99110159APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO ' ?' - - BUILDING.. FILECTHI:AL
BUILDING DIVISION APPLICATIONMERMIT PLUMBING. MECHANICAL.
ItUI LBING PROJECT IDBNTIF'ICAIION
FD
BIDING
IILR�r
mvTO Allis NAME LIC NO:
/ �4 a A,I1M 2� [:1Consullanr Fees Paid by Applicant (Initial)
T /✓� LICENSED CONTRACTOR'S DECLARATION QTY
I hemby affirm but 1 len licensed under pmvissiom of Chaplet 9 (commencing
WOZ with Section ]IX111 of Division 3oflhc Bri,messand Pndcsxions Cladc, end my licence is
in fell once and el 1.
CWF
G Lisxnse Clan Lic. is
Z W
FDate Co DIFCIr
In D L ARCIII'fEC'I':S DIiCIARA'TION
~oI
Z 1 understand my plans shall he used as public records
OZ1-a
Liccnval Rofessinnal
,esu,.J OWNER -BUILDER DECLARATION
G x Q I hereby union that I am exempt front the Cum muv,r'c Liccnsc haw for the
5xa M V following remon. (Section 7031.5. Business and Professions Code: Any city or county
W'3
WI- which requires a permit rt construct, alma improve, demolish, fir repair any "metals
oG prior In is issuance. also requires Neupatent fursuch pe -,iso file asigneJ smenwm
yIhatheislicemedpunuantmthepm) kions oRhe Contractors License Law (Chapter 9
�00 (eommeneingwith Se"loll]mq)of D'misllati1cdd Ba,incs,tmdlhdcexinns G,Ju)rr
that he is exempt loref ion and the oasis fire the alleged exemption. Any vinlmin l of
W .a to Section 7031.5 by any applicant For it reran subjects The applicant o a civil penalty or
not more than five hundred dollars ($500).
=O ❑hods, mi
pmpeny. eis u aloyced,c oarrges ns Nei(See 044. ration.
F. will do lhcwnrk and thcswcmru is nut in¢ndcJ nudl'cral frit aIle lScc. ]n14, Boniness
n�j' ad Professions Coda The Connector's License Law does nut apply to an owner of
prulxny who builds or improves ducal and who does such work himmlf or hrough
his own employ.,, provide) mat such improvements arc not intended lar offered I,"
sale. If, however, the budding fir improvement is sold within one rear or completion. the
er-builder will have the burden of proving that Ile did not bull) lar iapnwc ler nor.
pose o
1 an owner of the property, am exel u,lvety conVacfing with licensed nmrm"ors to
saucl the pmjec (See 7044 Business and professions Cde:)'[he Cnnvanor'sLi-
musel.awdecsno pl dpmpry who builds or impmvcsN"eon, and QTY.
whoeonnues frit' ProTja"s with u con tors) licensed proam nt the Conmtcmrs
Liana Law.
❑ I am csempl a . fl& P C for Phis+vaso
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
PANELS
UPI 0200 AMPS
SIGNS ELEC IUCAL
SPECIAL CIRCUfI'IMISC.
TEMP'. METER OR POLII INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OU'I [.[ITS - SWI I CITES - FIXTURES
NEW RESIDENTIAL F,LECfR
I hereby aOAml under penally of perjury one of the following doelamlionv
I have unit will maintain uCerifcusof Consent lawn mosure far WorkeT's Conlpea
labor. as provided for by Section 3711 of the Labor Cello, for the periirrmance of the
work flat which this permit is issued.
I have and will maintain Worker's Compensation Insurance, ns required by Section
3]110 of the LaWr Cale, for Ne performance of the work for which this permit is issued.
My Workers Compensation Poulenc carrier and Policy nanberale:
Cartier. Policy No.:
CERT IFICA'IT: OP EXEMPTION Il OM WORKERS'
CO) PRNSAI'ION INSUKANCE
(This,anion nad not bcmmplea d if thepe nd, k let one hundred doll:ua 151ND
of less)
1 certify ohm in the y ancc al the work lin which this permit is issued, l opersonN any mar
ll
sol employ any penn
y manner m as m become subject a the Workers' Compem
Z nation latws of Callfurnia Date
z 0 Applicant
z y NOTICE TO APPLICANT IL utmrnaking this Certificate of recreation, You should
C> become subject to the Worker's Comper'nion provision, of the Latin Curie, you must
W fonhw an comply with. such provisions or this permit shall he deemed revoked.
a�
CONSTRUCTION LENDING AGENCY
U Iherchy anirm Nm there m
crc isacnn¢tion lending agency for the perforance of
LL F the work for which this permnnisnucd (Sec. 309]. Civ. C.)
O U lender's Name
r lenders Address
ly I Beed, That 1 have rescind, application and an Nat the above infonnmom is
FN enrten. l agree a cnmPly will all city and county "'dinunecs and sin1 laws rimingIn QTY
UZ buildimgconamction. and worhymah on, evEor-tatives of thiscity I I"It" up on the
a lur.n reamed par my for inspection purposes.
cl ague ,indemnify and keep hunmlcas the Coy of CapcmI 'I against
liahilili gmenls.cml. at rises which sl ay In I way accme again.11 Bald City
n of dm 6taming nl lM1 noir.
sale I uvl' IN OFR STA N DS ANI WILL COMPLY WI it MLI. NON -POINT'
I
IIAFARDOIJS MA'I'IiR1Al S DISCI.OSIJR1i
Will the applicant or future building overtrain sore or handle hvardous numrad
defined by the CuperlLln Municipal Cnde, Chupmr 9.12. and the health :led Safety
de. Se tion 25532(x)^
[I Yes Fl No
Will the applicant or future building occupant use equipment or devices which
it hwarduus air cunlandna e, as liqued by Nc Bay Area Air Quality Mnnagcmcm
strict?
❑No
mad the hamrdws mate s requirements made, Chapter 6.95 of Ne Call -
YL' 0th & Sd'cty Odc, Sections 25. 5, 25533 rind 25534, 1 understand that If Nc
ilding Ic currently have u t"unL m I it is my responsibility to notify the overland
m. ,. entx s whabmastbentel ale lxsmncc nfu Ccrtifieme opOccul �
SO
TOTAL
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN & VENT'- WATER (IIA)
BACK FLOW PROTECT. DEVICE
DRAINS - MOOR. ROOK. AREA, GOND.
FIXTUREil - PER TRAP
GAS - EA. SYST]IM-1 INC.4 "UfLETS
GAS -BA. SYSTEM -OVER 4 B'.A)
GREASEVINDUSTRL WASTE INTERCEPTOR
GREASE 'I RAP
SEW BR - SANITARY - S'IOHM EA. 200 FI'.
WR'I'ER HEATER WIVRNTMAICTR
WATER SYSTEMrTREATING
WATER SERVICE
NEW RESIDENTIAL VLMH. SQ. 19'.
TOTAL:
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADI) TO MECH,
AIR HANDLING UNIT(TO 10,001) CFM)
AIH HANDLING UNIT (OVER 10,000 CFMI
EX HAUST HOOD(WIDUCI')
I IEATING UNIT OTO ImLODI 11 FU)
IIEATINO UNIT' (OV PIR I W,01113'1'(3)
VENTILATION PAN [SINGLE RESI D)
BOILER - COMP QHP OR 100.001 ITU)
BOII.ER-COMP(OVER IBE.000IFID
AIR CONDITIONER
NEW I(ESIDIiNI'[A]. MF,CH SQ. ET.
TOTAL:
OFFICE
FEE
50001
-2YP
NIC CONTROL#
BUILDING PERMIT INTO
BLDG ELIcl i 1'LUMI1 NUU
JOB DESCRIPTION
DF NTI A lI DENTI A L
RESIDENTIAL
❑SFDWL
01ITC101BN REMODEL
❑ADI ITION
Ll PLUMBING III: -PPP
❑MUTATUNIT
OSTRUCI'URAL
MODIFICATION
[I INTERIOR
EI CHIMNEY REPAIR
IMPROVEMENT
EJSWIMMINGPOOLS
BATH REMODEUREPAIR ❑ DIiMOLFHON
❑ (yl HI?K
COMMERCIAL'
❑ NEW BLDGIADDI'I'ION ❑DEMOLITION
[]TENANT ❑POOR SIIRVICIi
IMPROVEMENT
❑ OTHER
171. FLOOR AREA
PIANCRECK FEE
ENERGY FEE
GRADING FEE
SOUS FEE
PAID
Af�
r
05 FAL:
BIl I�DING " '
FEE SI S'MICFIT: 9
I:'" IRICFEIi
It, N1nINO.: sp_
t
MECIIANICN.1'1:1: -
CONSTRUCHONTAX
HOUSING bit HGATION FEE
PAID 33 r
Dam Rollin p aladd
ISSUANCE DA'I'177,
ISSUED BY: �l=