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S 4383 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING.ELECTRICAL PERMITNO. ..BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL S 4383 BUILDING PROJECT IDENTIFICATION t -- BUILDING ADDRESS SANITARY NO. APPLICATION NSSUBMITTAL �DATE OW 5E: PHONE: CO RACTOR'S NAME: LIC NO NIC CONTROL# `HITECUENGINEER: LIC NO: ADDRESS: -/ � � ❑ CONTAC`T:y- / PHONE: "BUILDING'PERMIT INFO ❑ ns UC / rl f4F)799Y1,196 Compliant FeeF.LECT Fees Paid by Applicant BLDG / a? _ PLUMB MI?ZCH LICENSED CONTRACTOR'S DECLARATION QTY 'ELECTRIC PERMIT FEE �/ Ll 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing _ _. JOB DESCRIPTION O o'Z widiSection700an.f Division 3oflhe Business and Professions CMe,andmy license is F W in full force and effect PERMIT ISSUANCE JOB �� Q V U Licen�,cjops Lic.# smwl_ .f�RITCHEN REMODEL y<G Dale 4- Cmanxitor 3 APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE ARCHITECT'S DECLARATION ❑MULTI-UNIT []STRUCTURALy p v2 Z I understand my plans shall be used as public records PANELS MODIFICATION oz-, UP TO 2M AMPS AIR P4 Licensed Professional ❑INTERIOR ❑SWIMMINGPNEY OL e 201-Mas"AMPS IMPROVEMENT SWIMMING POOLS Y , OWNER-BUILDER m Ce CoohmN OVER 1000AMPS ❑BATH RF.MODEUREPAIR ❑DEM LITTON C Q 1 hereby affirm on I nm exempt Iran the Cosine Co License Lew for the P4 O y U following reason.(Section]onstr Business andmpProfessions ve,de iu demolish, Code:Any city orccture SIGNS ELECTRICAL ❑OTHER GQS lin-C! 9/lAJYIC 3 LL ,which requires u permit to construct,alter,improve,demolisM1,or repair any structure � prior to its issuance,also requires the applicant for such permit to rile a signed statement SPECIAL CIRCUIT/MISC. y } that he is licensed pursuant o the provisions of the Contractors License Law(Chapter 9 00 (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL: L�o K that he is exempt therefrom and the basis for Ne alleged exemption,Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION 4• Section]031.5 by any applicant for a permit subjects the applicant to a civil pemlty of POWER DEVICES ern ❑TENANT ❑FOODSERVICE t mare Nan five hundred dollars 18500). IMPROVEMENT f?G1]Lothe work,the prosany,mmyemplayeeswilhwugesa t[a(S .compensates SWIMMING POOL ELECTRIC will dothewons andtheThe ctumConnector's ,tots License Law does not a ply to an Business []OTHER G3� and Professions Code The Costaereo License Law dins nm apply m an owner.( OUTLETS-SWITCHES-FN`fURES 0 psopen,own who builds or improves thereon,improvements and who tsuch work himself nr through his own employeese provided that such ssolw ore not intended or offered for NEW RESIDENTIAL ELECTR SQ PI'. sale.If,hrcwevee@have the burden orpromnt issoldhe(thinoneildoriumpletiun,Ne 5 �"�'FIA 8/S wneor mlder toil l have the buNen of proving thin he AIA not hotel or improve for par- U post of su1w). ❑I,a owner of the no,erty,em exnusi.aly contracting with licensed contrannra to T v J U L - 6 1999 muuet the pmJect(Sec.]044,Business and Profession Code:)The Contractor's Li- seLaw does not apply toanowner ofproperty who buildsnrimproves doman.and QTY, PLUMEINGPERMIT FEES who contracts for such projects with a contun.,(g)licensed pursuant to the Contractor's License Law. PERMIT ISSUANCE 3 B,l ❑IamexemptunderSa. ,B&PClm#a bmwm Dem ALTER-DRAIN&VENT-WATER(EA) VALUATION WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE I hereby union under penalty of perjury mne of the following dalmations: 1 r> 'J toner I have and will maintain a Cerlficate of Conscnno self-insure for Workers Carman- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONS RUCTION sation,as provided for by Section 3000 of the Labor Code,for the performance of the work far which this permit is issued I FIXTURES-PER TRAP ❑I have and will maintain Worker's Compensation Insurance,as required by Scnion /�. 37000 the Lab.,Cob,for the performance ofine work for whmh,da permits issu d GAS-CA.SYSTEM-I INC.4 OU'ME'IS ( v OCCGROUP APN My Wnrkeg'.Co pen tJD^Icarrierend Poti yin Carrier'�A'��-(s/-n) oPolicy Nc.:� GAS-EA.SYSTEM-OVER CERTIFICATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GREASFJINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES obis section need not be completed if the permit is for one hundred dollars(8100) or less.) GREASETRAP PLANCHECK FEE I certify that in the performance ofthe work for which this permit is issued,Ivhall SEWER-SANITARY-STORM EA.200 UP not employ any person in any manner so a to become subject to the Workers'Compen- ENERGY FEE Qz action Laws of California.Dam WATER HEATER W/VENT/ELECTR Z Applicant GRADING FEE rr ti NOTICE TO APPLICANT:If,after making this CeniOcam of Exemption,you should WATER SYSTEMOT EATING 1"I hccome subject to the Worker's Compensation provisions of the Labor Code,you moat SOILS FEE rIQ La81 ti forthwith comply with inch provWon,. this permitshal be deemed revoked. WATER SERVICE Q CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,FT. PAID V I hereby affirm that there is v construction lendingagency for the pedonamee of m Receipt# 4. Fthe work fur which this permit is issued(Sec.309],Civ.C.) Lenders Name TOTAL: V Landers Address TOT r -` y1 certify that 1 have read this application and sum Nat the above information is -- - - BUILDING FE 3 V1 correct.1 agree to comply with all city and county ordinances and state laws relining tu QTY MECHANICAL PERMIT FEE V Z building constructions and hereby vuthorrre representatives of this city to enter upon the SEISMIC FEE above-mentioned property for inspection purposes. (We)agree m save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC limilinea.judgmenu,costs and expenses which may in any way accrue against said City ALTERORADDTOMECH. PLUMBING FEE in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TO 10,000 CPM) MECHANICAL FEE SOURCE REGULATIONS. AIR HANDLING UNIT(OVER 10,M)CFM) CONS'IRUCTION TAX HAZARDOUS MATERIALS DISCLOSUR St,moneol'Appllcant/Cmunictur Date IxHAUST HOOD(W/DUCT) HOUSING MITIGATION FRE E Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU) as defined by the Cupertino Municipal Code,Chapter J.12,and the Health and Safety Code,Section 25532(x)? HEATING UNIT(OVER 100,0gp BTU) E3 yes ❑No VENTILATION FAN(SINGLE RESID) PAID _ Date Receipt# Will the applicant orfuture building occupant use equipmentor anawhich BOILER-COMP(3HP OR 100,(100 BTU) n hazardous air contaminants as defined by the Buy AroM Aron Air Quality Management rlml AL' to 9 ❑Ya E]No BOILER-COMP(OVER 100,00[l BTU) e 1 have real the hazardous materials m u under Comm,6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE yuirc p humin Health& fety Code,Sec' s 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT. 77 M1oildingd sn curently have ant.thin his my renpnnvihilltymnotify theoccupnm oft rc1 1 mm it is'uance.toCmifienenfLcetfamy. Owner o mhorized erg m Date TOTAL: ISSUED BY: r OFFICE ZeF. �coKTo� . j ove tel, APPROVED IN ACCORDANCE WITH THE CITY Of ?n���� �� CUPERTINO CODES AND ORDINANCES c� 9 JUL 0 61999 GATE SIGNED __ -_ -__ —�— 6LUG.INSPECTIONDEPARTNILNI This set ut p:;., n'+ cat ons ^r1Os1 CITY OF CUPERTINO be kept cn E,e ; '� "• = t>i,ies and it is un lawful to m�. a . or alterationE on came ti: m - I emission from. the buwllrg �.; C Cupaitino. The p,ng Lhs pear, and specifications SHA•O! be held to permit or to be ar approval of the violation of any provision' If any City Ordinance or State Law, J�MTt 1�Y1 N 6611 q - - ----------- ---- _._. --- n� i � o - � m r � m- T =w1. ti l r0 N Ul -a r ,o `D_ t: N rq1 � r i • 7 LA4 ti .� LiLn N 1 i a � b 1 W Lomg CP y co • "� _ c In Ln i v N Ln � r . . w u i i x � N (.aL43 V\ L 'x �n • � I `r r �n L • • • r M r N cs- \ .. 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