupum stnro or handle hueurJnus mmcrial HEATINGUNITOP010,INNIB'TU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety '
Cade Section 25532m)'! HEATING UNIT(OVER 100,000 BTU)
❑YesNo
VENTILATION FAN(SINGLE RFS(D) PAID .-
Will the applicant or few¢building==pant use equipment or devices which Data Rendpt»
BOILER-COMP(3HP OR I(111,W0 BTU)
emit harvJnue air contaminants as defined!by tlm Nay Am,,Air QwJity Management TO'f
DIsVIctR BOILER-COMP(OVER 1000)(0 BTU)
[]Ycs �i Nn
(have read the hoz o malen is aqui(c'n ndlSChepter mJS of tate Cali- AIRCONDITIONERfonia!!comm&Safety Ca onion 5505.2unJ 255)4.1 undcrsnnd that if the NEW RESIDENTIAL MECH. SQ.building does not currently titan n, tit es,msibiI ty to notify rho Occup t
ofthemquit mcntswhich I at I'• eifienrid enc91
. »
1.
OVdFirmimbonaedl agent ate I TOT'" ISSUED BY:
OFFICE