S 0561 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIl'No.
BUILDING DIVISION APPLICATIONAIERMIT PLUMBING-NIECHANICAL S 056q
1
IIUIIAING PRUdECT'IDEN'1'IRIGITION
sANI'IARY NO. AI'PLICA'1'ION$11BM1'1"1'AI.DATE
BUIhDING ADUIi S.
ly A i,-t. rI & no Pte•A0,4 O-IY-97
Ow a? 'S NA :: PHONE: CCNTRAC OR'S NAME: LIC NO:
„u. NIC CONTli01,M
I s�-Slid 4 S. revue
•ARCHIrECTIE GINEEK: LIC NO'. ADDRESS: ❑
CONTACT': PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) HLOG IiLECT PLUMB M1IECH
❑ ❑ Qom_ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hcrtyhaffirm met I an,Eceo,ed endo'nomefch:mtcr Y temttmenwns JOB DESCRIPTION
Cltz witM1 Seaian]flfl(11 ofDivisionJof the❑.,iotas unit Pmlcuinnx Gale,and m}licen:cis RESIDENTIAL:
w Q O PERMIT ISSUANCIi
�Iy,F in lull fora undeueeL. ❑SFDWI, ❑KITCHIiN RF.MODIiI.
,UU hmen,t Chi's Lie# APPLIANCES-RESIDENJAI. ❑AUDI TIPON [w}1T,'DM1IHING RF_P1PE
F Z m Date Comate""
tnQL ❑MULTI-UNIT El STRUCTURAL
ARCHITECTS DECLARATION PANIi1.5
C) Z I undcumnd my plan-still be used.,public rcconls SIODII'ICATION
` yQZ
UP1020OAMPS ❑INTERIOR ❑CHIMNEY REPAIR
W Licemed Profcnsiona 201-100CAMPS IMPROVEMENT �SWIMh11NG POOLS
Q 6 yn
kata following rtasnn.ISmio WNE-BUILinERDE DECLARATION
Cas Liccnsc Law for the OVER 1000AMPS ❑HAITI REMOUEIJREPAIR DEMOLITION
y�f OWNER-BUILDER DEChARA
d O W U dc:Any city or atom El OTHER
LL3[L F' ) Y SIGNS ELECT RICA).
C'.
which requires a permit m consumer,altar,improve.Demolish,or span any xwcmm
OQ prior In its issuance,also requires the applicant forsuch pemtilm file a signed statement SPECIAL ORGIIT/M
that he is lii,awdpe,une ,,the provisinmofthe Contracn ,Lleen,c Lit.(Cbapmr9
�00 (commencing with Section 70000F Us mon Joftc C
hBusiness and Profession, d0nr THMP METE
W moR ON POI I COMMERCIAL'
W a e K that he is exempt themfmm unit the hexa,turtle alleged e,emphon.Any violation of ❑NEW HLDG/ADDITION ❑DEMOLITION
W Senlott703I5 by tiny upplicunt for u permit wbjects the applicant to a civil Penalty of
POWER DL'VICI!S ❑TENANT ❑FOODSIiRVICI?
not more then five hundred dollar,1551X0. IMPROVEMENT
f=0 Q I,as owner of the property.of my employees with wages as their sole compensation, SWIMMING POOLELECT C
[101 HER
ce p. will it,,the w'ork.and thc,lonme is not inoaltalm fficed ter sale)Sec.70I4,Business
3 m end Prnfon,Code:The ConnaeloC,License I..w does not apply m an owns!of OUTIAU S-SWI'CCIIES-1*IX'NRP
e
property who build,or improves thereon,and he Joys such work hirmcfor thn,oih
his own employees,provided that such impeavemenu art not intetWed or offered for NEW RfSIDENTIAI,ELECT R SQ
sal,IL howcvcr,lha huiliingn,impmArtma,a,nlit withinene year oI ma,letinn,the SQ FT.FLOOR TR&\ $ISQ.IT.
owner-builder will have the harden of proving That he did sol build nr improve ins par-
ry se of tole.} PA
❑ I,as owner of the pnspemy.am exclusively contracting with licensed correctors to TOTAL: % D
construct[lie project(Sat.7044,Business and Precisions Cube:)The Contractor's wmI.i- _
c sclodoesnapplytoenowacrofpropmimics and QTY. PI.UMHINGPERMI'1' I FJE 441,014
who contracts]or such projects with a contractors)licensed pursuam to the Contractors
Liacr'c Low. PERMIT ISSUANCE,
(]lam exempt under sec. ,Hit PCfor this maven �u1s. V
ALTAR-DRAIN ffi VEN'T-WA'FEH(EA) QVALUATION
Owner Dao
WOR KER COMPENSATION DECLARATION BACK FLOW PR(yl'IiCT.DEVICE
1 hereby am ffiruad,,nder penalty of perjury one of the fol low in,dntlamtinns:
❑ )have andwill lot by Svli,,e icat of Comsat..Civic.
for Worker's Compere- DRAINS-FLOOR.ROOT.AREA,CONE). )TORIES "1'YP[CONSI'RUCI'ION
aauam r pm h hi pe by Sctlmn 7]01 rel the Labur Gds,lin the perbrntunec of be
work forwhich this panni is issued. FIXTURES-)'Eli TRAY
1 have and will oste,Err Worker's Comp of the
ew work
for
ah m,'mi by tissued
J]IXl nfthe Labor Gak,fonhc performance o[1M1e worA for wM1ich.hire permit.Rmcd, GAS-PLA.SYSTIIM-1 INC.J OOfLICS OCC.CROUP APN
My Wnr Ys )nrcna:ninn mm�ntt nincy lsc:number Carrier. I Policy lacy umber GAS-EA.SYSTEM-OVERJ(EA)
CERTIPICA'TEOFE IMPf1UN FROM WORKERS'
COMPENSAIPON INSURANCE GHEASIJINDUSI'HL WASTE INTERCEPTOR BUILDING DIVISION FEES
(This section need not be completed ifthe permit i,fornnc hundred dollen ISl W) GRF,ASE"TRAP
or Ice.) PLANCHECK Fill
Iccnlfythat in the performanecot the work fnrwhich thispenna isksucL I shall SEWER-SANITARY-STORM ICA.301 FT.
not wnpiny ea,petaun in any Tnanner in as to be.... e,ubjc,l to the Woderx'C epos. ENERGY ItiE
Z nation Laws of C:Jilnmia.Date WAI'17R I IEAI'ER WNEN'17ELECFR
ZApplicant ' CRATING FEE
= NOT ICE TO APPLICANC If.after making this Cenificate relExemption.you should WATER SYSTEM/IRIENI'ING
a ' become white)to the Win ch Cn ifetnminn provisions.P he[-.hot Colds,yo.nm st SOI LX FEE
fonlosith comply with such provi,mrso,mis permit shall be Jcemedoe,oked. ;R SERVICE
a �
r1z CONSTNIICI'ION hENUING AGENCY NEW Hf31DENTIAL PLAIH. SQ.PL PAIU
O Ihereby affirm that them is a construction lending agency for the performance of
U Da,&'-"P1
U F @e work for which this parmil is issued(See.JOY].civ,C.)
Ov U.
Landers Name 'OL\L:
I.1 Icmlcrs Address
Po 1 certify that 1 have read this application and state that the aMave informapon i, BUILDING PHI:
Fy crest,l agate to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U Z huildin,c toon"inn,and hcrthy out Lori m rtpm E uti—of this city In enter upon the SEISMICFE
ahawe-mentioned pmla'rty for innpectien purpom. PERM]I'ISSUANCE
(we).,mem,ve,indemnify and keep harmless the City of Cupertino against CLECIRICP E
IiahilltinJudgn¢ms,enOmale.peme,whichmay inany way mvac agamsOrlid City ALTER OR ADD TO MECH.
PLUMPING PEE
A APPLICANT
c (,RST in of this permit,
APPLICANT ON,DERST DS AND W M ,Y WITH ALL NON-POINT AIR HANDLING t1Nl'1'('I'O 10,0B)CPM) MECHANICAL IEIi
SOURCE REOit w
y H-97 AIR HANDLING UNIT(OVER I U.00DCF\) CONSTRUCTION TAX
K"
em
hemiticontaaor (J Date EXHAUST HOOD(W/DUCT) HOUSINGMITIGATIOf PEE
HAZARDOUS MATERIALS DISCLOSURE
Will tha.ppliaail nr Enure buildingo,,.pant_sore or Imndlc hat-edou,material HEATING ON]T('1O 110.000 IIT'U)
a,defined by the Cupenon Maniciiad Gde,Chapter 9.12,middle Health and Safety
CMc.Section 25532(a)'! HEATING UNIT(OVER U10.010 BTU)
Yc. n No
VENO TI.A'ION PAN(SINGLE RESID) PAID Date Rcccipta
Will the applicant or future Wilding occupant use equipment or devices which BOILER-COMP f3HP OR 110.00 BTU)
malt harmdom air contumimms as defined by the Bay Arca Air Quality Management TI IPL:
Dimri"', BOILER-COMP(OVER 100.000 BTU)
❑Ycx [IN.
I have read the haauNuu,mmeriula ropenoant,ander Chapter 6.95 of Is,Cali- AIR CONDITIONER ISSUANCE DATE
fmmia Health R Safety Code Stniom 25505.25533: 125534.1 andcnemd Thal if aha NEW RISIUENTIAL MECIL SQ FL'.
building does not currently have a meant,that it is my mslaamlbllity,to mnify the occup rd
of the mqueetrcnu which must be met prior it,issuance ref.Ceniticam of Occupancy.
Owner or.mhori red agem Dam TOTAL" ISSUED BY:
OFFICE