S 4333 f
LICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
Y OF CUPERTINO I1UIIAING-ELECTRICAL PERMIT NO.
ILIIING DIVISION APPLICATION/PERMIT PLUMB NG S 4333
BUILDING PROJECT IDENTIFICATION
DING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAH
D /R,¢inayr� /QaR9 7-G-99
ER'S NAME: PHONE: uG CONTRACTOR'S NAMIi', LIC NO'¢�/F�NAF4r04O1yLy/A,e /�q fNlc oNraoL a
ITELTIENGI EER: LIC NO: ADDRESS: f
Cv O ✓�t-L.r� !q 1.4
I CONTACT; PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLU B MECH
❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION Qry. ELECTRIC PERMIT FEE
1 hereby affirm Thal l am licensed under provisions m Chapter 9(commencing JOB DESCRIPTION
�0Z with Section7000pof Division 3 ofthe Business and Pndmsines Code.and my licence is I
u W. wa PERMIT ISSUANCE
F ly[�. in BE[force and ellen 3 S/' SFDWL ❑KITCHEN RF.MODEh
<UU 1."en'°°C - -� I'i`'M APPLIANCC$-RIiSIDENTTAL ADDITION ❑PLUMBMG RE-PIPE
yQL Da¢ 71 SDEor
ARCHI'I'ECI"S OIiC1.ARA1'ION ❑MULTI-UNIT ❑MODCTURAL
zC)z l understand my plans shall be used as public records PANELS MODIFICATION
QZ�Q UPTO 200 AMPS [I INTERIOR ❑CHIMNEY REPAIR
F�F-ul Licensed Pmfe...mal 201-10N)AMPS IMPROVEMENT 0SWIMMING POOLS
GY,�y OWNER-BUILDER DECLARATION
C OVER NM AMPS ❑BATA REMODEUREPAIR ❑DEMOLITION
W U 1 hereby (Sect that am exempt from the Contractor's License Law for the
X 3 a U following reasov.(Section]0315.Business and I'rofaxiom Cade:Any city or eoumY SIGNS ELECTRICAL OTHER
tD
LLE which prepare,a permit an eamstmet ulmr.Inmpmvq demolish,or ripen ony prucome
k]�O�
poor it)its issuance.also regaims the applicant for such Permit to file a signed statement SPECIAL CIRCUIT. C.
fey that he is licensed pursmnt w the prot,innnof the Contractors License Law(Chapter 4
(connnencing with Section 7(410)of Division 3 ofthe Business and Professions Code)or TEMP.METER O LE INST. COMMERCIAL'
a E C that he is exempt therefrom and the basis for the alleged exemption.Any violation nl' ❑NEW BLDG/ADDITION ❑DEMOLITION
mom
Section 7031.5 by anyapplicanl for a permit subjects the applicant to a civil penalty of POWER DEV ES ❑TF,NANT ❑FOOD SERVICE
not more than five hundred dollars($500). IMPROVEMENT
ESD (] Lvsowwrofthc Pmnpmy.onmy etnpoyms with wages as their solecntn,masons. SWIMM GPOOL ELECTRIC ❑OTHER
will do the work,and the structure is not intended or offered forsake(See.AW Businea
W 3 ec and Protesoinnv Came: the Cuntructor's License Law does not apply to an owner a( Of .D`S-SWIrCHES-F;Xl
proPeny who builds or aided In,hereon,and who does such tinte deed or or aid ter
his awn employeese provided that such impmveoemx are net intended or ofd red toe iW RESIUEN'rIAL ELF, 10 SQ FT.
owner
nI Cunei however,the building burinmmvencnt is sold widna:;'eyew ildori provetlngrr- SQ.ItI'.FLOOR AREA SISQ.FC
crMsil4r will have tM1c burden of staving thel he JiJ nm build nr improve far pur-
27
prse of sale.).
E]1,as owner of the formerly,am exclusively contracting with licensed contractors to AL'
nnxnual the project(Sec 71144,Ifmineau.,,it Piofiv,inm'GMe:)The Centmelorp Li "all-
cen,c Law doesnml apply to as awneeufp-,a,who builds or improves lbemm.and QTY. PLUMBING PER FEE
who contracts for such projects with a conuaclor(s)licensed pursuant to the Convuumr's meg,
License Low I PERMIT ISSUANCE
I am exempt under Sec. .B&P C I'or this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
11,11�'Iffii
eer Date 4_ .t
WORKERS COMPENSATION DECLARATION BACK FLOW PIECt.DEVICE $3 00.
I herchy of fin under ell of perjury one iii following declandiom:
I have and will maintain aCcnilicatcofConsenua self-insure forWorkers Copper, DRAINS-FLOOR.ROOF,AREA,GOND. STORIESon.us provided for by Section 3]IXI ofthe Labor Cade,forthe Pedormance ofthework fur which this Permit is issued. FIXTURES-PER TRAP
I have and ,H inanition Worker's Cnmltematiun Insurance,as required by Sectionof the Unfair Code,for the performance of the work for which this permit is issued GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUT'Workcr�opyyt l�y p_y�perand Policy num�cuu, i !_/ler AriT.� 'N/Vf/Policy No:
ry, WJ 9 GAS-L'A.SYSTEM-OVUR4IEA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASI%INDUSTRL NAS'IE IN'1'IiRC1iWUR
COMPENSATION INSURANCE BUILDING DIVISION FlifsS
Inc.section mad not he completed Bible scrout is far one hundred dollars 131(d) GREASETRAP
or PLANCHECK FEE
I cenify that in the performance ofthe work forubich this permit i....red,limit SEWER-SANITARY-STORM EA,200 FT.
not employ ony prison in ony poorer sur us m b- n_ uhje a Wurkerd Gtmpm- ENERGY PEE
Z smion laws of Cxlifomm.Da WATER HEATER WNENT/ELECI'R a
Z Q Applicant_-/',/�!(,n • �x ! GRADING FEE
= NOTICE TO APPLICANT 11,alter a mki mg this Cenificale of Exemption,your should WATER SYSTEMTREATING
a > became subject to the Worker's Compensation previsions of(he Lobar Code,you must, SOILS FEB
{.LI Inrthwithcomply with such Enovimmer this Permit shall be deemed revoked. WATER SERVICE
Q
7z - WNSTItUC1'[ON LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID Date Receipt#
U O (hereby union that is a construction lending agency forthe Performance of
F the work for which this Permit is issued(See 31107.Co.C.)
TOTAL:
QU Lender's Name
H] lenders Address TOTA1,: as�
1 I certify dm I have read This application and star than the ulnae information is BUILDING FEE
to correct.l agree to comply with all city and county political and state laws relining to QTY. MECHANICAL PERMIT FEE
U Z bding cn.utmntinn.not bcmby mdaori a reprove at vvsof ibis city am craft open the SEISMIC THE
above-mentioned property for inspection purposes. PERMIT ISSUANCE:
(We)agree to save,indemnity and keep harmless the City of Cupertino against ELECTRIC FEE
Iiabi l It lei,lodgments,costs and expenses which may in any way action,againsmid City ALTER OR AUU70 Al1iCH. PLUMBINGFEE
in cm ers,ra¢of the granting of Wks permit.
APPLICANT UNDERSTANDS AND WILL COMPLYWITH ALL NON-POINT AIR HANDLING UNIT(TO IO,IXpChM) MECHANICAL FEE
SOURCE REGULATIONS.
hn� A�,Q�f 74 -11 AIR HANDLING UNIT(OVER III, FMI CONSTRUCTION TAX
Signmireol'ApplianVC mhor / Duel EXHAUST GOOD(W/DUCl HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicumol name lwild'mg«cupam.circ or handle hannduux material HEATING ON]'r(TO 100,P41 U)
as Jetmed by the Cupertino Municipal Code.Chapter 9.L2,and the Health and Safety
Calc,Station 25532(x1'! HBATING UNIT(OV Lor' BTU)
VcsNn PAID
VEN'rILATI(IN NISINChIi RIi51D) Dnm Receipt#
Will the vpplicnnt ser future building uccupmt use cquipmmm ur devices which BOILER- MP 0111'OR 100,000 B"TU) �1
,n hmardous air contaminants as defined by the Bay Area Air Quality Management TUIAL:
District? Yes AN.
BOILF -COMP(OVER 100,000 BT U)
❑
I hove read the hemntuus n:ncriuls mijuiremmnu under Chapter 6.95 of the Cali- A/CON
ISSUANCE DATE
fmmim Bull,&$afco Cssde,Sections 25505,25533 and 25534.1 understand Nal tripe, NIiW RESIDENTIAL MECIL SQ.IT.
building dors nal currently hvvf v mnnm.Ihnl it ms my mspoauibility m notify the«cvpam
of the ruluire1gcnt, is must or t Perna issuun c of nif}`a¢ Oy�upunq.
d -(/- / TOTAL:
Uwncr nr umhori lagan atm ISSUED BY.
OFFICE