99100145 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY %`I 1UCI I �t,III-)
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
low
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. SOOOI
BUILDING PROJECT IDEN'I'IF'ICA'r1ON
IfUI1.UING ADDRESS'. SAN]VARY NO. APPLICATION SUBMI'TT'AL DAT
/n6,5_2 h e e� r J u-f--
sWNE :ti NAME:: PHONIi: CO
NICNCONMOCONrROLp
OS�jp
.CIIIUC'/ENGINIiI?R: LICNO ADDRI-SSt c ❑
JK
CONTACT'. PHONE BUILDINGS PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG_ ELECT PLUMB MEC I
LICENSED CONTRACTOR'S IIECLARADON QTY ELECTRIC PERMIT' FETE rL-JJI L^7/ rL-,T/
1 hereby affirm that 1 am licenced under prnvi,nme,of Chapter 9(commencing J013 DESCRIPTION
WZ wish Section 7(NXBof Division}ol the BusincsxanJ rm'ecxinns Crxlc,:mJ 'cense is RESI)FNTIAI•
p / PERMIT ISSUANCIi
1- in full force unit ellen. [ISFDWI, KITCHEN REMODEL
=14QUU License Class Lic' APPLIANCES-RESIDENTIAL CADDITION ❑PLUMBING RF,-PIPE
rFil z Date Con racmVol0MUI.TI-UNIT []STRUCTURAL
ARCHiI'ECI'S CCL R
PANELS D w MODIPICA'DON
Z C IA Z I unJersmnd my plans shall M used a.public olds UPTO 200AMPS OZ 4, CINTERIOR []CHIMNEY REPAIR
Foy 'ce Licensed Palmeatinal 201-HXX)AMPS IMPROVEMIENr []SWIMMING POOLS
y f„ OWNER-BUILDER DECLARATIONOVER NX)AMM
W 6 1 hereby affinn that 1 am es ❑BATH REMODEL/REPAIR El DEMOLITION
e
L IY mpt treat the Contractors License Law for the
IK�r LL U following rcaam.(Scctian 7031.5.Business and Profession%Calle:Any city or county SIGNS ELECTRICAL
yI CO'PI{IER
V, which requires a permit to construct.after,improve,demolish,or repair any stcrc
„E]�'�g prion..it,issuance,echorequims the applicant for such worlinn rile a signed statement SPECIAL CIRCUIT/MISC,
mat be is licensed parsmnnofhe provision,.!the Contractor.,license Law lChupnr4 COMMERCIAL
Wy f (commencing with Section 7000dof Di omi3oftbe Hauturssaod Professions Code, TEMP.METEN OR POLE INST.
ado X that he is exempt therefrom and the basis for the alleged esen primal.Any violation oI []NEW BLDG/ADDITION [I DEMOLITION
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES [ITENANT C1'001)SERVICE
of more than live hundred dollars IS500R. IMPROVEMENT
FSS ❑ I,us owner of me property,ar my employees with wages as their rete compcnsatinn, SWIMMING POOL PLEC I RIC
N wi 11 do the work,and the ssmcmm is not lntcndedouslf d fntsale(See.9044.Business COTHIiR
n st
3 m and Professions Code:The Contractor's License Law does not apply n, it n 011'1'LETS-SWI'T'CHES_Fix'1'URES
Property who hands ns improve,thereon,and who Jac,such work himself or mono
his own employees,provided that such impmvcments art not intended or offered or NEW RIiSIDFN'I'JAI,ELCCfR SQ ter.
sale.If.however,the building or impmvcmmut is sold within one year nfcampleHim,the .Q.14.FLOOR AREA S/SQ.Pr
cr-builder will have the burden of paving that he did not build or improve farput-
poseorsnle). TOTAL: Q
C I,as owner of the propcny,ant exclusively contracting wids licensed comraenrs to O
moan the pn'jan(Sec.70,14,Business and Professions Code:l The Contractors I u-
seLawdmsnotapplyln an owner of pmPmy It.builds nr latproves thereon. ad QTY. PLUMBING PERMITFEE
wbo corrects for such projects ,nh v contramor(s)licensed punuanuo the Contractors
License Law. M_R
ISSUANCE
1 am vevm,m under Sec. 13&P C for this mason
DRAIN -WAI'IiR IIIA) VALUATION
w R
Dale
WORKER'S COMPIiNSA'1lON IlECLAItA'1'ION PROI'RLT.III?VICE1 hereby affirm under penalty of perjury one of the follow ing declarations: OOR,HOOP,ARBA.COND. $'IORIIiS TYPE CONSTRUCTED
mum.a,provided for by Scctian 37W of me Iron Cade.for the peformance of the
work for which this permit is Issued. PER TRAPn 1 have and will maintain Workers Compensation Insurance,m required by Section �-I971X1 nI the Labr Cock,for the perhtrmanee ofthe work fur which this)vrmit is issued. STEM-I INC.J Ol111.7S OCC GROUP IN
My WOAcr's Compensation lneumnce currier and Policy numlerare: GAS-IiA.SYSTEM"OVERJIP.A) p
Carrier Policy No.: 1 3
CERTIFICATE OP EXEMPTION ITaOM WORKERS GREASP/INDUSTRL WASTE INTERCEPTORCOMPENSATION INSURANCE BUILDING DIVISION FFI-S
(ThisttetionnecJnotbecompleted ifthepennitixl'nronehundmddollae(SI001 GREASETRAP
1'LANCI{ECK FEEor lc,,)
I,corny that inthe perfunmvttceof thebe,no whichaidne'his to he Hot'isis,ued,Ismall SEWER-SANITARY-SIOkh1 EA.21X)1.1'.
nm employ any person in any m:mner sn as to become wbjecun the Wurkeri Compere ENERGY ITE
O Zfor ia.Date WATER HF,A'I'17R W/VENT/ELP.0 R RFDIN Er.'
wtlnn lows of Cali �1
o Applicant
'Z' y NOT 1111 TO APPLICANT't If:aflcnnuking This Ccnilisnm of H11111tion,you should WAT'F,R SYS'1EM/IRCA'1'INO 'tAL.'FEE
h" become subject to the Worker,Compensation prevision%of the lofts Code,you must It
C Q forthwith comply with such provisions or this permit shall be Jecmed revoked. WATER SERVICE nn / 7X999 t, 1
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.PT. I i y T Receipt#
UQ I hereby affirm that there is a construction lending agency for the Performance of
LL b" rift,work"ser which this permit is issued(Sec.1047,Civ.CJ TOTAL:
O ULcndar's Name TOTAL:
Lender's Addm,s I&
PC
0. I cenify that 1 have read this application and state that Ne above information is li ITR PC E
F-1h emrecl.I ugmen"dooply withuB city nwanlmyordimancesand state law%relating to QTY. MECHANICAL PERMIT FEE FEISMIC FEC
V Z building comsuaeion.and hereby authnnce mpresentetiva of ihi%city to enter upon the
uls,ve.mmotioned property for ilvsSection j u ful—, PERMIT ISSUANCE ELECTRIC ITC
(W a u,..sats rode and kap hornless the City of Cupcnino against
Ibmilitic'judge cot%,cnstsand xlwnsc, hich may many way accrue against said City ALTER OR ADDTO MECIL PLUMBING FEE
in Ion. e% the granting feallm
APPLIC uNTI DERSTAND'ANDW .LCOMPI,YWI'rFIALLF)N-1'( NT AIR HANDLING UNIT(TO I(LU011 CFM) MECHANICAL F17E
SOURC'RF.- LAr1ONS.
AIR HANDLING UNIT(OVER 10,000 CFM) CON."RUCTHON'1'AX
b'maned pplicom/Gmtrenor Dead EXHAUST I{OOD(WNUCr) HOUSING MITIGATION ITE
HAZARDOUS MATHITAI S DISCLOSURE
Will he applicvm nr fmurc building oe<upam arm or handle baurJ...matcnal IIEATING UNIT OT)100.0001111))
"dcfined the Cupcnimo Municipal Code,Chupmr 9.12, ,,it the Hmhh and Safety BEATING UNIT(OVER 101000 BTU)
cr % nn uslxa)^
..C Yes ❑NnPAID "-
VIiN'1'ILATIONFAN(SINGLEItESIDI Datc Ilacipt#
Will the applicant..lmare buildingrxaprmuve e<pui,nura or device,which BOILER-COMP(31111 OR 100.000 BTU)
cont haeardnui air contaminants a,Jcfined by the Buy Area Air Quality Management 'I O'I'A1. 0
Distrin? IIOILHR-COMP(OVER 100.00011TU)
❑Yes CNo
AIR CONDI"1'IONER ISSUANCE;DATE
1 mad the huzvdo mate B rcg2".1u under Chapter 6.Sa of the Cali-
IOmI: Ica b`&S:ley GxDe ,,tions 5115.25531 and 25514.I unit rend that if the NEW RESIDENTIAL MECN, SQ.PT. O
builcm it sunned maty hu mm .thmhismymspmvib B,,t :i reify vonOpmu 111
n'the tend w ' hmI et PH...at ,coria Ccnirca of( cupamy.
Done n vulLnriaMn Das TOTAL ISSUED tlY:
OFFICE