99120071 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY A4::- aW
CITY OF CUPERTINO - BUILDING-ELECTRICAL RMLTN U.
BUILDING DIVISION APPI,ICA'f10N/PERMIT PLOMBING.MECHANICAL ppW '
IfUILDING PROJECT IDPNI'IFICATION �Dp1l
BUILDING ADDRESS: SANI'T'ARY NO. ATION SUBMITTAL.DATE
S 2cv [� d/flEZ 2 -751 `
OWN 'S NI is E: CON❑RACIOR:S NAME: J� ��JJ IICNO:
l /l ./ NIC CONTROLg
s
RCHI'ECL'/IiNGINF.P.R: LIC NO: ADDRESS: ❑
CONTACT. PHOS: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby amen that I am licensed under previsions of chapter 9(commencing - JOB DESCRIPTION
,0„pZ with Scnion'lOtNBofDivisinn7ofthe llusinessand Pmmeoms Caie,and my license is pF.NMI'f ISSUANCE RF,SIDENTIAI-
LLD in 1.11l mceand elTect. []&FOWL. []KITCHEN REMODEL
=UU Liccnac Class Lic.M APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
�<� Date Commmor
ARCHITECTS DECLARATION []MULTh UNIT []MODIFSTRucICATION PANELS ODIP
z bpr/ZZ Iuad....und my plans eIts][he asci as public records ICA'TION
UPTO 200 AMPS
OZ—O ❑INTERIOR [I CHIMNEY REPAIR
F--I- 201-1000
AMPS Licensed professional 201-10AMPS - IMPROVEMEM' []SWIMMING POOLS
S y P j OWNLiR-BUILDER DECLARATION OVER Paul AMPS []BAT]I RGMODEIJRFPAIR []DEMOLITION
3g z dd''a I hereby aBlrm that I tin exempt I.mn the Contractors License Law for die
U following remora(Section 7031.5,Busimes..nd Pmfessimms Cali:Any city or county SIGNS ELECTRICAL ❑OTHER
R13 LL i" which requires a permit ra construct,rd,,innpmre,demolish,or.,it any svucm
I re a
F�•Oprmou,icsinamwo.alsorefers,theappµcadtorsion pennumfileo signed statement atent SPECIAL CIRCUIT/MISC.
•.1 that he is licensed purauam to the provisions ofthe Cement/s License Law(Chapter 9 _
- ORO (mnuncncing with Section](NNp of Division3ofthe Business and l'ndessmao'Co,e)or TEMP.METEROR POLEIJST/ COMMERCIAL; �
6 Ex c C that he is exempt therefrom and the basis for Ne alleged exemption.Any viol......of - ❑NEW BLDG/ADDITION []DEMOLITION
Way Section 7031.5 by any applicant for a permit subjects the applicant a civil pewhy of POWER DEVICES ❑TENANT' ❑FOOD S17RVICE
gz. nor more than five hundred dollars 55000, IMPROVEMENT
XxG E:1I,ns nwncndthe prnpsny,or my cmployws with wngcs os thcirsolc wmpemminn, SWIMMING POOL HLP,CTRIC '
will do he work,and the structure is not irncnded.,offered(., to(See 7B ,Business []OTHER
ad 3 m and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-Ft UR SI
property who builds er improves thereon,tad who does such work himself or through
his own nnp ,provided rovided than such InTim cments.'e not intended or offcaal for NEW R eSI DENTAL IILNCTTt SQ IT.
sale.If,however.the building or improvement is sold within one year ofcnmpletion,the' SQ.IT.FLOOR AREA S/SQ.FL'.
owner-builder will have the burden affirming that he did not Wild m improve for Pur-
gr.cy moos J.
rpoof, caner of the progeny,vm endusivdy convading with licen.ed convacmrs m
construct the pr.ject(Sec.]W4,Business and Professions Cale❑The Contractors crrmL,wd,I ..proves thereon and QTY. L I
who In.tmctsf rue rejects with a embrasures)licensed porsuamto the Commmors
License1. P HE E
tat er pt B&1'C(.,,his m.Irm
A - ) IN& ENT-WATER'(HA VALUATION
O ter Dam
WOR Lr :S COMPENSATION DECLARATION CE /Q �(•
Iherehy ulhrm ane penalty of perjury one of the following declarations: C/L
❑ lium,and,01 muinminaCenificam of Cansenunsdl'Insum lhr Worker's Cnmpen. N TYPE CONS'1'NUCfION
STORIESsatins,as provided for by Section 370E of the Labor Crile,for the Performance of the
work far which this permit is issued. FIXTURES-PER TRAP
I have and will mainmin Workers C.mpereation Insurancees required by Section
3700 of the lathor Cale,for theatipormurnance of the work for whiehhis permit is issued. GAS 0, SYSTEM IINC.40UTLCTS OCC CROUP APRT
My Workers Compensation Insurance carrier and Policy number art: `/
Carrier. Policy No: GAS-EA.SYSTEM OVER 4(IiA) Q
CI3RTIFICATH OF EXEMPTION FROM WORKERS' ORGSIYJNDUSTRI.WASTE IN TERCEPTOR
COMPENSATION INSURANCE. IWILDING DIVISION FEES
(This section need not he completed i(rhe permit is for one hundred dollars($100) GREASE'TRAP
I'IANCIIECK FEE
m los.)
I certify that in the performance of the work for which ibis permit is issued,I shall SEWER-SANITARY-STORM VA.200 FI'.
not employ any person in any manner so,as ,,become subject to the Workers'Compen- ENERGY ITC
Z
Z sabot Laws of California.Data WATER HEATER WNENT/ELECI'R GRADING PEC
Applicant s
Z NOTICE TO APPLICANT.If,after making this CeriOcme of Es<mptinn,you should WATER SYSTEMITRP.ATING
f•"' N!^ hewers subject to the Worker's Carepensmimn provisions of the Labor Code,yne must SOILS FCL
.kj ry fnnhwith wmply with such provisions,. his is mat shall be d.nord mvokai. WAI'Ell SERVICE.
LLLL Q'
CONSTRUCTION LENDINGAGENCY NEW RISIDENTIAI,I'Lh1B. SQ,PI'. PAID
V 0 1 herebyafirm m
that them iso construction lending agency for the performance of Dore Receipt
LBF the work for which this permit is issued(See.3097,Civ.C.)
OU EAndds Name
Lk7 TOTAL.Line Address -
G i cenify that I have read this application and at th
state the abma
above information is RLDINGr E�\
h rmmO.l agreemcomply wuhall eiryman
d ro.mymdincesantl.mmlows relmimgm QTY. MECHANICAL PERMIT FF:B I
building construction,and hereby amhorPr.o reprwmnatives of this olky�otam'"I'm he - tee;
PEI:
above-m mfikowd property for inspection purposes. PERMITISSUANCE01999
(Wo)agree m save,indemnify and keep tombless the City of Cupertino against '�
Iiahilities,judgmems,costs cad expenses which may in any way accrue agiinstsaid City ALTER OR ADDED MECH.
I.UMBING FF.F.
in nmsnptenw.f th 6rvming of thin pumiT.
AYI'LIC I STANDS AND WILL COMPLY WITH ALI.NONPOIN'f A1µHANDLING UNIT('1'Olo.(NN)CFM) ° HAN'ICAL FEE
SGUas i -( L IONS. .__
AIN HANDLING UNIT(OVER 10,(W CFM) -iVTSPRVCL101G_T
SignumreofApplieun Cmvactor D.c EXHAUST HOOT) W/DUCT) HOUSING MITIGATION PEE
1 RDOUS MATERIALS DISCLOSURE
NTLI Nc vpplic mundanebuildingaacepantmnc mhandlchautNousmatonal HEATING UNITOO 100,0X0 BTU)
as defined by the Cupertino Municipal Cnde,Chapter 9.12,and Ne Ilealth and Safety IICATINC.UNIT(OVER IBd,(NNI BTU)
Code.Section 25532(nl° ,k��J - -
❑Yes fMN. VENTILATION FAN(SINGLE RESID) PAID --
r`
Data Receipt a
Will The applicant or future building necmpvnt use equipment or devices which µ❑LEEN-COMP(311P OR IIXI,ONIBTU)
emir hazardous air commummi s as defined by the Bay Area Air Quality Management TO'T'AL:
Dlstriet7 BOILER-COME(OVER 100,M)BTU) -
[]Yes
AIN CONDITIONER
I hme rend thJI
Mous mmenals rcyuimmcnts under Chapter 6.95 of the C.E. / ISSUA CE DATE
in fl-[Ili 'd
a,Sections 255(15,25595 and 25534.1 understand that it the NEW RESIDENTIA1,MECH. SQ.Pr
huildinge aven renan4 that it is my reepamibiliry to notify he rccupant
mfthe req ra t 1st tpriorm:sumacofirCmiB f euPa
Ow c nam nrincJ agent D c TGIAL: ISSUED BY:
OFFICE