S 4393 APPUCANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CPPV OF CUPERTINO BUILDING-ELEMMICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 4393
BUILDING PROJECf IDRNTIF'ICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
3 9 9 HZltA VISA ROA P _ ?: g
OWN R'S NAME: yIN ��Z CONTRACIOR'SNAME: LIC NO:
RAO_ /Tlef/Isr /.J N/C CONTROL
ARCHI'fEC'I'/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: LLYM PHONE: BUILDING PERMIT INFO
15AD— /, ,,/ ,F_7 T r � ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECTPLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
a Z I hereby affirm that I am IlcensN under provisions of Cheerer i(cnmmencimg JOB DESCRIPTION
WOO wi@Sectinn]tM07 of Divisitnlef the Husiness end PndessitnsCode,unJ mylicenseis PERMIT ISSUANCE RESIDENTIAL:
FI— in lull race and effect. ❑SFDWL ❑KITCHEN REMODEL
L)'u License etas o.p
Dnl [)air—
APPLIANCES-RESIDENTIAL ADDITION PLUMBING RE-PIPE
ye Gwmuclor []ADDITION
l-Dit,V,z ARCIII N,use DECLARATION PANELS ❑MULT4UNIT ❑STRUCTURAL
Z O y Z I undersmnd my clans shall he used es Public rcenrds MODIFICATION
OZ 4O UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
ate—j Liccnmd Pnsfeuional 201-1000AMPS IMPROVEMENT 0SWIMMING POOLS
W Y f_1 OWNEffirR-BUILDER DECLARATION OVER 10X0 AMPS ❑BATH RE ION E PAIR DEM LRION
a a Q I hereby am that 1 am exempt(Tom the Cormamr
c 's Lanese Law for the
°x'O a U following reason.(Section 7031.5I. ,Business and Professions Code:Any city or county SIGNS IiLECI'RI 0(MIER N � �•'
Fwhich requires a permit s construct,altar,impsve,demolish,or repair any structure
JJJ
prior to issuance,also requires the applicant for such permit o file a signed statement SPECIAL CIRCO 1
Q� That he is licensed pursuant to the provisions ofthe Contractors license Law(Chapter 9
O (commencing with Seetion]IXIBLIf Division 3 ofthepusinushad Professions Code)or 'TEMP.Mif IEAR P COMMERCIAL:
tl 6 p e: Ihul he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
^N
Sedition by any applicant lira permit odjeets Neapplicaut m a civil penally of POWER DEVICES CITENANT ❑FOOD SERVICE
II mom than five hundred dollars(MOD). IMPROVEMENT
Sp ❑ Lea owner of Ne Pmlzny,or my employees wiN wages as their sole mmpcnselion, SWIMMING POOL ELECTRIC
F- will do the work,and the structure is not intended mothered for sale(Sec.7044.Business []OTHER
LLa1 ani Professions Cale:The Canwnur's license Law does oat apply ro en owner of OIIfLI:TS-SWITCHES-FIXTUR
�'3 property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are nor intended or offered
for NEW RESIDENTIAL ELECTR SQ ET.
sale.If,however,the building or improvement is sold within one year ofcmnplei^n,the SQ.FT.FLOOR AREA $/i FT.
ow^erbadder will have the harden of proving Nat he did not build or imPrwe for par-
poscyLuµell.
,,,,c� r of the pr^peny,um exclusively contouring with liansul ennummis m Tdl Al.:
Cenenacl the psjecl(Seo.7044,Business and Professious Code:)'The C^nnatim's Li. -
nscLuwJcesnotapplymanowncnsfOmpemYwhobuildsorimprovesthemon,and Q'TY. PLUMBING PI7RMIT FEE
who contracts for such projects with a contmerms)licensed pursuant to the Contractors ^•- "0
License Law. PERMrIISSUANCE ' `�
E3 em exempt un er Sec. .B&P C f I axon �try
ALTER-GRAIN&VENT'-WATHRD; I II 'VALUATION
• Owner — Pan" — �ji� JUL - 7 999
WORKER CA .N
OSATION DECLARATION HACK FLOW PROTECT.DEVICE
lull
1 hereby ill mai under Carly to Perjury one of0cfollowing decWormi'Co
0Ihevc and will maintainsCeni ofConsch the Lab Code,
surcfor WorkersCompem DRAINS-FLOOR,RUDE,AREA,CONT). STORIES TYP STRUCTION
action. r provided for mi Section 3710 of the Lubar Cude,for Bat lmrinrmance of the
Irk lir which this permit is issued. FIXTURES-PER TRAP
0 have laid will maintainhe Pero er Performance
w Insurance,as hhis permit is
Section
.17(0 of the labor Code,for the performuntt of the work for which this Persil is issued, GAS-EA.SYSTEM-I INC.40UTLEIS 4 APN
My Worker's Compensation Insurance dammer and Policy number arc:
Carrier: Policy Na: GAS-EA.SYSTEM-OVER 4(PA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE OREASI%INDUSTRL WASTE INTERCEPTOR BUILDING DIVISION M
phissection neednnl hecompletrdifthepermit is foroaehundandnllars(HUR) GREASETRAP
or less) PLANCHECK FEE
I certify that in the pedormancearthe work for which this permit is ksteJ,IMail SEWER-SANITARY-STORM EA.200 IT.
nor anploy any parson in any manner al us s became s000ra m the Warkern'Cramer- ENERGY FEE
0 Z virion Laws of California.Date WA'I'EIt HHATER W/VENTATI CI'It
Z Applicant GRADING FEE
fA
NO['ICE'10 APPLICAN I:If,alter making this Certificate of IixenOtion,you ahould WATER SYSTEM/TREATING
a ; become subject to the Workers Compensation provisions of the Labor Code,you must SOILS FEE
{k7 forthath comply with such provisions orthis perch shall be deemed revoked. WAITR SERVICE
a
Z CONSTRUCTION uctNDING AGENCY NF.N'RESIDENTIAL PLMB. SQ.F[ PAID
V O I for
rwhichirm that isaconswe.3097lending agency for the pednrmance of Date Receipt If
0 F
the work which This pencil is armed(See.3097,Cie C.)
U Lender's Name TOTAL:
HI<nJcr'
I Address TOTAL.y certify that I have rend This application and ntnte that the uM1nve information is BUILDING FE9
Z] correct.1 mace to comply whit all city and county ordinonees sod sutra laws relatingto QTY, MECHANICAL PERMIT FEE
Uz huildingdonsloodmi,and henhymahorima,prwaulives ofrhis city meme,.fon the SEISMIC ME
ubnve-nrentiomed property for Insperion parpows. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELIiC RIC FEE
habifirics,jularams,eciasand expenses which may today wayaccmeugrumosaid City ALT HR OR ADD TO MECH.
in consequence of the granting of this lwnnir. I PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE
MECHANICAL FEE
'.ATIONS.
� AI R I TANGLING UNIT(OVER 10,000 CFM) CONSTRUCTION X
SIB tanofAldwilma7marecrar ` Mara EXHAUST HOOD(W/DUCI') HOUSING MITTGATI NFEE
HAZARDOUS MA . IALS DISCLOSURE,
Will the upplicem or f slum hnlldiny^ccapeal atom or handle hanodana nmrnal I IEAPIN(,UNIT(TO 10B,(glll BTI)
as delined by the Caperton Municipal Code,Chapter 9.12,and the health had Safety
Code,Section 25532(a)] HEATING UNIT'(OVER 100,100 BTU)
❑Yes Fl No PAID
VENTILATION FAN SINGLE RESIDI• Date Receipt
Will the applicant or future building occupant use equipment of If p01LF.R-COMP(3HP OR IOO.IXIf19TU)
emit hazardous air contaminants is defined by the Bay Area Air Quality Management AL:
District]
E]Yet ❑No BOILER-COME(OVER 100,000 BTU)
I have real the humNary nater al,acrimonious under Chaplcr fi 45 of the Coli- AIR CONDITIONER ISSUANCE DATE
f..on Heulth&Sefny Code,Scnluns 25505,25533 an125514.1 understand that tithe NEW RESIDHN HAL MECH. SQ.FT. -
^_� to
"'g
Jlws of currently have a non.that it is mynaleau xibilily to truly lheoseapunt C/ / r
ofih mal"Ifich rt prions' ofe Cdniacju��upy2
Ow onzedagen GJ TI/).,a TOTAL: ISSUED BY: t
OFFICE