99120096APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY 'LO O 1 to
CITY OF CUPERTINO
BUILDING - ELECTRICAL
IIUII.DING DIVISION APPLICATION/PERMIT r1NO PRNc- T IDENTiFIC
BUILIIING PROJECT IUEN'1'IFICAT[0lN
11 No
7GFLxS
BUILDINGADDRESS.
SAN]FARY NO,
APPLICATION SUBMIITAI. DAf
OWNER'S NAME: GC/' I QO ,a `41f�f /
G K f/ ^/
CO AQj()R' NAME:
f/✓1 J
NEC
❑
CONrROL#
IT A7 LIC NO:
AILD ' _ ,r — / _• �_. (#f�'
-t
' NTAUl
11 -DING PERMIT INFO
,PHONE:
� 3 ! v , / �
Fuses Pa
❑Consultant Fuses Paid by Applicant (Initial)
87 ELr:Cy PLUnty nIF:C/FI
VrJA IrLJ/ LSI
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm mat 1 um licensed under provisions of Chapter 9 (commencing
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
/ PERMIT ISSUANCE
with Snnion]IXIUl of llivisinn3o(mc Bu,insxnml ['nrfcssinnscodc anylnyl"cn.xvix
infull fi-re and effec f/O' tea/(
RESIDENTIAL:
❑SFDWL CKITCHENREMODEL
APPLIANCES -RESIDENTIAL
License Clus Lic#
Dam Conlmctm
ARCHITEC I'S DECLA11,01'10
1 nderstanJ my plans shall he used as public rmoNs
❑ADDITION ❑PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
L1 INTERIOR ❑CHIMNEY REPAIR
./,(�MPROVIiMENT ❑SWIMMING POOLS
TA
CJIIAT'lIREMODELdREIR DEMOLITION
❑OTHER
PANELS
UP TO 200 AMPS
Li,emed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I um cxcmpl Crum the Counsel."" Lavin, Law for the
following rectum. (Section 7031.5. Business and Profession, Cade: Any city or county,
2011-1000AMPS
OVER 1000AMPS
SIGNS ELECTRICAL.
which r.,mm, a permit m cmrvinml, .1m,, imp rove, demolish, nr repair any s eemrc
'
SPECIAL CIRCUCOMISC.
prior to its issuance, also lcquims the applicant for such permit to file a signed statement
that he is licensed pursuant m the provisions of the Compactor', License Law (Chapter 9
i (commencing with Section 7000)of Division Sof the Business and Prefic,ion.s Code)or
that he is exempt therefrom and the basis l'or me alleged exemption. Any violation of
TEMP MIET..R OR POLL INST.
COMMERCIAL:
❑ NEW BLDGIADDITION ❑ DEMOLITION
POWER DEVICES
So,don 9031.5 by any applicant for a permit mhjecls the applicant to a civil Penalty of
not moa than five hundred dollars Wool.
EI1, as owner of the pmpeny, nr my muployce. with wages ns their sole contpcnsntinn,
will Jo the work. and the structure is not Insendedorofpercd for sale (Sec. 7044. Business
❑'TENANT FOOD SERVICE
IMPROVEMENT
❑ OTHER
SWIMMING POOL ELECTRIC
and Profusions Code The Cnnlpi,na's Liven,, Law docs not apply In an nwocr of
property who builds or improves thereon, and who does such work himself or through
his own empinyeas, pro, ided Thal such impnrvemems are not intended or offered for
v1e. IL bowevee the buildingorimpowemein ix solA witbinonc yearofromplenim the
owns r -builder will have the burden of proving that he did n..l build or improve for par-
OUTLETS - SW ITCHES -FIXTURES
NEW RES I DCNT1AL ELECT R SQ FT: I n A
-TA II�'I
--� SQt FT C' 00
TUI 1
SISQ, Fr.
p.m of vie.).
❑ I,ruowner ofthe
16 1999
J
'DOTAL:
The ods Li-
Sec.70,.a. BexclusivelycontractingwithI)CTheC Corrosives i-
coosuum the project (Sec. Rosiness and
bus
co Ban
ds ori
who nrainummu Banco. =it
Law does not o on rty who
QTY. PLUMBING PERMIT FEF.
whoeinchin Ives,tnerofpropeny
who contracts for such in Ives wise u pmlmmor(s) licensed pnrxmm Io the Commaor'x
License law.
❑ I um exempt under Sec. .Bk PCfonhis rcasvn
/ PERMIT ISSUANCE ' V
ALTRI-DRAIN & VENT- WATER (F,A7
Owner Dam
VALUATION
WORKER'S COMPENSATION DECLARATION
13ACK FLOW PROTECT. DEVICE ILI-
I hereby allirnt under penally of perjury one of the following declarations:
041
DRAINS- FLOOR, BOOR. AREA. COND.-all
I have andwill maintain aCertifrcarof Consentm sdf-msumfor Worker's Compen-
station, as provided for by Section 37W of the "No Cotte, for the performance of the
STORIES
TYPE C(INSTRUCfIC
work for which this permit is issued
FIXTURES - PER TRAP
Fl I have and will maintain W'orke(s Compensation Insurance, a, aquirW by Section
is
My ofthc L; hnr ode, for the,,`6 anemd me work fur which l�
rk envr'in lsss n car^ wLlcy �0
GAS-P.A.SYS'IP.M-I INCA OII'1'hHTS
— OCG GROUP
N
Cn...... No.
GAS- EA. SYSTEMOVER 4(EA)
le
U
� �� y
CERTIFICATE OF EXEMP110N FROM WORKERS'
COMPHNSA'I ION INSURANCE
(Tcis section need not be co ndened ifthcpcmtil is forone handsel dollars (8100)
,it u,")
GREASFIINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION ETES
GRF.ASF'I'NAP D
PLANCHECK FEE
SEWER -SANITARY -STORM EA. 2W FT
lic,trythat in the performince.fthe work for which In, permit in issued .[,hall
not employ any pbrain in any manner so as to become subjecuo me Workers Croatian -ENERGY
IEE
WATER HIiATEk WIV ENI'IELIfCTN
,no. Lows of California. Date
I Applicant I
GRADING FEE
j NOTICE TO APPLICAN"C If, m, making his CeniEcme of Exemption, yon should
' become mbject to the Worker's Compensation provisions of the Labor Cotte. you must
WATER SYSTEM/IREAT[NG
SOILS FEE
WATER S17RVICE
I'orhwith comply with such provisions or this pernot shall be deemed revoked.
CONST RUCTION LENDING AGENCY
NE RES[DECCIALPLMB. SQ, Fr.
PAID
jIhaebyaRnm mm them is. ..... auction lending agency fort he peforrour.of
Dom Rccciptn
t the work for which this permit in issued (Sec. 30197. Civ. C.)
TOTAL:
1,pocr's Name
Lender's Addrece
TOTAL:
1 cer ify that 1 have read this applicationand state that the above information is
BUILDING FEE
correct. Iagree mcnmply with all city and county ordinances and state laws relating to
QTY. MECHANICAL PERMIT FEE
, building construction. and hereby authorize representatives of this city to enter upon the
SEISMICPEE
obore mentioned property for inspection purposes'
(Wel agree in save, indemnify and keep harmless the City of Cupertino against
PERNU I' ISSUANCE
ELFCI'RIC FEE
I inhilities, judgments,costs and expenses which may in any way scene against said City
consequence of me granting of this permit.
ALTER OR ADD TO MECH.In
PLUMBING PER
AIR HANDLING UNICILMJ
'1'(TO 10.00(
MECI LW [CAL FEE
APPLICANT UNDIES'FANDS AND WILL COMPLY W'IT'H ALL NON OINT
SOIy/µCE REG(' . TIONS yds
�V /y
AIRHANDLINGUNI'I'(OVER 10.000CFM)
CONSTRUCTION TAX
SigmnumofAPp cz OCo.upoo ale
IIA[ RDOUS MATERIALS DISCLOSURE
EXHAUST 11001) fWIDUCT)
HOUSING MITIGATION ITE
HEATING UNIT (TO 100.000 BTU)
Will the applicant or future building occupant store or handle hazardousmatedm
ax defined by the Cupertino Municipal Coale, Chapter 9.12, and the Health and Safety
Code, Section 2553210]
HEATING UNIT LOVER lull" BTU)
❑Ycs [2 No
PAID -
VENTILATION I-AN(SINGLE RES[D)
Will the applicant or furore building occupant use equipment nr devices which
I hmnrdous air comaminanls as vainest by the Bay Area Air Quality Management
)111110?
❑Yes 0 N
aquircmen p
I have mail the hamrdous maarialxis on der Chapter 6.95 of the Cali-
Dmc Rece,pl is
BOILER -COMPDHP OR Wit RTU)
'I(YfAL: 1015.qf
- BOILER COME (OVER I(p,0(III BTU)
Olel
AIR CONDITIONER
ISSUAN F DATE
NEW RESIDENTIAL MECH. SQ. Fr
Cunni, Health A Safety Cale, Sections 8505, 25533 and 25534. 1 understand that if the
build' it notcurrently have t not, met it is my nsponsibilitym nufym uxu nm
oft requirerKcnl. ich mu sect nnrmissmncc ofa epifi t
I—
ISSUED BY:
..."rateri of f Date
TOTAL:
OFFICE