99120108 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY "1"1 an 0 d
CITY OF CUPERTINO BUILDING.-ELECTRICAL. Pra 1T NO.
RUH,I:�NG DIVISION
APPLICATION/PERMIT PLUMBING MECHANICAL
BUILDING PROJF,L'T IDENTIFICATION
jSAN,11 NO. APPLICATION SUBMI"FIAI.DATE
BUIL ,NGADURE,S:
/OW -RS NAME: i'HONE: COM RACH)RS NAM,: LIC NO: CONTROLp
�l
tC IFFECI'/ENGINEER: LIC NO: A E S:
CONTACT': ,'l IONS: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLIH'i ELECT PLUMB MECH
❑ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY, ELECTRIC PERMIT FEE JOE DESCRIPTION
I herchy al3ine that 1 am licensed under provisions or Chapmr 9(commencing
WOZ in fun folic and erect .....on3nnhe nnxinax.ane rrofexxionxexile,non n.y Eaenxe ix RESIDENTIAL:
wuM1 Sedinn]IXNI)of U PIiItM I'i'ISSUANCIi
_ ❑sFnwl. ❑Krrcln:N RISMODIa.
QUU Licence Lic.X APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RI:PIPE
Dme�T mr
NQ6
A CH,lliCT'SIC
l-S DECLAR N PANELS ❑MULT6UNR OSTRUCTURAh
Z 0O or)Z l understand my plans shall he used as public records h10DIFICAPION
O ZUI•'T( IP OR ❑CHIMNEY REPAIR
F VH F]; Licerseal Pn.Icssionnl MillVI!M13NT SWIMMING POOLS
�sj•E OWNER-BUILDER DEOLARA'I'ION OVE EMODI?I.IREPAIIR ❑DEMOI.I'1 ION
CI hereby affirm that 1 am exempt from the Cunnadur's License Law for the
K0 following masna.(Section 703 L5.nosiness and Professions Code.Any cilyor county SIGNS ELECTRICAL
� ❑Ol'IJIiR
W LLy< which requires a permit w construct,a,tor,improve,demolish,or repair any structure -
F�OJ priomoiu filature,also requimx the applicant for such permit to file a signed.tmament SPECIAL C IUITI
F;!I} that lie licensed' p pursuant they far Contractors License Li (Chapter9 FR 1
�ap0 (cum g 'IhS t ]1X1111 ID ." 3 fth N :' .. dP r..' 'CWUnr 'TI:MI'.Mli I!
160 .haul h pt tl f J the ha'. t th II y I pt A Y FI..of ❑NI!W RLDGIAODITION ❑Dl!MDLII'IFN
Sect 7031.5 by y applicant l , IsubjectstI applicant I I penally llY of PDW C ❑FOOD SEIZVEC17
nota than f hundred dllrs(S500). t 1'R( .HENT
=O D I,a.owner of the para .or my cmpleyeex with wegc1-1 their sole compensation SWI. . ..'C C
F. will Jo the work,and thestrvaure is not inundation offered fortune(Sce.A—,one, . OVILFTS-SWITCHES-FIXTURF_S
rohe m
13 m and Pfirlds nn Code:TComcmr's License Law docs not apply m un owner of 1
property who builds or improves thereon.and who does such work himself or through /A\ (�
,non employees,provided that ouch improvements about.mended or otl"cted fin NCW RESIDENTIAL.HLIiCTR SQ tri'.
sale.If,however,the beddingof bouprnvcmant it"lid within arc year of a.n.plminn.thc n SQ.FFPI_OOIt ARD BISV.IT.
ermilder will have the burden of proving that he did not build or improve ler put- I•/
p:.mof.wled. TOTAL sivDEC 2 01999
❑1,as owner of the propenyl am exclusively contracting with licensed n.mmctur.m
on.wm the prujecl(Sec.)(W,Boniness and Professions Cadr:)The Contractor's Li-
centeLawJoesnotapplytoanownerofpropenywhobuildsorimproveslherenn.and QTY. PLUMBING PERMIT FEE
who coreark for such acts with aambocmr(s)licensed pursuant to the Contractors
L'mcnsc Law. PI!HMIT ISSUANCI! Bit
l um csempl under Sec. .B&P C for this ruu.wlb
NAV R-DRAIN&VIS'-WATER(i!A) VAI.UAI]ON
Cus., Data O
WORKER'S COMPENSATION DECLARATION HACK FLOW PROI'IEC..DEVICE
I hereby affirm under penalty of perjury one of the fallowing declarations:
lhave:md will maintain a Certificate of Consent in self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA.GOND. S'1 ORI[S TYPE CONS'BUCIIOA
salts r,nx provided for by Scalia 3700 of the Labor Core.lin the pt ri.mmnce of the
work for which this permit is issued. Iq%'I'URGS-PER[RAI'
El 1 have mW will mainmin Wnrkdx Compensation Inmrarea.ax required by Sectio p
3700.Dhe L.WrCode.fonhe performance mine work for which this prod,is i.mad. GAS-EA.SYSTEM-1 INC.4 OUTLETS C.GROUP / A'
My Workers Com,brin ion Imumncc carrier and Policy numb rare
Carrico: Policy Nn.; .✓w GAS-EA.SYSTI!M-OVERJ(EA)
CERfIFICATEOVEM!MPTIONFR( AORKERS GREASFANDUSTRI.WASTE INt'ERCEPH)R
COMPENSAION INSURANCE ❑UILOING DI V ISIIIN FEES
TThlxxxtinn nccdnotWn... lead iidw,arn.fist or ono hundred dolls,IS I Al CREASE'I'RAP PLANCIII.CK FEE
lea.)
I sexily that in an, ammonite of the work for which this pernitis issued.lshall SEWER-SANITARY-STORM EA 200 tri'. ENERGY FGIi
nat employ any Person in any Tanner no al bttt�e subj I m de W'urka.ti Compen-
OZ nation Laws ofRaliRX�t.Oat/�� � — G WATER NEAIF.HK'/VI!NTRiLECfR GRADING IIiE
Z Q Applicant 41
4 1
.N. NOTICE T I'61C��jj/l T:It niter making this Cunllicare of Escmpuon,You should WATER SYSTEMO REAPING SOILS FEE
hcennt.uljem w Ne'Workerx Cumlens;e.on pmvixlons of Phu LnWr Cndo,you muss
Iunhwi0.mmply withCONSTRUCr10N LENDINGAGENCY
coed rcvokcA. N�'rER SERVICE
p moi
0. � W RESIDENTIAL PLMB. SQ,FT PAID Dat Rcaipt4
U0 l hereby affirm that Nem is a construction lending agency for the performance of
D+ the work for which Nis permit i.nnued(Sec.3001,Civ.C.) TOTAL:
0 LcnJers Name TOTAL:
{U Lnndcr's A.mrcxu BUILDING ITH
0. I cariry deed I have read than'applicmivn
n and late Nal the aMrvn iou...mtinn is
N caner.l agate mcomply with all city and roomy ordinances and sate laws rtluling to QTY. MECHANICAL PERMIT FEE SE,SMIC19i113
U Z building consuactim,and hereby aumorim reprawmadmes of this city to enter uP.m Ne
aMve-mentioned prapcny for inspection pearpose.. PERMIT ISSUANCE ELECTRIC ETI!
(we)agree to rave,indemnify and keep hmmlcu the City of Cupenimo against
Ilabilitics,judgment,casts and expemes which may in any way accrue against said City ALfERORADDTOMECH. PLUMBING FEE
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH At.[,NON-POINT AIR HANDLING UNI'I'TO 0,000 CFM) MECHANICAL I7EL
SOURCE REGULATIONS,
AIH HANDLING UNIT(OVER 10.00)CFM) CONSTRUCTION TAX
Signaurenf ApplicvnVCantmemr Fate EX HAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or labor,building.rcupant store or handle hacodous material HEATING UNIT 00100,000 BTl1)
nt Ielined by Ila,C."I'do Municipal Code,Chaplet 9.12,and the Health nnJ Safety IIPAONG UNIT'(OVER LURIKK)B'I'ID
Code,Scaion 25532(v)'t �L
C]Yes ul.o VENTILATION PAN(SINGLE RESID) PAID
" Uare Ncceipt X
Will the applicant or future Wilding occupant use equipnem or devices which BOILER-COMP(3111'OR 100.000 BTU)
Jiit humdous air contaminants as defined by the Bay Arca Air Quality Management TOTAL:
strict? BOILER-COMP(OVER 100,000[11 Of
• ❑Yes �No
AIR CONDITIONIERs�
1 have read the hNmdm
vanus ntea requirements under Chapmr 6.95 ordeal Cali- L
Traria Nadd,&Safety Cade,Sections 25505.25533 and Vi534.I understand that if the NEW RESIDENTIAL MECH. Sl).Ff. IX i
Wilding does my currently have a tenant,that it is my mlamsidilly to notify the rccupam
of the r uiremems wIt th mus W met prior to iauance of a Cunif me of Ovv.,my.
inz
0 teal mgcm
Uwe 'TOTAL: ISSUED try:
1 OFFICE