B 0634 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL �pp PERMIT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL JVVB,� Sl0&0
BUILDING I'k(tdECT IDFVI'IF'1 MECHANICAL
OVVV
BUILDINGADDRESS: SANITARY NO. APPLICATIONSIIBMITIC'AALDAATIi
OWNER'S NAME. yHONE: CO, ACT1 NAME: LIC NO,� _
6 / o1W_ ` , r N C CUNTHUI,p
ARCHITF. /ENGINEER: LIC NO: ADD J �q /� ❑
0 os-S S"1 0
CONTACT: PHONE; BUILDING PERmrr INFO
2-
7 F (1 El Consultant Fees Paid by Applicant(Initial) 0� ELECT PLUMH NlhCCH
LICENSED CONTRACTOR'S DECLARATION l7 T QTY ELECTRIC PERMIT FEE 2
1 hereby aRfm mal l am licensed under povisiuns oif Chapter 9(commencing JOB DESCRIPTION
QWZ with Section VMXBofOiA,mr 3milm Buninessand Professions Code,and my license is RESIDENTIAL
000 PERMIT ISSUANCE
vX W m full force and elle q S C SFDWL C KITCHEN REMODEL
.�U( i,icause Class,Y�-3� 1.ic.N APPLIANCES-RESIDENT AL ADDITION [I PLUMBING RE-PIPE
�2� DmeSELT Contractor_z ❑MULTI-UNI []STRUCTURAL
Gly AR CHITECPS DECIAR T ON PANELS
p N'Z Iundersrvnd my plans shall he uuJ as public rttoNs MODIFICATION
OZ—O UP'102lXIAMPS I []INTERIOR ❑CHIMNEY REPAIR
F� Licemed Professional 201-II10IAMP$ IMPROVEMENT CSWIMMING POOLS
OWNER-BUILDER Ce Corf oo OVER 000AMPS - C BATH REMODEIJREPAIR DEMOLITION
T nerany arum mot I nm eaentpl o-am me etumraamra uanae Law),r me
O6 U following meson.(Section 7031.5,Business and Professions Code Any city or county SIGNS ELECTRICAL ❑OTHER
a Wa which requires u permit m consaucn alter,improve,demolish,or repair any structure
FY'OJ prior to its issuance,4110 requires the applicant for such permit,Ne asignedslammmn SPECIAI,CIRCUFUNISC., f6
fly that he is licensed put-wardl ml he pmvisions of the Cmansc,rs Lfcenw law(Chap,r9
WI (commencing with Section 7")of Division 3 of me Business and PrnfeW...Code)or TEMi1 MID'ER OR POLE INST COMMERCIAL-:
6 G C mm he is exempt herefrnm and me hasis for me alleged exemption.Any violation of ❑NEW BLDG/AUDITION ❑DEMOLITION
4• Section 9131,5 by anyuppliwnl Got......ritsuhjacts the npplicnnuuacivil penally al POWER DUVICN,S, ❑TENANT CFOOD SERVICE
FF.. not moa man Eve hundred dollars($500).
q Q ❑I,ds ownerof the pmpeny,or my employees with wages an their sole compensation, SWIMMING POOL ELECTRIC OTHER EMIiNq'
6262''3, wiU do the work.andlhe structure isnot in,ndedmmiered forstk(Sec.7014,There. OTHER
W m end Professions Cone:The Contractor's License law does not apply to an owner of OI1TLlff$-SWITCHF_S-FIXTUNf•S
6 3^ property who builds or improves thereon,and who does such work himuIf or this
his own employees,provided thal suchimprmemenla arc nm imended or offeed for NEW RE E)FNUAL BLECrit SQ IT.
sole.ILw
hoavcr,mebuiliingormn,nocmcal isxold within nnoycmof mntplvdin,the SQ.PT.FLOOR AREA $/SQ.FT
nwner-0uilder will have the burden nl'proving that he did nm build or improve for par-
Tom of salad.
C I,as owner of the property,am exclusively convecting with licensed contractors ol 'f(YfAL: a
consult the project(Sec.7014.Business and Padf e,samts CWeJ The Comrvctor's
lease law docs not apply to an owner of property who builds or improves named,and QTY PLUMBING PERMIT FEE
who contracts for such projects with a cam eretm s)licensed pursuanfto the Coulow ar's II J
License Law. PERMIT ISSUANCE
um2 5 1999
❑Iexengnnnder Sea ,il&P C fmmis rowan
ALFER-DRAIN&VENT'-WATER(BA VALUATION
Owner Daa
WORKER'S mNSAT10N DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty natty of perjury one of the following for dedatutionr.
❑Ihave and will maintainaCion ofConsent he LubmCall,for forormernsCtumpen- DRAINS-FLOOR,RDOEAkFA,COND. RUCTION
workas provide)for by Section 3700 of me Lahnr Code,for the performance of Ibe
work for which this permit is issue). FI%'1'012175-PER TRAP
❑1 have and will ode,fan he pli f's Coopemmian Imnrnmq us required l i Semlon
370X1 nl the LOhnr Code,forme perhannance of the work for which this permit is issncd, GAS-I:A.SYSTEM-I INC.4OUTLETS OCC GROUP APN
My Workers Compensation Insurance carrier and Policy number are:
Carrier: Policy No.: GAS-EA.SYSTEM-OVBR 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASIT(INDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE IIUILIBING DIVISION PIiES
(1'his,econe need not be completed iflhe permit is fortune handreddidma l$11X) GREASH'IRAP
or less) PhANCI IECK 1131
I certify that in the peromance lithe work for which this per mit is ixsaed,111ta11 SEWER-SANITARY-S'I'(IBM EA,200 MI..
not employmy person in any mannersous to become subject,the Worlent'Compere. ��r--qq l!--�� ENERGY FEE
O Z soba.laws of Cul;fnrme Dale WA9P.R IIIiATER W/VENTB7LCCTR a C./'v GRADING E
7 O Applicant
NOTICE TO APPLICANT.If,after making this Certified,of Exemption,you should WATER SYSIEMGRHATING SOILS FEE
become subject m the Workers Compensation provisions of the Ln1mr Code,you most
�.t forthwith comply with such provisions urthis permit shall he deemed revoked. WNI Pit SERVICE
Q
� z CONSTRUCT(ON LENDING AGENCY NEW RESIDENTIAL PLMIL SQ 17K PAID Dal keceiptk
U 0 I hereby after that thele is a construction lending agency for the performomccof
he work for which this pend)Is issued(Sec.3097,Clv.CJ
;1.F't Lenders Name TDTAI..
[U Lenders Address T LAI"
fps 0. 1 certify mut I have read this updicmion and statethat the above laformmloq is BUILDING IT
Fhcorrect.lagfeem comply with all city t deounry tudinunees and save laws relating to QTY. MECHANICAL PERMIT FEE
U mildir,ouTivaitun,andhmahyaulli ameresemativc,ol lhiacitytoantara,o the SEISMIC PEE
above-memioned property for inspection parpota, PERMIT ISSUANCE
(Wel agree to save,indemnify and keep homeless the City of Cuperagainst ELECTRIC PEE
liabilifies,judgmems.costs and expenses which may in any way deems,against said City ALTER OR ADD I OMHCI I. PLUMBING FEE
in emleyaence of the grunting of mis pemtit.
APPLICAN" N sRSTA' S NO TWO L COMPLY WITH ALL NON-POINT AIR HANDLINGUNTT(T010,000CFM)
MECHANICAL PER
SOURCE.RI'ULA ONS
Y--0/r-�5 AIR HANDLING UNIT(OVER 1(I,Wo CFM) CONSTRUCTION'IAX
Signature of Appli to onor Date / EXHAUST HOOD(W/DUCT) HOUSING Nil1IGATION IEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building Accepted store or handle hazanlous national 11 RATING UNIT(TO 100,100 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(0)! L.� HEATING UNIT(OVIiR I I0,g0 BTU)
❑Yes IANtu - VEN'I'lLA'I'IDN PAN 191NGLI:IiB511p PAID
Data lee 1p
Will the applicant or future building occupant use equipment or devices which BOILER-COMP OHP OR 100.000BTU)
mit hazardous air contaminants as defined by the 8,Arco Air Quality Management T AI-:
DlslnctP67
❑Yes 193✓✓✓Nn BOILER-COMP(OVER 11010.00lORTU)
,
I hove IunSJ the hzmdnus nw,rinls reyuiremenB nndcr Cbnp,r 695 nl Jm Cali- AIR CONDITIONER ISSUANCE DATE
Ina heath d1 ntbty Cook.Sell v,25511.5,25533 and 25534.1 understand that if the N17W RUSIDEN'GAL MHCI I, SQ.Ff. Q D
building docsore d IT dtcnanI that itis my oq....abilhy to notify the allowed
of Ne requires vwhic o. berm^I poor to issuance of a Cenilicate of 0ecn ancy.
Owmerssf0aho'd age Dat TOTAL ISSUED BY:
i OFFICE