99100118 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY G� LAL�1
CITY OF CUPERTINO Bm1.mNc-ELECTRIcnI. —r ITN
BUDDING DIVISION ON4APPLICATION/PERMIT PLUMBING-NIECIIANICAI.
BUILDING PROJF.CT iDrNTIFICNfIOM _ �BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAALDATE
/DERSNAMEPHONE: CONTRACTOR'S NAME: f+ LIICCNNO:
�(L 6/� J 16A.IS rs61 N/CCONTROLp
RCHITGCTTNGINEER: LIC ADDRESS:
CONTACT PHONE: , BUILDING PERMIT INFO
Y'\ S p 4rI°klls 83.T �S11-P1� ❑ Conevltanl Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MELD
31
ElzV ❑ EJ
LICENSED CONTRACTORS DECLARATION QTY ' ELECTRIC PERMIT' FEP,
1 hereby offrm that 1 am licensed le Provisions.of Chapter 9(comms mg JOB DESCRIPTION
QWZ with Section 7phap cf Dmtsion 3 ofthe BusitiessisdefPfssiom Ode,und my license is RESIDENTIAL•
n full fora and a PERMIT ISSUANCE
W p;; ❑ADWL ❑KITCHENREMODEL
U O License las Lie,#
H,x infi Conimdor APPLIANCES-kBSID[?NTIAL El ADDITION ❑PLUMBIKITCHEN BETTER
ARCHITECT'S DECLARADON - ❑MUUH-UNIT El STRUCTURAL
p no rz Iunde - PANELS
ZOyj mand my plans shell be used as publle records MODIFICATION
O
UP TO AMPS Z'^❑ ❑IN'PROVk ❑SWCHIMNEY MINGPREPAIR
Licensed Professional 2111-I OLID AMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DBCLARATION
OVER IWOAMPS ❑BATH RP.MODEL/REPAIR El DEMOLITION
C 1 hereby affirm it,.[1 am exempt from the Conamphor's License Law far the
iW5 6 U followiun reason.(Section 7031.5,Business and Professions Code:Any city or aunty SIGNS ELECTRICAL ❑OU IER _
W y which requires a permit m construct,alto,improve,demolish,or man,any structure
In to its issuuna,aEorequire-a thoapplinat period,peran.file stunned smmmam SPECIAL CIRCUIT'/MISC.
y that he is licensed pursuantintheprnvisinnsofthe Contractor License Law(Chapmr9
(amrmarter,withSection 700abol'Dlvision3efineBu,iness and Profes,inn,Code)., TEMP.METER OR POLE INST. COMMERCIAL'
that he is exempt therein i and the basis for the alleged exemption.Any vlolieion of ❑NEW BLDG/ADDITION ❑DEM0I.11 ION
^ Section 9031.5 by any applicant for a permit subjects the applicant to a civil Fenahy of POWER DEVICES
w ❑TENANT ❑FOOD SERVICE
c not marc than fee hundred dollars y employee,
IMPROVEMENT
X�0 ❑ Lo the work,the pmpeny, remyot intended withwrad for their Sec. 044,8 sines' SWIMMING POOL ELECfkIC
?• will do the work,and the structure is natimendedomfferedforsale(Sec.]044,Business ❑OTHER
Wand Professions Coale:The Contractor's License Law does not apply m an owner of OUTLETS-SWITCHES-FI UR
.. his o ny who builds or improves thereon,and who fines Such work Kiri _
M1d own employees,provided,m such improvements are not intends d I F
sole.ILhower will have the Impirpnnement itsold be aid rou arborf m Or SO FT.FLOOR AREA $ISQ.FT.
Ros er-builder will have the harden of proving that he did urn harbor r p
Rose of sale). -
❑ 1,os Owner of the proper,,um exd.,waly Contracting with licemel cont rs to ALr
construct the project(Sec 7044,Business and Professions Code:)TheContra 's LI-
emmse Law dons not apply m an owner of property who huildt or improves the PEE
who convects for such projects with a wmmemgs)licensed pursuam to the Ca
License Law. i SU
acm
❑ I am exempt under Sec. ,B&P
wrie Dna A k VALUATION
WORKER'S COMPENSATION DECLARATION PL k0 QCT.DEVICe ,
I hereby affirm under penalty ofpeglury one of the following dedaretiene: U Q
❑ I haveand will mainmina CeniOcnte nfGmsentwself-inwre for Workers Gmmpen- DRAINS-FLOOR,ROOF,AREA,GOND. STORI. TYPe CONSTRUCTION
stairs,as provided for by Section 3700 of the Labor Cole,for the performance of the
for which this permit is issued. FIXTURES-PE TRAP
w 1 have and will unchain Worker,Compensation Insnrna,as required by Section
.]00 ofihe Labor Code,for the performance ofthe work foPolicy Orr which this permit
tiiss issued, GAS-G.SYSTE .4 OUTLETS OCC,GROUP ANN/�
Cy Workek mippJns rtic Poly No.: �v • GAS-EA.SYSTP VER 4 BOO G]
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEONDUSTRI, NTm 'Ok
(This section need not he completed if the permit is for one hundred dollars D100) " s ' r BUILDING DIVISION fp ES
or lest.) GREASE TRAP P•<NCH ECRETE
I emitrythat In flue erforrnanceofthe work for w rich this permit is issued,Lshall SEWER-SANITARY-STORM q
not employ any person i oy man 1 so xytpe j to the Workus'Compeu- EROY PP,F
O z salion Laws of Cal' at N .— --- WATER HEATER WNENT/ELECTR
z Applicant GRADING FEE,
h NOTICE ICAVE after making this Cenificute of Exemption,you should WATER SYSTEM/TREATING ES R3C
h became w to the 's Compensation provisions of the Labor Code,you mutt
Qfonhwim amply with such provisions or this permit shall be deemed revoked. WATER SERVICE
az CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB SQ IIT.
U O ' I hereby affirm that them it a construction leading agency for the pprfommaose of d, -Date. R aipt#
V. r-I the work for which this Nerit is issued(See3097,Civ.C.) m
O U Lenders Name T a3 I A
W Lenders Address TOTAL JE I rffy tht Ih dth: ppf t d,rit thtm b f tons BUILUNG IEE'(p cort t l get comply ith II ty do ty J c a J t t t ng m QTy.- MECHANICAL PERMIT t F
U build gconstruction.u Ahenhy uu@acre ep Senn tivestfth'9 city to entenapon the SEISMIC I'EE
above-mentioned property for inspection purposes. PERMIT ISSUANCE i
(We)agree m save,indemnify and keep harmless the City Of Cupenue against I_ FjLP.O'I'R161iP.E
liabilities,judgments,costs and expenses which may in any way arcane against said City ALTER ORADDTD MUCH,
in asequence of the granting ofthis permit, PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT AIR HANDLING UNI UTO 10.000 CFM)
SOURCE REGULATIONS. - MECHANICAL FEF.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of ApplirnData EXHAUST HOODjWNUC9) HOUSING MITIGATION NEE
HAZARDOUS
MATERIALS t,dm handle
Willy(lieCpe,('..futurehuilI Cinc Ch tt 912 had to Hadth anmaterial HEATING UNIT(TOIfN1,OfN1BTU)
as defined by t25 Cupanino M. Ipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)" � HEATING UNIT(OVER IW,OW BTU)
Yes 0 PAID
VENTILATION PAN(SINGER RBSID) Dam Receipt#
Will the applicant is nts a buildingoccupantthe B use ea Air Qat or devices which BOILER-COMP(3IIPOR 100,000 B'ru)
Droit hazardous air conmminants as defined by me Bay Arca Air Quality Management - '1'91FAL:
Diatrie.m 1Ae .. .
❑Yes - ' BOILER-COMP(OVER 100,1100 BTU)
Ihave read the haznrdoos materials regvircmems under Chaptu 695 of the Cali- AIRCONDITIONER ISSUANCE DATE
foria Hca t &Safety Code,Seel s 25505,25533 and 25 I-understand that if the NEW RP.SIDENI IAL MECH. SQ.FT.
bnildinn docs mac responsibility to notify the eacupant
of the requirect put to inseams ofa Cenireme of cup ey. C�
Owner thorize em are - TOTAL: ISSUEDBY:
OFFICE