99080156 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL P , T.NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL
F777777BUIL)ING PROJECT IDENTIFICATION
BUILDING ADDRESS: .. SANITARYNO. APPLICATIONSUBMITI'ALDATF
( 0 ?,3_67 SiQFLX e 62 J Qfllril Cacsi S 2 -,L3 - 2
OWNER'S NAMIi: PHONE: CON9'RACI ORS NAME: LIC NO:r�
C fyL H/ (R�A'vDtl/41 r4hl 77 SNe)etiwiAXI /c_ NIC C//1� CONTROL## 2
�RClIIT�ZAA V 04 I, rF LIC NO: ADDRESS: l C I, / / t 7 ❑ l � I 3
CONTACT, PHONE: BUILDING PERMIT INFO
�L.N"/f � ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT' / Pl U /ME❑CH
LICENSED CONTRACB)R'S DECLARATION QTY ELECTRIC PERMIT FEE LrlIY/ �rP�/
I hereby.ffinn that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
OaZ wish Sepakm7(M)0)of Dnicim3mfle Businessnnal Professions Cede.ndmy licenwr, RESIDENTIAL:
n)O PERMIT ISSUANCE
F�12 in lull force and elfivel.12Z ❑SFDWL [I KITCHEN REMODEL
aUU License Cl .s Lica �1� APPLIANCES-RESIDENTIAL C1 ADDITION ❑PLUMBING RE-PIPE
yQW Dlllc Cnmracwr V/ Y ✓1•
L ARCHITECTS DECLARATION El MULL-UNIT
-1 STRUCTURAL
FDu)'/K I understand my plamathali W used.,Public records PANELS MODIFICATION
Jz-a UP TO NO AMPS [I INTERIOR ❑CHIMNEY REPAIR
QHF'W Licensed Professional 201-I00OAMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER II WAMPS ❑BATH RI',MODELREPAIR ❑DEMOLITION
C Q 1 herehy.firm Ill.t I am exempt from the Commcmra License I,aw for the
KO a Ufollowing reason.(Section](131.5,Business and Professions Code:Any city nr county SIGNS ELECTRICAL ❑OTHERA'3 n.F N which requires a penal to consuum,alter,improve,demolish,or repair tiny spreare 0`q_.
.1 n
" 0< prior bits issuance.alko cyaims Neappli,nntl mauch pemril to ble.yi8ned,bomem SPECIALCIRCUD'IMISC. yl-Lf/52511
S y 'her he is licensed pursuant mthe provisions Of she Contractor's License LW(Chapter 9
y CC�L�(commencing wltb Section TXXU of Division J ofthe Business and Professions Cada or TEMP.MEFI?R OR POLE INST. COMMERCIAL'
L a c C that he is exempt therefrom and Ne basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W^vi Section 0031.5 by any applicant for a Permit subjects the applicant a civil Penalty of PUNTER DEVICES Ll TENANT ❑FOODSERVICE
not more than five hundred dill...(S50(). IMPROVEMENT
FZy I,a,owner of lbs n with wages their sole coni t SWIMMING POOL ELECTRIC
H 4 ❑ property.structure tar emit ogees wi ges.. pen si bit,
❑ and pr Newon,Co,:(li [heCo is nor intended r,poe Law
mal does rale(Sec.,,an Bonet op ❑OTHER
3 pard property
who
Gxle:The Centrtiereo License Law soca nm work
hi is am net of D OUTLIfI'S-SW I'I'CIII?S-FIXTURIiS f Q
his o ny woo build.,or viided that
thereon,i ups who doe,such tinte himself or through
his own employees,provided Nat such improvements arc not intended or offered for NEW RESIDIiNT1AL ELECTR SQ FT.
sale IL howoor,the building or improvcmcm is sold within one year of completion,the SQ.FT.FLOOR ARfiA S/SQ.FT.
tier-builder will have the burden of proving that he did not build or improve for pur-
pose mf sale.).
71 1,as owner of the property,am exclusively contracting with licensed contractors m TO
rmuum'ne prnju'I(Sac,7IY14.Raciness urn]I'm(ctsions CoJc',I The Contractor's Lb
t'clr
se Lew doesnolapplym an n,be,of'mo,voy whit build,or improv,thereon,and QTY. PLUMBING PERM / P. -
who contact.bottles projects with a emnn'nons)licensed pursuant b Ne Cor mac or's
License law. PERMIT ISSUANCE
❑ I has exempt under Sec. .B&1'C far this ru an
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Date
WORKER'S CaltyofNSATI on DECLARATIONlowing SACK PLOW PR(TIIiCT.DEVICE TO
I hereby pff nn under penalty of penury one of following Aculna'iene. Cl
Donn as nod wie forby
aCcn fcatc of the i.ano xdNnarclia Worker's Ceofth- DRAINS-FLU(tR,ROOF,ARBA,CONU' S'FURII?S 'I'Y!'13 CONSTRUCI'IUN
wino,t,provided fpr by Ss i... 3](N)of the lahor Code,for the perhrnnencc of the
work for and,ill somal is issued. FIXTURES-PIiR TRAP
I have and will maintain Worker's Compensation Insurance,ash required t i Section
J]glofthe L#Mit Gde,Tenho peAommnce of the work for which this permit is brand. GAS-EA.SYSTEM-I INC..)OUTLETS OCC GROUP DPN
My W�rker••SS ion)rysr�yra�y�e piney No.� ���7 �• GAS-EA.SYSTEM-OVER 4(EA) � O
Cameo J I T
Cliltl'119CAFE OP EXEMI'd]ON FROM WORKERS' GRF.ASFJINDUtiI'RI.WASTF.INTIiRCEPIOR
COMPENSA'HON INSURANCE: INII,DING DIVISION FEES
('FhLseetionnccJ not becomplacdlflbepenin is fnonchinled Joll...(S100) GREASETRAP
nr Icts.) PLANCHECK PEE
I terrify that in the Performance of the work for which this permit i,isaeq]shall SEWER-SANI'T'ARY-STORM EA.200 IT.
not employ any Person in any hour ',V yl�yJp�yt bjem m the Workers'Compen. ENERGY FEE
,Z ,man Laws of C�lanor a.Date 1, l7cIM�mr-�-�T WATER HEATER W/VENUPIELECTR
zApplicata_(Sj A�!Z�'SJ'=T` GRADING FF:F
NGFICE TO APPI,CANT:If,after making Ibis Certificate Of Exemption,you should WATER SYSTFMH'BE ING
7 hot se abject to Inc W..ker,CBmpencmaon provisions of Inc Labor Code,you mus' SOILS PEI?
R'i Q Iimhwith comply will,such provision or This penin shall be decmed'evoked. WATER S17RVICI:
C CONSTRUCTION I.P.NDING AGENCY NEWRESIDENTIALPLMB. SQ. PAID
U Q l hereby alum.that them is a construction lending agency for the performance of Dae ReceiptN
f' the xnrk fur which this permit e:asses lScc.3tri],Civ.C.)
Lender's Name TOTAL'
C W Lcoder's Add rcx TOTAL:
1 certify Lha'I have mad'hi.s applicminn and state that the above information is BUILDING FITE
F-' Zi u rm".I tg.....co.np1y with all cat and cmmy ordinances and slam laws mining to Q'I Y. MECHANICAL PERMIT FEE Au—,
U 2 building consumption.and heresy uuthome representative%Of NN
is city to enter upon e SEISMIC n I r
akne-mentioned property for inspemim purpouc PERMIT ISSUANCE
(We)agree to save,indemnify and keep ha aa she City of Cupertino against ELECTRIC�� EJ I'
IiuM1ilitio.judgmemx,cns'sandexpenses which easy wvy wane eguinm sail City ALTER OR ADD'IX)MECH. PLUMBIN FF.N 1
9state of Em graming mNis permit n v`Fl D 7 I
APPLIC NT UNDE ST tD . 'D LCOMPLY WITH ALL N N-POINT AIR HANDLING UNIT(TO IO,M)CFM) MECHANI AL FEIi
SOURCI REGU -
AIR HANDLINGIINI'1'(OVER 11,000CFM) CONST'RD 'PION TAX
7
.igba to of Applic nwcmr Dom EXHAUST HOOD(WIDUCF) HOUSING SNDII6AgQN.�F'ti—�� j
{ IARDOI NIA'] Rl LS DISCLOSURE
Will the applicant or fauns ildin ( cupam store or handle he ousen racial HEATING UND CDO 100.0p)BTU)
as defined by the Cupertino Municipal Ct c,Chapter 9.12,and the Health and Safety
Gds.Section 25592(a)'I HEATING UNIT(OVER I(p,"BTU)
EI Yes 7 N VENTI LAT ION PAN(SINGLE REST D) PAID Ila'c Resets#
Will the applicant or future building occasion use equipment or devices which yOILER-CONI'IJfIP OR I(MI,gMI BTU)
mit hazardous air contaminant as defined by the Bay Area Air Oe. 'tyr anagemen' TOTAL:
De ried? BOILER-COMP(OVER 100.000 FIT U)
❑Yes ❑N. 2—
I
I have real the ha u mat net,requires is under Chapter 6.95 of she Cali- A]R CONUIT'IONER ISSU NCE DATE
/f
fomia 5b& act ,Sstio 2 155, . 25534.1 unJcrstanJ m'iIthe NEW RESIDQNHAL.MECH. SQ.FT. 13 Q
bun ngdoemntl - yh . .dna Its I Iy ccs I sibiruymnnlifylh oxupu' t /
11
requiren soft critical (kuAnd.ambo ragent ()me c TOTAL: ISSUED BY:
ner
OFFICE