S 2906 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
BUILDING PROJECT IDENTIFICATION 2906
BUILDINGADDRES4 SANITARY NO, APPLICATION SUBMITTAL DATI
,loS S pj
OWNER'SNAME; PHONE. _ CONT ACTOR'S NAME: LIC NO
�J NIC COMI'ROLN
NCHITFCI' EER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECTPLU B MECH
ID 11 ❑
LICENSED CONTRACPOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby alum that I am]located under provisions of chapter 9(ennumencdng JOB DESC ION
WOO with Section 900mm Division 3ofthc Busimm�s and PrnfesxinncCod,,and my llecnsc is 'I11
WOO C PHRMI"f ISSUANCE
Idain full force and effect .L -� FDWL ❑KITCHEN REMOUEI.
�ZUU Date eC 7� Lic.p APPLIANCES-RESIDENTIAL DADDITION ❑PLUMBING RE PIPIT
NQ6 Dulv`----� Cnnlf< r
.^pp ARCHITECT'S DECLARATION PANELS OMDLTI-0NIT OSMOODIFDIFfURAICATIOO
N
Z p in Z I understand my plans shall M used as public records
OZ—Q UPTU200AMPS DINTERIOR OCHIMNEYREPAIR
F4LZ Licensed PmleWcoil 201-1IIXIAMPS IMPROVEMENT OSWIMMINGPOOLS
g�a
tie7; OWNER-BUILDER DECLARATION OVER I(gN1AMPS D BATA REMODEL(REPAIR 0DEMOLITION
ar m Q 1 hereby affirm that 1 am commit from the Commences License Law for the
O p U. followins broom.(Section 7031.5,Busines and Professins Code:Aryciy m entintySIGNS ELECTRICAL
DX+ 3
0V1whcKrmt m contmct,ar, ntr emosre o t t X0
4dk�
Fy � SPECIAL. e
�;!IQ�
In.,lot licensedp mart th p r : fd C t t I License law(Chapmr9 COMMERCIAL
W��0 (cnn meneng with Sedan7000TofDivision 3nflFe lomoressand Profess.Code)or TEMP.METER OR POLE INST.
6 y C that he is eaempt therefrom and the hasis far the alleged exemption.Any vinlmion of D NEW BLDG/ADDITION ❑DEMOLITION
LLXJ {vy Section 7031.5 byanyapocint mrapermitsubjectstheapplicannoucivil penalty of POWER DEVICES DTENANT [I FOOD SERVICE
'
t:it more than five hundred dollars($500) IMPROVEMIiN'T
2p ❑1,an owner oOheprolwny,nrmyempinyectwith wages ustheirsota armPcnsmion, SWIMMING POOL ELECTRIC
$y� will Jo the work,and the stmmure is not intended orolfered for sale(See7014.Business ❑OTHBR
a 3 and Professieno Code:The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
Fropeny who builds err improves thereon,and who does.such work himself On through
his own employees,provided that such improvements are not intended or uttered for NEW RESIDENTIAL ELECTR SQ FT.
sale.IL however,the building or improvement issoldwiminoncyearofcompletian.the SQ.IT.FLUOR AREA SISQ.IT.
owner-builder will have the harden of proving that he did not huild or improve for pur-
pose of ants.).
C11,at owner of that property,am exclusively contracting with licensed commemrs m TOTAL:
omsaaa the project(See.9114,Business and Provisions Coda)Me Cammctnr's Li-
craw Law does notapply in an owner of property who builds or improves thereon,and QTY. PLUMBI PER FEE
who eomnmts for such projects with a mmramooO licensed pursaans In the Convectors
License Luw. / PERMIT ISSUANCE
D I am exempt under Sec. .B&P C lir this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION HACK FLOW PROTECE DEVICE
( l hereby alfinn under penalty of perjury one of the following declarations:
❑ I have and will maintain aCenificam of Consenuoself-insarefor Worker's Comperr DRAINS-FLOOR,kOOF,AREA.GOND. STORIES TY PE CONSTRUCT 101
.sminn,as FrnviJed for by Swetion 39110 of the Whwsr Code,far the per amentice of the
wo for which this Permit is issued. FIXTURES-PER TRAP
I have and will maintain Worker's Compensation Insunmee.as required by Section
-100of the lrbor Code.rnr the Polmomnccafhe work fur which his permit it issued. GAS-EA.SYSTEM-I INC.4 OUT LETS DEC.GROUP ANN
My Worker' Com ens tit, Intl Fm'c cact��i55r and Policy nam4r or
Inmcr: UPolicy No.:�% 99a W-1 GAS-EA.SYS'TEM.OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEIINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
fThit senounced not henrmplemdnine permit,,Intone hundred dollars S EXT GRP.ASETRAP
or less)in FET:
I certify that in the performance ofthe work for which this Permit is issued,l shall SEWER-SANITARY-STORM FA.200 FI'.
not employ any wrom in any manner so as m become subject to the Workers'ConaNn- ENERGY FEE
Oz soon Laws of Califomu Date WAI ER HEATER WNM IMLECTR GRADING FEF
z 0 Applicant
f-+ 71 NOTICE TO APPLICANT:EL utter making this Cenific:um of Exenmtion,you should WAT17R SYSTEM"ll INE
F' hecto is subject m the Worker's Com enmtioa f the La om Cale,you must SOILS FEB
d n provisions
forthwith comply with such provisions onhis permit shall be devoted revnkeJ. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NIiW RESIDENTIAL?LMB. SQ.FI'.
LJ 0 (hereby affirm that there is a construction lending agency for the KTArnmoceof O' 0 kecep N
(•-t the work for which his Permit is istued(Sec.3097,Civ,C.) 0
0 U Lender's Name r 'TI>I'A_ l
W Lender's Adii TOTAL: "] S0
0. certify that 1 have mad this application and stare that the above information is INC[JFla 3 1999
In correctI g.o,cmunly withal]city and county orrl'munces and.state laws relating In QTY. MECIIANICAL PERMIT FTE g, MICFEE
UZ building consunc0on,and hereby authorize repmon,nve,of this city to enter upon he
above"nicntionwl propeny for inspection purposes. P[RMI'I ISSUANCE
(wa)ogree m save,indemnify and keep families he City of Capenin,against li.F. RIC FEE
Iiahllitics.judgmems.c...smadespenci,,which may irony way accrueagaintt said City ALTER OR ADDTO MECH. P
in consequence of the granting of this permit.
APPLICANT ON DH RSTANDS AN O WILL COMPLY WI'OI ALL NON-POINT AIR HANDLI NO UNIT(TO 10,0010 CFM) MF:CHANICALI F.
COUk��l S. Z/C"
AIR HANDLING UNIT(OVER 1(I,lbII CPM) CONSTRUCI'1 N'r
gaan�Applican mvecmr alter E%IiAUST'H(IOD(WIDU("I HOUSING ON FEE
HAZARDOUS MAI ERIAI S DISCLOSURE
Wlllheapplam,or future building wcuparcm b or handle trradous mnreriad HEATING UNIT(TO 10(1,000 BTU)
u defined by he Cupertino Municipal Code,Chapter 9J2,and the health aM Safety
Cada,Section 2553im)'t / BEATING UNIT(OVER 100,IX1)BTU)
❑Yes �fst VENTILATION PAN(SINGLE RISID) PAID
D or Receipt It
Will the applicant or future building occupant use equipment or devices which BOILEk-CO IP(31 IF OR I(m.00i BTI)
mil haarlmom air moment nacos as dcfimed by the Bay Arca Air QwJity Management T
District? BOT LIE-COMP(OVER IUk(KKI BTU)
[:J Yes
I have readthehmurdsm5 nmmriaks myuiremems umfer Chapter b.95 miler Cali- AIR CONDO ISSUANCE DATE EGG+++
humin Health&Safety Cale,Sections 25505 ta
J 25 and 25534.1 undersnd that if he NEW RESIDENTIAL MECH. SQ.PT.
huiliing does not currently haven ten s yresponsihility to notify rhe acnrpant
0 the requirements whiehmuvt ul�' r)p+w9nee ofa Certificate of OccuPuney.
Owncna authnriud agent / �z l Dare TOTAL ISSUED BY:
OFFICE