99110051 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PF. MIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDESG.yODRESS: SANITARY NO. PPL.ICA AL DATE
p Jo&A)So/J /}mac _ � (n
OWNIiR'S NA o Syr{ONIi: - CONTRACrOR'S yAME:LES i+ 1'IC NO: NIC CONTROL#
CH I FITC17E NGINEER I LIC NO: ADDRESS: Jl{/ J ❑
-3s,4-5- 506""P P G s•
CONTACT PHONE vBU ILDINGPERMITINFO '
"A is l,/ ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB
MECH
((., D C(7 , ❑ yr ❑
LICENSED CONTRACTOH:S DECLARATION ,QTY ELECTRIC PERMIT FEE
1 nereny alarm mm 1 ton ucensed ander provixmn.t enaln r 9 en _.. .._. ._. l JOB DESCRIPT N
IFOO in full 700goof Division 3of the Business an6dp���c L 1 RESIDENTIAL,
CSFand Iffice J s n ❑SFDWL CHF.#REMODEL
aUV License Clexs Liv#
F6 Date .._R D ❑ADDITION 0PLUMBING RE-PIPE
vi6Contractor /
F.Dh ARCHITECTS DF:CLARAT PA i?LS []MULTI-UNIT [I STRUCTURAL
'�Z_ 1ondcmanJ my plans shall be usrd os blic rev MODIFICATION
Oz"M pu 2 \ '1- EI INTERIOR ❑CHIMNEY REPAIR
F.N..F.WJ Licensed Prufcssinnal tl g�.,,IMPROVEMENT SWIMMING POOLS
�ld�'.4 OWNER-BUILDER DECLARATION a 1 AIpSrAIH RF,MODEIJRF.PAIR [2 DEMOLITION
yy CNC D 6 I hcrcny nrlirm that 1 am exempt from the Contract Licca
k 3 d F following moon.(Section 7031.5,Business and Prol'es.sim G f1E! city or county p ❑OTHER
LLF O m which rnluires a pcl'lnit m cmnsvuct,alter,improve,den alish,nr rmys"'Intica
ret e
qq prier et it,issmatIo,knmgmors the applican toreuchl, q9sm ntt nnthat he i.s l icenscd pursuunuo the previsionsnftheCnnv:ulnater
C (connnencing with$eclion llNlo)of Oivisimn7ol lite flus esu .R P LEINST.that he ix exempt therefrom and the basis for the ollegcsof ❑NEW BLDG/ADOITION ❑DEMOLITION
to
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
W^ren ❑TENANT [I FOOD SERVICE
act done rive thundredty,or (SSW).
F Z Y IMPROVEMENT
=6 0 do the work,the propeny,mmyemes waffereesastheirmle compensation, SWIMMING POOL ELECTRIC
C F•� will Jo the work,and these Commences
intended License a w do s not apply of an Business ❑OTHER
a3
and Professions who
Code:The Contractors License Lowdocsnot apply m I owner of OVI'Lfil'S-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or thmogh
his own employees.provided Nat such improvements arc not intended or oRemJ fur NEN'RESIDENTIAL ELECTR SQ • .
so1c er•the building or improvement is sold within one year of completionthe SQ.FT.FLOOR AREA S/SQ.FT.
w dlh th horde fp ng th th J'J tb 'IJ i p frpr-
5
nn p p nr 1 Ir t t s m l cd con,
ract m TOTAL:
r,nxt r A n Iret 19 7n44 B d P f: c 1 )rn c t :Li. - - .., - .
sal war es nm,pplyt an nwner�rprnpenr n�nm 11s - pnv�s tnere�m nif QTY. d PLUMBINO•PERMIT; ' FEF.
who contracts for such projects with a comracam(s)licensed prourritto the Convector's
License l..I. PIiRMiT ISSUANCE
❑ 1 am exemp under Sec. 2tig .B&P C far this reason
tuner Ilam ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARAI'[ON BACK PLOW PROTECT.DEVICE ^ O
I hereby affirn under penalty of perjury one of the fallowing declarations: D
I have and will maintain a Certificate of Consent n scff insam for Workers Cooper- DRAINS-FLOO]CROORAREA,COND. STORIES TYPE CONSTRUCTION
satinn,es provided for by Section 37M or the Labor Code,for the Performance of the
work for which this permit is issued. FIXTURES-PER'IRAP _
❑1 have and will maintain Workers Cmnpemation Insurance,it,required by Section
3700o(lhe labs,Code.for the performance of the work for which this permit is issued. GAS-HA.SYSTEM-I INC.4 OUTLETS OCC.GROUP
My Workers Compensation Insurance carrier and Policy mumbcr are: L /
Carrier: Policy No,: GAS-FA.SYSI EM-OVER 4(EA)
S'HRTIFICATE OF EX17MVI'ION FROM WORKERS' V 3
COMPENSATION INSURANCE GRuASIJINDUSTRI,WASTE.INTERCEPTOR _ BUILDING DIVISION PHE§ -
flhisxccl oned amt be completedifthe permit is far one hundreddolara(S 100) GREASE'I RAP
or less.) PLANCHECK FEF.
I artily that in the performance of the work forwhich this permit is issued,l shall SEW17R-SANITARY-STORM EA.20)FT,
not employ any person in any manner so as to become subject to the Workers'Conjoint. ENERGY FEE
ZZ satinn Laws of Coli(mmio.Doc WATI7R HEATER WNENT/ELECfR
LD Applicant yyy�ppll�� GRADING FEE
y NOTICE TO APPLICANT:If,afar making this Cenirrr.........___......rrr T: poi�4ayo_ Id N'ATIiySY.GTt TIN SOILS FEE
? become subject um the Workers Compensation pnwisi, lr C&k. 'mu mu t
forthwith comply wieWmI provisions or this permit, t rcvaked. WATER SERWC.
d (1'•'. \`� J AID
r7. Z CONSTRUCOON LENDING A IiNCY - NCW RESID .M SQ.FT. Da Be i t#
UpIhrebyaffirmtan dureisnconstmenvalendin9 ag• fn the.perfonnanceof, r°,
the work lis,which this omit is issue)(Sec.3097.Civ,C.1 ktl f A /�.""<� I "' t
E-t Lender,Name R6ss1 If �'•s\ 1 IOTA
0.L) Lenders Address L—•rt- :1 TOTAL: - ,S
un ly that 1 to a I th ppl at J t t th t d H e Inf mtdt s a IDI l� 1999
ti
y 'uni I agree to ci vply'ifli all I nJ c lY d at t lI reining t QTY AL PERMIT FEE, ..
V Z budding construction,un thereby th ize p hkurtyl mnupon that ( 1 aF;•i SMIC FEE
above memo oned property for abjection pt rTio ,n (yJ.�,.��1���I l tp't F t
(We)agree to save,indemnify and keep he V�:�CY".�����§$LLgqret i ECTRIC FEE
r-t lianilities,judgmems.costs and expenses which maymany way uceme ago".'! TCRy pLTEN OR UTO MECH. ��—
in mmeyuence of the graining of this permit. h1 IiYGtEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CPM)
SOURCE GULATION/// LJ ���/JJ qq MECHANICAL FEE
X
�-f') f/ ����/ AIR HANDLING UNIT(OVER IO,OgI CFM) CONSTRUCTION TAX
iSignam n�nt/Commnnr C/' //� Date / EXHAUST000DOYMUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stare or handle hazardous material til?A'L'INC,UNIT(TO 100,00 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 2553200? HEAPING UNIT(OVER I W.00)BTU)
F-1 Y,, L]No PAID
VHN'I'1LAFION CAN(SINGLE RESID) Data Receipt#
40 Will the applicant or future building occupant use equipment or devices which Hf11LE12-COh1P THP OR I W.IXq RTU)
nit h:mnduus air cormorants as defined by the Bay Area Air Quality Management TOTAL:
District?
❑Yes ElNo BOILER-COMP(OVER 100,000 BTU)
I have reed
the materials rcquirets¢tasunder Chapter 6.95 of the Cali AIR CONDITIONER ISSUANCE DATE
fnmie Health&Safety Code,Sections 8505,8533 and 25534.1 understand Nat tithe NEW RESIDENTIAL MECH. SQ.Fr.
building docs not currentlyhave tenant,droitns
is my respoibility to iffy the occupant a/•�"t31 ' ��
hih m t prior eatf a Ceni icate of Occupanry
( G/
r
(one",wouthorizedemt
of c is wc
Date TOTAL: ISSUED BY:
OFFICE