99120046 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI'T'Y OF CUPERTINO BUILDING-R1,HCTRICAL - PERMrr rva
HDILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL, it Q90
BUILDING L'ROJLi6T LI11iNi9f1 CATION'
BUILDING AUDRR.SS: SANMRY NO, API'LICATIONSUHMITTALDATE
070 364/kvD2 12 - •
DWNE 'S NAME: PIIONE: CONTRACfOR'SN ML+: LICNO. NIC CONTRULX
ED Oki e ❑
ARCHITECT/ENGINEER: LIC NO: ADDRESS.
/O 4) lvr/1 SS S/2
CONTACT: PHONE: BUILDING PLRM1TINFO
❑ Consultant Fees Paid by Applicant(Initial) BLD ECECf PLUMB MECH
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC Puma FF11
I hereby affirm Nat I an licensed under pmvirmre of Chapter 9(commencing JOB DESCRIPTION
WQ a'Z with Section 7006).f Division 0.fthe Bminevvixi Pmfee,mru Code.and my license is RESIDENTIAL'
ftlOp PERhITI'ISSUANCE
F nfvn force andc0e ❑SFUWL ❑KITCHPN REMODEL
�UU Limnsc lass - hicp 'S5`S 2- APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
�naiDate — Commetm
i ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
ZpH❑ L understand my pIbm,1 II hammdas,amic mends PANELS MODIFICATION
H
OZ'.Q UL'T02W AMPS El INTERIOR ❑CHIMNEY REPAIR
E+{3[gm Lkensal professional 201-IINXIAMPS IMPROVEMENT E]SWIMMING POOLS
q;tA g•-•l OWNER-B c pa,2 m CLARATION OVER IOW AMPS 1 ❑BATT{REMODEURITAIR El DGMOLI'I']ON
LRJ W I hereby affirm that 1 um exempt G.m the Contractor's License Law I'm the _
y p y U billowing rcasnn.(Section 7031.5,Itusionss and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER _
'3 e Pon,,.which requires a permit to coreareci.offer,improve,demolish,or repair any nmre clu
F-�OQ _
^ Pono its iss...ce.alsa requires the applicant fortieth fit..signed smmmem SPECIAL CIRCUIT/MISC.
O-J
.��} that be is licensed pursuant m the previsions(tithe Contactors License Law
W yp0 (commencing with Section 7")of Divi"mr,3 ufthe Business and Professions Code)or TEM,.METER OR IY)LF.INST. COAIAIERCIAL'
d 1x c M that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W�.y Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of POWER DEVICPS 0TT:NArrr ❑FOOD SERVICE
nmore than five hundred dollars S500. IMPROVEMENT
F G ❑ I,os owner of the papery,or my mnployee,with wages as their sole compensa+ion, SWIMMING POOL BLECI'RIC
no
will do the work,and the sweture is not inwb&d or offered bustle(Sec.7044,Imoticxe ❑OTHER
14, and Professions Code:The Cmumcuo'x I......m Luw dues not apply m m+owner of GUTLHTS-SWITCHI?S-p1%'TURES
prnpeny who build,or impmvcy'herenn,and who does such work himself or Through '
his own employees,provided tam such improvements um not intended nr offcmd lou NEW R&SIDEM'IAI.131.IiC'I R' SQ FT.
sale.IL however the building or impmvemmat is sold within one year ofromplelum,the SQ.FT.FLWRARI?A $/SQ.FT.
.wnerbodder will have the burden of proving that he did not build or improve for at.
form of sudet.
I,as owner of the property,am exclusively contacting with licensed co micion to TOTAL:
consume,the project(Sec.7144,Business oad Professions Code:)Tbe Comacmr.LI-
cenxLawdresnotapplytoannwneroffmfeny who builds or impnrvez Nerenn,anA QTY, PLUMBING PERMIT FEE
w'h.contracts for such projects with a carnations)licensed pursuant to the C marucmrs
Liovd a Use P AV /VI
I on exempt under Sec. .B&P C for this
VALUATION
Owner Data
WORKER'S COMPIiNSAI'ION DKLAR MON CK P L': 'I'.Its I
I herchy affirm under pwtalty of perjury one of the following decl.mforl:
Q l have and will maintain.,Cenifcam orcersen to self-insure for Worker',Cn'npem ( tli ] S RIES 'L'YI'ECONSTRUCI'ION
cation as provided for by Sedian 371X1 ol'tbe Lnh(tr Crile.lolthe perfor.nmce o1'thu -
work lorwhich this permit isisseed. F P /
I have and will maintain Workers Contaminate Insurance,as required by Section
3700af Ne Luber Code,for the pvrtiomanec fthe wnrk far which thisp.it is issued, fiAS-FLA.SYSTEM-11 C O S OCC GROUP 9 A
My Worker nm - tion vane,carrier and Policy nutter A. i (Iowa ( _ _
Currier.F Polley FROM
CERTIFlC I N FROM WORK[RS'COMPENSATIONedenctINSURANCE C 5 S' I RC HULLOING DIVISION PEf:S
('this section need net berompleted ifthe permit is(Loon,hundred dollars(SItX)) GREASETRAP
it lesx.l PhANCHECK FEtl _
I verify then in thepevinourecalthe work for which this permit is issued,I mail SEWER-SANITARY-SJOB EA.200 FT.
na employ any pers.0 In any mannersu mm become subject to the Workers'Cnmpeo. I LIRGY FEE
O'z smion Law,of CaH1.mi..Dote WATHR HEAT HR W/VIINTIIiLI!CI'R GRADING PEC
O Applicant
NO7ICH TO APPLICANT:IL after making'his Cenificate'If Exemption,you should WATER SYS'TEMfI'RHAI'I NG SOILS PEE
a ; becmne subject to the Workers Com,m,mionpita kind,of the Labor Code,you most
Forthwith comply with such provisions or this penni'shall be decmedo,tiked WATER SERVICE _.
0.
CONSTRUCTION com mtom NG AGENCY NEW RFSIDEMDAI.1'LMB. SQ, PAID
V Thereby affirm that there isaamstaninn lending agency for the ped'ormoncc 0f F Dae ReceiptM �1
{4 E•-' the work for which this penult is issued(Sec.31197,Co.C,I r 1
Lcndcrs Name TOTAL3i
IULI Lenders Address TOTAL: �^^
Cy 1 verity that I have read this application and spm that the ubme information is
N correct 1 ugrce m comply with Ill city and cnumy oNinonces and state lows relating to QTY. MECHANICAL PERMIT FFI3
V on,and herchy unth.rir.e nprmssmutivex of this city m,mer tpnn the + SHISMIC FCE
buildingcons+adi
dor-ou n0unud prnpeny for inxpec'Inn purpose,. I
(We)agree m a..indemnity I keep huonlnsx the Ci' f Cu r lin against PEBMI'f ISSDANCG ECI!C'I'RIC PEE
6 Yen+ P strove
Pe b _
incon,et,jrreafthe lossind exlwnseswhiah'nuy in any way accac against said City gLTI!N OR ADD'D)MIiCIL PLUMBING FEE-
msCANTe of Nu Ranting of this Permit.
. APP (CANT UNDERSTANDS AND WIL1.COMPLY WITH ALL NON-POINT ALN HANDLING I1NII'(TO IO,IXN)CI>M)
l�-I�y� MECHANICAL FEE
A, /�REGII 4TIq:X$
(�,\) i.,-6-99 AIR HANDLING UNI'I'(OVIiR IBOW CFM) CONSTRUCTION TAX
Signamm.fApplicvmCmmxcmr Dam MIAUST HGOD(W/DUCT) HOUSING MITIGATION FISH
HAZARDOUS MATERIALS DISCLOSURE
Will tMapplicant or future building sxcuparn,uncnr handle hamrd.mu material HEATING ONL'I'ITO I(gIXXI BTU) -
as defined by the C.,mro Municipal Code.Chapter 9.12,and the Health and Safety
Cade,Section 25532(a)? HPATING UNIT(OVER 1011,000 OTU)
❑Yet F1 No VEN'L'ELATION PANS I NGLI!ItHSI DI PAID
Date Nmeif'p
Will Ilse applicant or future beilding occupant use equipment or devices which
ends ho.nNnus elr contami.unts os defn+md by the Bay Area Air Q..Ihy Management BOILER'-COMP(7HP OR IIXI,IMX)BTU) - ,RHAi.
District'!
❑Yes ❑Nn HOLLER-COMP((')VL'R I110,(g013TU)
I have read the hmnrdoasmutetials requiremcnfe under Chapter 695 of Out Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Code,Sections 25505,M533 and 25534.1 onderstaal Nm if the NEW RESIDENTIAL MECH. SQ.FT. - 12--
� ^/� 4
building does not corten0y haven tenant that it is ivy responsihilay to notify the accupent r
.f the requhemcnts which most M RRt prior to issuance of a Cenificmc of Occupancy.
Owner or authorized agent Dole TOTAL ISSUED BY:
OFFICE