99070015 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLYPEKMIrOU J
CITY';}F CUPERTINO BUILDING-ELECTRICAL T NO.
BUILDING DIVISION APPLICNI'lON/PERMIT PLun1BrnQ,MECHANICAL
BUILDING PROJP:CI'IUENI'IFICATI08 MOM
BUILDING ADDRESSSANITARY NO. APPLICATION SUBMIPEAL DAFT
0003 LaK 064"C , � 9 - Y ?
OWNER'S NAME: S � rAC/gttSSSIFS LICNO:'
NIC CONTROL11
t'Q�C_ OG_351
_ 6 �
GHITECTn;NGINEEW LIC NO: ADDRESS: ❑
CONTACT': PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
❑ P" ❑ C�
LICENSED CON'FRACI OR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9 oxmmmucing JOB DESCRIPTION
�S�ZO with seniors]IX0)..f Division)of the Business and Pmfcssions C,de,and my liccnu is ` p RFSIOENTIAI_
W O PERMIT ISSUANCE J
1 'n lull Lace and cited. [ISFOWL E)Kit REMODEL
'CLU Class Lica APPLIANCES—RESIDENT'IAl. ❑ADDITION ❑PLUMBING RE-PIPE
F Z W Dae Cummctor
,n6a ARCHITECTS DECLARATION ❑MULT-UNIT ❑STRUCTURAL
F-Z I ondcrsmnd nmr plans mall be used as public rocmds
PANELS MODIFICATION
OZ4O OP TO 200 AMPS 1 ❑INTERIOR ❑CHIMNEY REPAIR
W Licensed Professional 2014000AMPS IMPROVEMENT ❑SWIMMING POOLS
�,1 J
OWNER-BUILDER UECLnRATIONOVER 1000AMPS ❑BATH REMODEUREPAIR EIDE MOLITION
C 4 1 hereby affnn that I am exempt from the Contractor's License Law for the
X 3 i U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL [_1 OTHER
til LL H which requires a permit to construct,alter,improve,demolish,or repair any structure
0 aion..lbi....ece.nlaon,.i..the applicant for such permit to rile a signed stalamcm SPECIAL CIRCUFUMISC.
f�Y that he is licensed pursuant to The provisions of the Contractor's License Low(Chapter 9
11yO� (commencing with sa,ion]OW)of Divizion3 o(,he Business and Professions Cal<)or TEMP.MITER OR POLE INST.
L a c COMMERCIAL'
C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
XmLL Scxyion]IIJLS by any upplicum Tnrvpv7n1it slhjcde the vpplicam macivdianolty..f POWER DEVICES
❑TENANT 0
to not more than five hundred dollars(5500). IMPROVEMENT
FOODSERVICE
G=O ❑I.as owner of the propcny,or my employees with wages as their wle compensation, SWIMMING POOL ELECTRIC ❑THER
(.. will do the work,and the ntrumurc is not al,ndednrnffcred Onside(Sec.](H4,R.,uaw
13 20 and Poolsoons C,de:'rhe Cn dowim'e Ll....e Law does nm apply to an owner of WTLITI:S—SWI'FCIIES—PI%TURES
pmpeuy who builds or improves thereon,and who docs such walk himself or through
his own employees,provided that such improvements one not intended or offered for NEW RESIDENTIAL ELECTR SQ E-n
,dr.If.howevc,the huildcaneringar in:provcntenl is a old wlthlnoic,ew of complctian.me QELPLWR AREA J USO.FT.
-builder will have the burden of proving that he did not build or improve for par-
vis \ 7
, e 4'le.). TOTAL"
x\]
properly,
r of the ton exclusively contracting with licensed contractors,a
11
.........cT fw projec,(See.7044,I livair s and Dot'asions Coda:)'Me Commaors JUL 2 91 99
Li- I L.I I D
c se law docs not apply to an owner of progeny who builds or improves thereon.and QTY. PLUMB P: - IT FEE Lr
who contracts for such projects with a contmctorc)licensed pursuant to the Contractors L
Liccnac Law. PERMIT ISSUANCElam exempumder,Sea .B&P C tarthis reason
Ilse ALTER—TRAIN&VENT—WATER(EA) Uta VALUATION
WORKER'S COMPIINSA'TION IIECLARAI'ION BACK FLOW PRTr;CT.DHY 11
Fire
herchy alllnn under penally of perjury one of the following drelorationa
❑Ihave amt will mainminaCenifcam nfComm�uoself-inmmfor Workers Comped- DRAINS—FLOOR,ROOP,ARd.0 STORIES TYPE CONS'IRUCF10N
.mien,us provided lar by Section 3"100 of the tabor Code,far the performance n[the
work lar which this permit In ixwcd. FIXTURES—PER TRAP
❑1 have and will maintain Workers Compensation Insurance,as required by Section
37M of the labor Cede,for thepeformunce of the work for which this proton is issued. GAS—EA.SYSTEMd INC.40UTI.MS OCC.GROUP ZAPN3Z
My Workers G oo,cus tion[a...unce earricr and Puliey number ma: DD
Currier: Poli1Y Nu.: GAS—EA.SY$'FEM-OVIiR 4
Chat IFICA]'I;OF EXI;MPTION FROM WORKERS' GRGSUINDUSTRL WASTE INTERCEPTOR O
COMPENSATION INSURANCE BUILDING DIVISION FEES
(TM1i,,ou need num be cotnpldod i(the permit is fm'one hundred dnllors(EI01) CRHASI?TRAP
or less) PLANCIIL'CK FEE
IGenii,that inthe arymrntroo,thework for which gle,loths,W kJo;'C,ishall SEWER—SANITARY—S'FORM EA.2110 FT.
Oil employ any person in any manner so as m become subject m the Workert Cumpen- ENERGY FEF:
Z sation l.awx of Cxlilin nor.Dam WATER I IEATITR WNENT/ELECTR
Anglican, GRADING FEE
Z
z h NOTICE TO APPLICANT.It,after making this Cer ificme of Exemption,you should WATER SYSTEM/TREATING SOILS FEE
F� ? become subject o the Worker.Compensation provisions of the Labor Code,you mus,
to dociM comply.,,It such provisions of this permit shall he deen¢d revoked. WATER SERVICE
Z" CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMH. SQ.FT. MAID
Vp1crehy affmthat ico,is a congmtion lending agency for the performance of Dam Receipta
F ,he work far which this permit is issued(Set.3097,Co.C) T'AU
0 Lender's Name TOTAL:
sI' {ULl I,cndcr's Addtcss
0. 1 Gro fy Lha,I have tool la,nP Awalior and rile'hill the aNvc'm Runuution Ta BUILDING FEE
E" N c nett 1 ugmc us nsmply with all city ane county ordinances anJ senate laws relining m QT'Y. MECHANICAL PERMIT FEE SEISMIC FEE
UZ building coronation.and hereby cartoon,representatives of this city to enter upon the
above urnTlood propcuy for inspection Purp..ees. PERMIT ISSUANCE .J� ELECTRIC FEE
(We)ngive h,cave,mdmnni lY and kccp hurinle,the CIT,al Caped lno ag.inst
hairlines.judgments.costs and expenses wbicb may in any way seem,against said City ALTER OR ADD'R)MECH. PLUMBING PEI;
in consequence of the gmn,ing of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT AIR HANDLING UNIT(l010,000 CFM) MECHANICAL IEE
,S'OURCP R� ONS.
SSS11TL
AIR HANDLING UNIT(OVER IU.XNI CFM) CONSTRUCTION TAX
ignawre nl'Applicunl/Qmtrmnor Ilmc EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building rccupantstore or handle hoeardous material HEATING UNIT'(TO 1(0,100 BTU)
as cultural by the Calcium,Municipal Code,Chapter 9.12,and the Health and Safety
Calc,Sri,iun 25532(ap HEATING UNIT(OVER 100.100 BTU)
❑Yes ON. PAID
�: VENTILATION -AN RESIU) Date Receipts
Will the uppl leonun l al are bnlldingoccnP.n,use equipment or devices which BOILI?R—COMI'(xHP OR 100,000 BTU)it torturous air aonWmmant as delined by the[lay Arca Air Quality Managanen, TOM)
DionrO BOILER—COMP(OVER IW.000 DTU)
❑Yes ❑No
I have read the hemrdous nal ic turcomnts under Chapter 6.95 of the Cali- AIR CIINUI'1'IONHR ISSUANCE DATE
famiv Health&Safety Cede.Section.25505.25533 and 25534.1 undersand that if flue NEW RESIDENTIAL MECH. SQ.FE rY
nanniTmgdyF,nm entre ey lmave.tcnant.mmitmnmyres,vmnain'Tli,y,a na6ry me oceans^t /
ofthe re�,1p,C whennmaxt h�.+w1jualmiloonee ofaeenlream nroeenp.ner.
Yl�il it (i L•---�. T
watt, outhorited agent Dam TOTAL: ISSUED BY:
OFFICE