B 0400 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL 1 /p�PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL 50001 O -T O o
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY IK). APPLICATION SUBMITTAL DAI
1p �r� C S=/2_
OWNER'S NAME: V PHONE: CC '"[A�e Ntr Ah 1{y/over y LIC NO:
(( t ; NIC CONTROLp
• ARCHITECT/ENGINEER: LIC NO'. ADORES ���� (��J,t ❑
rCOMIAC PHONIi �3--�30 BUILDING PERMIT INFO
Cm Igaillanl Teets Paid b Appllca9t(Initial) BLDG :LEC'1' PLUMB MECH
LICENSED CON CT R:S DECLARATION QTY. ELECTRIC PERMIT FEE
y allimr thm 1 an lice rued under pmvi+ions.I Chapter 9 fcommencin6 JOB DESCRIPTION
Z000)oMBvislon 3 oflbc Business mid Profession.Code,and my hccnae i, RESIDENTIAL
O PERMIT ISSUANCEF- ud c((ect 2 ❑SFDWL ❑KITCHEN REMODEL
aVj Lic.N APPLIANCES-RESIDENTIAL ❑ADDITION Cl PLUMBING RLPHF
his zC-i Dntc Cnnvacmr
RCHITECTS DECLA 1
E3 MULTI-UNIT ❑STRUCTURAL
PANELS
z0o,z I understand my plans shall be used as public records MODIFICAUON
Oz=O UPT02MANIPS [I IN] [}CTII�NHY REPAIR
F.,W Licensed l'mfcssinnaI 201-INMAMPS IMPROVEMENT L]SWIMMING POOLS
Cad OWNER-BUILDER DECLARATION OVER 1000 AMPS El BATH REMODEVREPAIR [I DEMOLITION
C C Q 1 hereby affirm that I am«empt from the Contractors License Law for the
E:0 c.V lonowing rcvson.(Section 70315.Business and Professions Code:Any city or county SIGNS ELECTRICAL C1 OTHER
W 3 W y whi,h,c,,ae,a pernit m connntn,uher,improve,Jem.Inh,in repair any xvunvm
pno,to its mmajor.al.eo requires the applicam foroich permit to file aligned naRtne.l SPECIAL CIRCUIT/MISC.
E y that he is licensed pursuant to the provisions of the Conuanors License Law(Chapter 9
�a G� (commencing with Section 9tJlq).fDivLsiov3 of the Business and Pr.fersiors CiiJeptr TEMP.METEROR POLL'INST. COMMERCIAL:
m 0.o y that he is exempt therefrom and the basin for the alleged exemption.Any violation or ea. BLDG/ADDITION ❑DEMOLITION
x g LL Section 703 L5 by any applicant for a permit subjects the applicant a civil penally of POWER DEVICES
ad�,� tt ❑TENANT ❑FOODSERVICE
F-=Q
not more than live hundred dollar,D500). IMPROVEMENT
❑I.;is ownerof the property,or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC
F.O will do the work,and the nmcmre is not intended or offered for sale(Sae 7044.B sines. UITIFR'
W w and Protract...Gyle:The Onuacmrs License Lew'does not apply to an owner of OUTLETS-SWITCH17S-FIX]ORES i �P. �..
ts'3 property who Wilds or Improves thereon,and who docs such work himself or through
his own employers,pmvidcd that such improv,ri am not intended or offered for NEW RESIDEN'UAL ELECTR SQ FT.
aide.If,hoverer,the building or improvement is sold withioonc yearid,nm,lo a,'he SQ.FE FLUOR AREA SQ.IT.
percr-bmlder will have the Kooken of proving that he did not Wild or improve for par. MAY 12 1999
e.f,ala.).
1,an owner of the property,am exdmlvuly comment,with licensed contractors v, TOTAL:
V'
cense La the es but (Sec.YDLI.Business and Professions ds ori The esntmnor.Li
se Llwdcesnmapptyu,an with
aofpropeny whored pursuant to the Contra andors QTY. PLUMBING PERMIT FEE By
wM1n cnnmucts for writ projeeln with a ttnnrucnn(,)licensed pursuant t.the Commemth
Liccnsc law. PERMIT ISSUANCE
Iamexerrimmocr .Sec. ,B&PCfmthisrcns.n
Owner Dvm AI.IY.R-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE O
I hereby affirm umfcr pcnalsy of perjury one of the following declarations: Q
❑ Ihavcaod will mvimaina Ccnificntc of Conant to self-insure for Workce,Compcm DRAINS-FLOOR,ROOF,AREA.COND. ST IES TYPECONSTRUCTK
vain.,as provided for by Section 3700 oldie Labor Code,fonhe pe rho mancc.I'the
ark for which this permit is issued. FIXTURES-PERT RAI'
E] I have and will maintain Workds Compensation Insurance,as required by Section
3700 of the baht C.it for performance ofthe work 6r which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS
My Workc' rppc 'trot ncc cu rand Policy. t r OCC.GROUP I N
Cartier: a Policy N..: 9 GAS-GA.SYSTEM-OVER4IEA) �e'1 I C� 10
CER'1'IPICATEOFEXEMPTION FROM1, ..KERS' OREASUINDUSTRL WASTE INTERCEPTOR
e/\
COMPENSATION INSURANC17
(This sesui a n.ed not he completed irme,armat isfornnc hurtled dollars($100) BUILDING DIVISION FEIS
art less.) GREASETRAP
,caul,Lha in Thu performanee.f the work forwhich this permit is issued,I shall PLANCHECK FEF.
n.t empl.ymypcmm w
in mi nnnuro, so) mm
We. ceuhulthe Werke,Co.,.- SEWER-SANITARY-STORM EA.21X1 FP.
Z sa.mLawsof Califomia.Date j ENERGY ME
Z O Applicant 1 WATER HE W/VENTB;LECTR
GRADING FEE
NOI.Na
become
TO APPLICANT 11:alter ranking this provisions
cme.f FLabor ion,you should WATER SYSTEM/TREATING
a , �rine semis,to the Wrnker'n Compensation erniit ha)of the Lubin Calor you man SOILS FEE
fEl forthwith comply with such provisions nr rhis permit shailhdecmed revoked WATIiR SERVICE
7z CONS IRUCTION LENDING AGENCY NEWRESIDENTIAL PLM1IB, SQ,17. PAID
L) O herchy rte thin there i.vued(Sec.30lending agency Ponheperfornnnec.f Dar eeiptM
� F the work for which this pmnit is issued(Sec.3tly'/,Civ.C.)
O v Lender's Name 1, FAL
r Lender's Address TOTAL:
I,enify that 1 have read this.pplivation and state that the above information is BUILDING FEE
F'f�il rnrtect lagree mc.mpy with all city and<oamy.Ninan,cs and vac laws rclming ai QTY. MECFlANICAI.PERMIT FEE
U Z building construction.and hereby authvriec representatives oftbis city to enter ul.mthe SEISMICPEE
uMrvo-mcntioned pra,oy for inslsectiou purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep hamlese the City of Cupcnino against ELECTRIC FEE
liabilities.jadgmems,cost and expenses which may inany way accrue against out City ALTER OR ADD TO MECH.
mscyucnec nl the grunting of this permit. PLUMBING FI?E
APPLICANT UNDERSTANDS AND WILL PLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,00(ICFM1U
SOU�/�,y/p'GULATI Nn MECHANICALFEE
V/�/ C �✓ AIR HANDLING ONIT(OVER 111.01X1 CFM) CONSTRUCTION TAX
Si,mamc.fAp1 temesComuutof v Date EXHAUST HOOD(W(DUC) HOUSING MITIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building meta m store or handle M1aeadeus material HEATING UNIT LTO 10OL Xl BTM
as defined by the Co,,"ma. pal Code,Chapter 9.12,and the Health and Safely
Cala Section 25532(a)9 HEATING UNIT(OVER 1110.000 BTI)
❑Yen'
is
VENTILATION FAN(SINGLE RESID) PAID
Dm. Rmcipt is
Will the applicant or future building occupant use equipment or devices which BOILER-COMP IIHI'OR I00,IXX1 BTU
cmil limousines air conmminanu an defined by the Bay Area Air Cattily Management )
District'! BOILER-COMP(OVER HI0.IXIBBTU) I V
E]Yes �Nn
1 have read the bwarJnus materials AIR CONDITIONER ISSUANCE DATE
regmmauem.under acuter stand that df,he �^
brain Health&Safety Code.Sations 255(15.25531 and n 4.1 understand that if the NEW RESIUF.N'TIAL MECH. SQ FT. l 2-
mu. ,
n
FuilJi ly have ateamt,that it is my bility m andify the occupant 7
ofilm ahr, is ntnpdormi.r enlfiwle of[scar ncy.
Ownersor audmri dagent Date TOTAL: ISSUED BY:
OFFICE