99120091 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 12-10 Q
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION A PLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING 1'ROJRCIIDENTIFICATION
BUILDING ADDRESS: // SAIQ FAIRY NO, APPLICATION SUBMITTAL DATE
E-bWb 2_ i� 99
Oµ'NER'S NSA ,T BAPTIS' �G CON'TRACTOR'S NAME: LIC NO: NIC CONTRl1I,p
RC1II'f C'F/BNGINEIiR: IdCNO: ADDR4SS: ❑ -OQ
-'1
CONTAC': PHONE: BUILDING PERMIT INFO
Mi` � C, J _ 1 44
, 4,r� ` ,� ❑ Consultant Fecs Paid by Applicant(Initial) HhDG / / PLUMIIi ME
CH
LICEN�SED�C'ONNTRACTOR'S DECCLL•ARRATION (�/ QTY ELECTRIC PERMIT FEE LTJ/ LJ ALJ
I herchy affirm thin I ant dittnced under provisions of Chapter 9(commencing JOB DESCRIPTION
,C)Z wiN Section]000)of Division 3oRhe Business and Professions Code.and my license is
Fly= in full forceund dfen. PERMIT ISSUANCE TIAL
F SFDWI. ❑KI"TCHENREMODEL
I-ZW License Cluu Contr
Foul Date Qmwaor APPLIANCES-RBSIDENTIN. ❑AUDI'HUN ❑PhUMHING RE-PII'li
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL,
Z 1 unde t d m hall he used as public recmds PANELS
',LOr- Rg#pp rzf'W"ss MODIFICATION
O Z-� X Pro rFp [Asl�+ UPT02ro nMP5 11 INTERIOR
-1 CHIMNEY REPAIR
Fs�Fp'41 Licensed l4ufcssronal 201-1000AMPS IMPROVEMENT SWIMMING POOLS
GY�j '
OWNER-BUILDER DECLARATION Contr ON OVF,R H00AMPS ❑BAI'II REMODEIJRHPAIR 0D17MOLITION
y p(W Q 1 heady vffinn that 1 am exempt s an the Cssions o license city
o for the
x 3
Q.F- following rims a(Section]ons mBusiness improve,
Eve,damns Code:Any city ar man1Y SIGNS ELECTRICAL ❑On HER
F- C which requires a permit re consumer,aper,improve,demolish,orfile
repair any mrucmre �s�
m mionnslicenadpursu,requires previsions applicant for such ContrarmiuofileasLw(Cha mem SPECIAL CIRCUIT'/MISC. �6���
Y Q� thmmalic a licensed pursuant the of D"ionsoftf eBoxi... License Law(Chapter9
(hot he I,xempth Sectionn]Imad h bro,onr ofthee,rdvsxand
m.An Cos.)If 'fF.MP MET'T:RIIR POLE INS'I'. COMMERCIAL'
III o y�q Sent io Is exempt zany applicant
li anJ the naris air the alleged exemption.Any l Penalty oEJ DEMOLI I]ON
f
YN Semon mos by any applicamfor aprmit subjects the applicvnnoacivil penalty Of POWER DEV ICES ❑TE AR G/ADDITION ❑f OI)SF.RVICIi
t more than five hundred dollars($5(N). PROVEMENT
�=Q ❑Las ownernf Ne pmpeny,or my employees with wages as their sole compensmion. SWIMMINGI'OOL ELECTRIC
04.F, will do the work,and the structure is not intended orrilfered for wIn(Sec.]D1A,Business HER
a3$ and Professions Cade:The Cormadorx License Law does nm apply m an owner ofOUTLETS-S HES-FIXTURES Q
property who builds or improves the or.and who does such work himself or through
his own empin,ces,provided that such impmvemrnls arc not intended or 011'med for NEW REMDh LECfR SQ Fl,.
sale.If,however the building or improvement is sold within one year ofcompletion.the SQ.FT.FLOOR AREA $/$Q.FT.
owner-builder will have the burden of proving that he did not build or improve for pur-
poseofsvleJ. �f .M 1
E] 1,m owner of the property,am exclusively contracting wise licensed amunnnrs to TOIAI.: i2404-Sp `g„)V
coast mct in.project(Sec.]OW,Bralnds,and Professions Cede:)The Contmular's
crave Law does not apply men owner ofproperry who builds(ir improves thereon,and QTY. PLUMBING PERM FEE
who contracts for such projects with scontmemrrs)licensed pursuanvo Ne Contractors 444 !�
License law, PERMIT ISSUANCE D
❑ lam csempt order Sec. ,H APCfar thls reason sq/+/Gr(Ip�
—p AUPER-DRAIN R VENT WAFER IEA]
OCL -2-is �j VALUATION
•re WORK :NCOMPEN6ATl NDECLARATION BACK FLOW PROTECT.DEVICE O a
Iherchyalarm under Certificate
to perjuryone oftheimme,following
a,declermions: �.!
❑Ihavc and will for by Section
Certificate of the%cmLab mCode,for
eic Worker's C,of the DNAINS-FLOOR.ROOF,AREA,CORD. STORIES TYPE CONSTRUCTION
cation,as provided for by Section 3]fNl of the Utha Calc,for the perfonnuncc of the
Lwork
]Iherrwhich this rrimmiin issued. FIXTURES-I'IiR'I'RAP
❑I have Sed wild maintain Worker's Comp offla,w rk for hi as ids peed by Section V /�f
MyWo Ne Labor Cadg[or nNsurance canceoflhewlic (number aNix permit is issued. GAS-EA.SYSTEM-]INC.]OIpTLEFS OCC.GROUP g/O p
My Workds Compensation Insurance artier and Policy number am: /,/
PJ
Carrier. Policy No.: GAS-FA.SYNTLMOVER J(EA) g2-30
C[RTIPICAIT,Op EXEMPTION FROM WORKERS' 1`
COMPENSATION INSURANCE (IRGASFJINUIIN'FRL WASTE IMI ERCEPFOR BUILDING DIVISION FEES
(This section need nm he complexed if the penal is fon,nchundred dollars($I W)
or less.) GR BASE TRAP
PLANCHECK FEE
Loy my Person
in the any
of the iorjhNis permit is issued. shall SEWER-SANITARY-STORM EA.300 Fr.
not employ vny person in any manner so a m hecnme suM1jecuo the Workers'Compen- ENERGY FEE
C A,li Lows ar Culifomiq l)t �f��^�Q
Q AOPliCE �-rlI✓ WA'1'F:R HF.AI'ER WNENT/ELIiCI'R
�I GRADING PEE
.~N.r Nt]TIC,.hj APPLICANT:rs for making t pr Gestin m of Exemption,you should WATER SYSTEM?BEATING f�---�-�
1"S , become subject m Ne Wnrkcr's Compensation provisions minor labor Calc,you must 1 /,-SOILS FET:nWATER SERVICE
aQ
forthwith comply with such provisions or misPermit shalt he m
JeeedrcvokeJ. nI �.Z] u
CONST RUCTION LENDING AGENCY NEW RESIDENT IAL PI-MB. SQ.yr V' PAID
U O l hemby mfinn dud mere is a eorarnaian leading agency far the perfor na ,c nr ceipt 4
W N the work lin which this peril is issued(See.30197,Cie C.)
O U Lender's Name TpTpl,:
Lender's Address TOl'A1.:
0. I certify that 1 have mud this application and state that the arrive infommdmi d, p BUILDING FEE
ti
fn correct.I agree n,comply with all city and cnamy ordinances and state laws miming to Q'fY. MIiCHANICAI.PERMIT 8 EEE .
U � huildingunnsimctinn.and hemby vuNorizamprenenmtivesnl'xhiscitymenterurym the -� mm.,
idame-menlioned property for inspection purposes, PERMITISSUANCE I
(We)agree m cave,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
lamPiria,judgmcnts.carl-nd expect¢x which may inany way accme against said City AL'FERORADDTOMECU
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WELL COMPLY WITH ALL NON-POINT
SOURCE RI .UI ATIONS. 4 AIR HANUI.ING UNIT(To 10,000 CFM) MECHANICAL FEE
x ,� t ' �_l�� AIR HANDLING UNIT(OVER 10.000 CFM) CONST RUCTION TAX L4
SignmGre OfApplicanVC=mr KKKiii Date EXHAUST HOOD(W/DULT)
HAZARDOUS h T" IALS DISCLOSURE: HOUSING MITIGATION PEE .�
Will the applicam Otfnwrc buil mg uccupam sem Or hunJlchazardous mamrivl HEATING UNITPID I(gk00011'1'U)
as defined by the Caperlino Municipal Code,Chaplet 9.12,red the Health and Safety
Code,Section 25532(s)P HEATING UNIT'(OVER 100.00)B'I'U)
r]YO, Fl No VENTILATION I'AN(SINGLE BESIDE PAID -
Uvte Receipt#
_ the applicant or fmbuilding occupant use equipment or devices which BOILER-COMP(3 HP OR I00d)(1O BTU)
mit hazardous air crimnminanxs a as defined by the Bay Amu Air Quality Management TOTAL:
District!
❑Yes r-1 No BOILER-COMP(OVER 100,gX)BTU)
I have mad the hazardous materials is under Chapter 6.95(if the Cali- AIR CONDITIONER
requirements n Ater ISSUANCE UA'I'li���fff
fomie Hcephm Safety Cndc.Nations25505,v,nnyand 255)].1understand Nat upant NEW RBNIDBNTIAI.MECH. SQ.I'I'.
or theng Nes nm currcn0y hove o mnvm,the t it Ix my responsibilhy n,nrnify She hareem2 15
ar Ne reyuirem' with nest beme}slpior m issuance rife Cenifcme of Occupancy.
�� s -��
mhorirM egem Date TOTAL: ISSUED BY:
OFFICE