S 2779APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING . ELECTRICAL
CHANICAL
BUILDING DIVISION APPLICATIONIPERMIT PINC IRf7T H)ENITF CA
IIf11LDING PR T IIIN:N'TIPICATIUN
PERMIT NO.
C 2 7 7 Q
J 1 1 V
7��
BUILDINGADDRESS: / I O
002
a'
/�( AjOO
SANITARY NO,
AI'1'LICAI'ION SUBMITTAL IIA'1'li
N
^COM'N(ll.n
OW "S NAME: �/ / P'HO`NE:
1 �/✓� ii(/}N L/ L.a�� 3
CpLNTR/5'CTOR'S�Nq/f_1H: LIC NO'.
I� ` f/fJ Alp3���G�
NIC
❑
BUILDING PERMIT INFO
i RCHITEC ENGINEER: LIC NO:
T CONTACT: PHONE:
ADORES: .-.
(
BLDG ELECT TLLUUUM_B MECH
❑ Consultant Fees Paid by Applicant (Initial)
LICENSED CONTRACTOR'S DECLARATION
1 hereby aRrm that l am licensed under pmvizinns of Chewer 9 (commencing
with Section 7") of Division 3 of the Ruvinesx and Profession Cute, and my license is
in Fall tomcand effca.
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL'
❑KHCHFN REMODEL
PERMIT ISSUANCE[DSFDWI
APPLIANCES -RESIDENTIAL
Licensey�/u�� Lica
Date.—yrP� Comore 30/
❑ADDITION - ❑PLUMBING RE -PIPIT
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
El INTERIOR El CHIMNEY REPAIR
❑SWIMMINGPOOI.S
gyp'H REMODEIJRF.PAIR 1]DEMOLII'ION
I
(] OTHER
ARCHITECTS DECLARATION
1 understand my plans shall he used as public records
PANELS
UP T02110 AMPS
Gconsed Professions
OWNER BUILDER DECLARATION
I hereby .mese that I L exempt from the Coumaoh License Law for the
t (Section lonstr Business and sen Cede: Any city os county
guires
201MORDANTS/*PROVEMENT
OVER I(NN)AMPS
SIGNS ELECTRICAL
de
which its is atonia m juiry rum, uheq improve, memMiN, or repair any structure
whicha improve,
' prior In its issuance, also requires the utmlicum for such permit o file nsigned wammem
1 that he is licensed pursuant to (lie provisiomnf the Connotur's Liens Law (Chapter Y
SPECIAL CIRCUITIMISC.
COMMERCIAL'
—ions Cle)or
ess d Prol'm
(commencing with Section 7") of Division 3oflhe Businan
that he is exempt therefrom and the basis far the alleged exemption. Any violation of
Section ]031.5 by any applicant for a permit subjects the applicant to a civil Penalty (if
TEMP. METER OR POLE INST.
❑ NEW BLDG/ADDITION ❑ DEMOLITION
EITENANT ❑FOODSERVICE
POWER DEVICES
not mon than five hundred dollars (35(0).
�01, nsawnerof Ne property,or my employees with wages as their sola compensation,
will Jo the work, and thestrvcture knot intended or o0bmd I'nr sale(See90.14, Business
D and Professions Come: The Conlraaors License law does not apply to an owner of
IMPROVEMENT
❑ OTHIiR
SWIMMING POOL ELECTRIC
OUTLET'S - SWITCHES - FIXTURES
NEW RESIDENTIAL. ELECIR SQ FT.
RAN 95Q. FT.
property who builds or improves thereon, and who draw such work himself or Nrough
his awn employees, provided that such improvements arc not intended or offered for
sale. 11; however the building or imprwernenl is sold within one year of completion, 'he
eeloulder will have elm burden of Proving that ho did not bund m improve for par-
�°""`n'"
❑ L a% owner of pmpen,e am exclusively connecting with licensed commencmrs In
TOTAh:
MAR 2 9
999
QTY. PLUMBING PERMIT FEE
orernct he praj«I (Sec. vow. Blume,, and Pmfcasion Cade:) The Catamount, U.
ave Law does not apply to an owner of pmteny who builds or improves lhereoq and
who tannins ser snob Fmjena will, o connacmr(s) licensed, ... limit will. Contractor's
License law.
I am exempt under Sec. . B & 1' C for this reason
Y
PERMIT ISSUANCH LQ
AUTER -DRAIN & VENT- WATER IFA)
Owner Dote
WORKER'S COMPENSATION DECLARATION
BACK PLOW PRDIECT. DEVICE.
�/�YrYA�•
VWW
' IDarby aflnn under penally of oneo,oncol lie fallowingdcclarm Ion s:
❑ I have and will maintain a Cenificam of Consent o self -insure forWmkers Campce.
DRAINS -FLOOR. ROLE AREA, GOND.
STORIES
TYPE CONSTRUCTION
saimn, as provided for by Seakine 371X1 of the labor Code, for the performance of the
work for which this permit is issued
Q
FIXTURES - PER TRAP V
❑ I have and will maintain Warker's Compensation Insurance, as required by Serino
3900nf the labor Calc. for the lw,ft .... come of the work for which this pcnuil is issued.
GAS-ITA.SYSTEM-I INC.40UTLETS
OCC. GROUP
_3P
GAS -ITA.SYSTEM-OVER 4EA)
My Workc%Q Cyryyty' 'er nd Policy numb
Camicc �1�V OXY, nlicy No.: r C�
l/
CERTIFICATE OF EXEMPTION MOM WORKERS'
COMPENSATION INSURANCE
GREASMNDUSTRI. WASTE INTERCEPTOR
BUILDING DIVISION FEES
GREASE TRAP
PLANCHECK PEP.
(This section need not be completed if the permit is formic hundred dollars(3101)
or loss.)
SEWER - SANITARY - STORM BA, 200 FT.
ENERGY THE
I certify that in Neperfmrmaneenf the workfrwhieh dais permit is issued, l shall
mariner so as to becomsubjecn e Workers' Counter-
ploy any peon in any manbecome subject th
not emrs
WATER HEATER W/VENT/ELFCTR
GRADING FEE
Notion laws of California. Date
Applicant
SOILS PEG
NOTICE TO APPLICANT: If, error milking this Ceniticate of Exemption, you should
became nobjer, m @e Worker's CmnpenNoaion provision. of the Labor Cade, you must
WAI ITN SYSTEM/I'RIiA'TING
PAID
Date Receipts
y fmnharm comply with such previsions or permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a consrmaion lending agency for the performance of
0 the work for which this permit ix issued (Sea 3099, Civ. C.)
Landers Name
WATER SERVICC
NEW RESIDENTIAL PLMB. SQ. IT.
I
to Ill AI.:
Lender s Address
BUILDING FF.E
1.1 certify that 1 have reed this application and state that the obese information is
r, cmancOlagrectocomplywuhallcnylndcoumynNinas and stutclawsrelatingm
building construction, and hereby au@nriee representatives of Nis city m en¢r uMm rhe
oho e.neernioncd property Ino insparinn pmpmses.
(We) agree us wve, maternally and keep hornless the Ciry of Cupertino against
Iiabilirics.judgmems, costs and expenses which may inany way acerve against said Ciry
- onscquenceoflhe ingmfthis permit.
UN .' ANDS I 'ILL COMPLY WITH AL1, NON -POINT
QTY. MECHANICALPERMIT FEE
I
` PERMI'T ISSUANCE
ALTER OR ADD TO MF.CH.
iE
AIR HANDLING UNIT (TO IB(NIfI CFM)
E
V
U NS.00,
((
AIRfIANDLINGUNIT(OVP.R 141N111CPM)
ONnew
fPLICANT
of Applicaa C Dan
HAZARDOUS MATERIALS DISCLOSURE
Willthe applicant or future huildingmcupxmsmeser handle hamrdous material
EXHAUST HOOD(WIDUCT)
IGATION .E
HEATING UND('1'0100.000 HI Of
as dclumd by the Consortia. Municipal Cade, Comoro 9.12, load the Ilovhh and Safely
Calc, Section 2553200) l
HEATING UNIT (OVIiR 100.000 11 TO)
VENTILATION FAN (SINGLE RESID)
❑Yes ❑Nn
PAID Date Recalls It
e Will the applicant at future building oaupvnt use ryuipment or devices which
mil hamodous air conmrommat, as define) by the Bay Area Air Quality Managcrunl
BOILER - COMP (TOP OR IU9JNIa BTU)
TOTAL:
BOILER-COMP(OVER 1000)( OU)
Disvlcll
E] Yet ON.
AIR CONDITIONER
ISSUANCE DATE
I have mill the hasnlous materials requirements under Chapter 6.95 of the Cali-
Form Health & Safety Cak, SeetionY705.15533 and 25534. 1 understand that if the
NEW RESIDENTIAL MECH. SQ. ET.
bulldiugdd snmament hove oleo: Jhat it is my mnrymsibilirytunmify rho occupant
of 11 Ircme s muFr Friar In issuasee of a Cerill" ems Ckcupa ey
'Z
ISSUED BY:
TOTAL:
woes, ambo ttJ ug n Date
OFFICE