S 2857 — -APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPF.RMIT PLUMBING-MECHANICAL.
BUILDING PROj HCF IDENTIFICATION
RUILDINGADDRIE:SS: SANITARY NO. API'LICATIO9917 DATE
/40003 Lt. L 14, Y-8- 99
OW SESAME:
Sm PHONE: D S CON[ CTOR'S NAME12o / 1q, r4 E 1C N{D
N/C CONTROL#
R HITECDENGINEER: LIC NO ADDRESS, ❑
/c6??-7 5„Q- ,dnat 61V.A—
CONTACT: PHONE: BUILDING PERMIT INFO
�• h� ��_O6 ❑ Cons'ullant Fccs Paid by Applicant(Initial) BLDG ELECT PLUMB
MECH
11
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby eflirm That I not lice...under provisions of Chapter conmmrem, .1013 DESCRIPTION
O C',g whh Sociom]Blhllof Division 3ofthe Emacssund Prnfeader,Cnde,and my license is RESIDENTIAL:
F,= in full force and,ffnl. PERMIT ISSUANCE
ly— ❑ADWL ❑KITCHENREMOUCI.
�UU License Clan Conte APPLIANCES-RESIDEN'T'IAL El ADDITION $IT.tlMHING RE-PIPIT
on Z= Dam TS DECLARATION
C ARCHITECTS DECLAkAT10N ❑MULTI-UNIT ❑STRUCTURAL
g.7 y PANELS
y p w- understand my plans shall used as pnhlic records MODIFICATION
024O IJI'TO NIIIAMPS ❑INTERIOR [I CHIMNEY REPAIR
F'Ld Licensed Professional 201-1000AMPS IMPROVEMENT C)SWIMMING POOLS
Q Y f J OWNER-BUILDER DECLARATION ❑RATE REMODEDREPAIR ❑DEMOLITION
yC C� I hand,affirm mm I am excnau fear the Con,ecm ”
I,,',Licvve Law for the OVER 1100 AMT'S
off,U following mason.(Section](131.5,Business and Professions Code:Any Cil,or county SIGNS ELECTRICAL El OTHER
613 LL H which requires a permit to construct.alter,improve,demolish,or repair any structure
I"�-at priorm its issuance,also requires the applicant lin such permit m file.signed statement SPECIN.CIRCUIT/MISC.
yThatheisllcenlod, rsmatudiclarnvi....mafThcContr..on,Licenxa Law(Chapter 1)
f+I�aO SO 0mmmereingwith Se"ion]tggq of Division3of the Business and l'ndessions Coder or TLMP.MITER OR
POLE INST. COMMERCIAL:
d q o tL that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Tact 4. Sande.90315 by any ap,hran,for a perutsnh,i.1,the applicam to u civil vackyaf POWER DEVICES []TENANT ❑FOOD SERVICE
rn a mom than five hundred dollars(5500#.
F Z Y IMPROVEMENT
_< ,i Luc¢work,the prnpcnrum,is ,,,an eeswith rood 1 as.lei(Set. 044.Beaioq SWIMMING POOL ECfItIC I
0: well Bothe work,and themacumre isnot intendW nr rRorcdlio eala0Sre9034,Rusinms DOTTER
I m and Professions Code:The Connector's License Law does not apply to an owner of OUTLETS-SW I F.S-ITXTURLS JO/A�
property who builds or improves thereon,and who docs,ach work himself or through
his we employecn,provided that such improvements arc oat intended aro offered far NEW RESAorTIAI,ELECTR SQ IT.
rale If,however the building ortmpmvvarwat ie sold withii
nane yvar.1 cols:..,the SQ 17.FLOUR ARRA LSQ.FT.
nerbuilder will have the burden of proving that he did not build or improve for pur-
pose of,ilad.
I,as owner of The property,am exclusively careening%an licensed comn¢mrs to TAL:
o...reci The puma"(Sec.90,14,Business and Pmfessiom Coda)The ComuncenT's LI-
nseLaw dersnot apply toanowner(if property who builds or improves thereon,and QTY. - PL ERMIT FEE
who contracts for such projects with o comm"ags)licensed pursuant to the Contractor's �•
License I,aw. PERMIT ISSUANCE -5o
1 am exempt vale,Sec. .B&1'C far this reason
A LTF.R-DRAIN&VENT-11AT (I. VALUATION
ar
,. Owner Dae
WORKER'S COMPENSATION DECLARATION HACK PLOW PRUI'F.CT.DEVICE
1 hereby of en under penalty of perjury one of the following declarations:
"' ❑ I bavcaml will maintain a Certificmcof Ccmcm mself.ir,mc for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TY PECONSTRUCTION
salon,os provided fm by Section 3900 of Ile Libor Coale,for the pedamunce of mho /
work for which this permit is issued. PI%TURBS- 66T
1 have and will uminmin Worker's Compensation Insurance,as required by Sactive EL'S nn'' 01
3900 of the Lahr Code,fur the performance of the work For w�hjich this perm !M�it is issued. GbA.SYS C.4OCC.GROUP P
Cyirieor SCo tp m ullplu.cf m^°Poky N,and Y/'^ / G .SYSTEM OV ER 4 IEA)
CIfiRTIFICAd'I�i OMF til% I'TION IItOM WORKERS'
COMPENSATION INSURANCE kill BUILDING DIVISION FEES
(This section needme be rompleed ifthe permit is Enron,hundred dollas($10H GRA$17 TRAP I -less.) PEE
..r Iess
`. I certify that in the performance ofthe work for which this permit is issued,l shall SIT 'ER-SANTI'ARY-STORMF.A.2001"T.
nor employ any pen.a many manner sn as m become,.hjecuo the Workma Compen- ENERGY FEL
O z anti..Lawsof Cdifomm.Date WA - GRADING FISE
z 2 Applicant
NOTICE By APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMn RF.ATING SOILS IF
a ; become subject to the Worker's Compensation prvisinns of the Labor Cale, no mel
W forthwith comply with such.......inns or This permit shall he deenmJ evaded. ' WATER SERVICE RE zo
1
o z
CONSTRUCTION LENDING In AGENCY NEW RESIDENTIAL PLMII. SQ.FT. PAID Da Receipt#
I hereby dithi that there is a construction(See.30 lending agency for the perlrmana of
U 0 the work for which this ponnit Is iaxueJ(Sec.3(19].Civ.C.)
F'mLemirea Name 'TOTAL:
0 La
V LcndetAddress TOTAL: �
'l O a NI
I
�
L.m ccrdfy Ihm have read this upplicnnion nnA stole that the above inl'arnnninn my 1{UILUIN( mliE
ti
Ta/1 comt l agree to comply with all city and county ordinances and state lawsrelaingtu QTY. MECHANICAL PERMIT FEE
<) z hulltlingemste"ion,and hereby vmhnlz<repmuntaivcs o[this city to enter upon the SEISMIC EC
.have-mentioned property fir inspection purposes. 1'E:RM[I ISSUANCE
(We)agnea m save,indemnify and keep harllos the City of Cupertino against ELECTRI TIE
Iiabilitics.judgmetns,costs and expenses which may in anyway accrue against said City ALTER OR ADD TO MECH.
in aansegpence of the gaming ofer rt PLUMBING IN
A PPLICAN'T ON DL RS ND: >WTI,I.COMPLY WITH A I.I.NON-POINT AT R HAN ULING U N IT(TO 10.00 CPM)
SOURCE RIiGUI MECHANICAL FL
�_�99 AIR HANDLINGUNIT(OVHR10d0p0CFM) CONSTRUCTION TAX
Sign eof Appicant/Co for Date EXHAUST HOOD(W/DUCf) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the uppllcanl nr Teem building cccatom,tomor handle luzurdou,nunnial HEATING UNITUO I00,00(1 BTU)
as definal by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
CWe,Section 25532(x)? HEATING UNIT(OVER 11)0.000 BT U)
❑Yes o VENTILATION HAN(SINGLE REMD) PAIS) Use Receipt
Will the applicant or future building occupant use equipment or devices which BQ{LER-COMP 131fP OR I(10,00011 DO
emit hazardous air contaminants as def red by the Bay Area Air Quality'Management pl.:
DLsnleR BOILER-COMP(OVER 110,100 8'I'U)
❑Yn
I hove read the hmurduus material,nea menti under Chapter 695o the Call- AIR CONDITIONER ISSUANCE DATE
Inmia Health&Sagely Cdc,Sections 25 B5, 33 and 2551J.1 undemmd that if the NEW RESIUENB'IAI.MECII. SQ.I'I'. / 1
buildingdaesnotctur yJ,vcale vmnyrestanzihl' n fy�cupant
of the nal oem ( Put lock ranee elifcumof acy Il
Oxner aro.mho ,gem Dae TOTAL: ISSUED BY:
OFFICE c