S 0397 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT No
BUILDING DIVISION APPLICATIONFI'ERMI'r PI.G.MBING-MECHANICAL S 0 3 9 7
BUILDING PROJECT IDF,NTIFICATION
�/+J J� /�J �/� SANITARY N(I. AI'I'LICAT[ON SUBMITTAL.I)XIE
HUIL140 D Ili Nm Y/II �/ W/ C �C g
OWyER'S.NgAfE: PHONE: CONTRA R:S NAME: LIC NO: NIC CON['ROLk
\RCI 11111 PCC OHNGINEER: LIC NO ADDRESS: 1:1� ILDING PERNHTINFO
CONTACT: PHONE:
11PConsultant Fees Paid by Applicant(Initial) Bury 111.IiC" PLUM, tern
O /u� ❑
LICENSED CONTRACTOR'SD L ATION QTY ELECTRIC PERMIT 17EE JOB DESCRIPTION
I hereby eRinn Mat I am licensed under pownimis of Chapter 9 murnmen am,
MWZwith Section VIX101of Division Sol the Rosiness enJ Pofes,innsC c.and my liana is RESIDENTIAL,
NTIAL,
�1_ in full force and eRect. pF.RMIT ISSUANCE EL❑KITCHEN REMODEL
aVV hmarreC _ LiaN gppL1ANCE5-HIiSIDENOAL INTION ❑PLUMBING RE PI1'Ii
tF�µLL1 Du¢ Cnmmeh'r LTMH1.1 MINH ❑STRucruRAL
Cry' A Clil'ECI'SUI:CLA A'I'ION PANELS MODIFICATION
F D Z I understand my plan,shall he used m Odiic rttnrds
OZ`—m UPT0200AMPS ❑INTERIOR p ,allIMNEY REPAIR
O IMPROVEMENT? Y''�k E]SWIMMINGPOOLS
[.�iF.ly LiwnmJ prnR's,mml OVER
I'S
OWNER-BUILDER DECLARATION
C W Q I hereby affirm that 1 um exempt Irons the Contractor's License Low for she OVER ELL TRIC ❑BATH REMOOIiI/RIiYAIR f CATION
j�3 a V Iidlewing reason(Section 7031.5.Bmineax and Pmfnsim s Gods:Any city or eauntY SIGNS ELf:CfRICAI. C]OTHER {l
W LL y which requires a permit to construct,alter,improve,demolish,or repair any structure
pnonu its issuance.atm requires the vpplieam for such Permit o file v signed statement SPECIAL CIRCUIT/MISC. .. D
E y that he is licenred pursuant m the provisions of the Commen'%License Law(Chapter 9 FR V
W a C) (commencing with Section 7000)of Division 3 oflhe Business and Pmfcssinns ewe)it TEMP.MU17R OR POLr:INST.
t i Mulahe is exempt therefrom and the basis far the alleged exemption.Any violation of ❑NEW BLD ADDITION ❑DEMOLITION
WIN Sceiion 7031.5n applicant for lsubjects the applicant o civil II f ENEWRESIDENTIA1,
y any apP pcntd J PP Ixnu y n ❑7F,NANT []FOODSERVICE
t marc Ilan live hundred dollars($5tXp, IMPROVEMEN'P
�ydQ I;mowncrnt the pmpcdFar my entpfoyce,with wages m lheirsolc cantpcn'ta"m. LECTRIC
w 111 int the work,and the arucmru is not intended.....fared kn otle(Stu.9044.[ktsinuss El OTHER
anA Erofcxsinns Ctdc:The Contruunsr'x Liccnm Law docs no,apply m an awncr of li$-I'IX'fIJRC
property what build,m improves thereon,and who does such work him.wlf nr though EhliCl'R SQ Fr.his own employee,,provided Malsuch impmvemcnts am not intended or offered forSQ.I-L FLOOR AREA $ISQ IT.
mole.IL however,the building or improve rem is sold within one year of completion,the
mer-builder will has',the burden of paving that he did not build or improve fur pur- , ]r
ptve of xiTOTAL:
❑L ax over,of the pmpedy,um exclusively common,with licensed Common to
construct the project(Sec.7 4al.Business and pmfcaiuns Crude:)The Common,',Lieci - FEC
se Law,does not apply to an ownerol property who builds or impnove,Mereon.and QTY. PLUMBING PERMIT
who conuucl.s fur such projects with a eommoms0licensed pursumno the Cantemor's
Liana Law'. PERMIT ISSUANCE
❑ I an.,coda under Scc. .B S,PC fur lhi,mall
on
nt ACIL'R-GRAIN IS VENT-WA'1'P.R(EA) VALDA'IION _
�Owner Duro
WORKER:SCOMPE gAIIONDF.CLARNHON BACK FLOW I'klYrliCl'.DE VICE. O
1 hiald v0irm under penalty of perjuryone tothefmllow mef dcelke,Cs
(](have and will mainminn Ccdificae o(Cnnsenuo molt-insure fur Worker's Cnmpem DRAINS-FLOOR.ROOK AREA.COND. STORIES TYPE.CONSIRIICI'ION
amn,as provided for by Section 3900 of the Labor Cede,for the performance of the
work for which this permit is issued,
FIXTURES-1'f:R'TRAI'
I have and will maintain Workers Compensation Insurance,as remained by Section
37X0 ofthe Lnbni-Cale.for the psromanrnfor,work mrwhow
d,
this permit isissd. GAS-EA.SYSI'IiM-1 INC.J OUTLETS OCC GROUP MIN
My Workers Compensation Insurance comer and Policy number are: OAS-EA.SYS'fEMAVIiR J(EA)
Conner Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' GRI:ASF/I NOU STRL WASTE IN]FREEST OR
COMPHNSA'I]ON INS U RANCE I )I (VISI ILIUS
('Ihi,s.molon need ua lrecnntpincd i f IM1e pcmail 1,floor,modnddolla,($101) GREASE TRAP PLANCHEC Cl
or Ica.7
I certify that in the perlirrmunec nl'Ihc work fur which this permit is lssued,Ishall SEWER-SANI'T'ARY-SORM EA.XX)F['. ENERGY i1i
not employ any Mrson in any munneno as b beam w Ject us IM1e Wnd.ri Compen-
z scion Low,of i'rni tc J WATER HEATER WIVIdxTELECTR GRADING ]i
ZO Applicant E
N. NOTICE TO APPLICXNT.IL a lar mukm OIs Ccmficam of Exemption.you should WATER SYSTEM/fRIiU'[NG SOILS FEE
a > Mnsmc subject to Me Worker's Compensation provision,of the Tutor Cock,you must
funhwiah comply with such provisions or thin permit shall he deemed revoked. WATER SERVICE
0. G 1
CONSTRUCTION LENDING AGENCY NEW RESIDENI'IAL('LMB. SQ,17.. PAID
7 ztime Receipt p
V k tor
ichthi that Mem is sued(Sec.3( lending agency.) tor,he purhvmanec of
� Mit,work aur whim lM1ia pcnnit is issued(See.3(19].civ.C.)
U17' Lender's Name RHAL:
W lanim,Add,,,, JURLDIN 'lilt
G 1 credit,that 1 have read thin appficntion and slam The,the abuse mutilation Is
L
te umttt.l egrccmcomply with allcily and county odinancesund stmt lows mlmingm QTY. MECHANICAL PERMIT IIiF; SEISMIC FEE
U building construction.and hereby authorize representatives of this city to enter upon the
alawe-mentioned property for inspection purpose,. PERMIT ISSUANCE ELECTRIC PEE
(We)agree to save.indemnify and keep harmless the City of Cupertino against
linbilities,judgments.cos¢and espenses which may in anywayacerue agoinasaid City ALTERORADDI'OMECH, PLUMBING ITE
in mwquence of the gaming of Mis peanut.
APPLICANT UNDER TANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNir(TO 10,000CF,M) MECHANICAL IT
SOURCE RE ULAT S.
-VV
o✓y^/� RUCTIONI
-9h AIR HANDLING UNIT W.000 CFM) CONST
Si,petff5FAppli<nVContractor Date C
EXHAUST 11001)(WIDUCf) HOUSING MI'1'IGAA R Nhili
HAZARDOUS Mail TRIALS DISCLOSURE
Will the applicant or fame buildingaCupanl more or handle hazardous mmerivl HEATING UNI1'N 01(X),0k)BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and IM1e Ileahh and Safety HEATING UNI'['(OVER J00,000 BTU)
Culp.Suction 25532on?
0Ycs (J N'oVENTILATION FAN(SINGLE RESID) PAID
Dane Receipt
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(311P OR 100.000 BTU)
mit hazardous air contaminants inas as defined by the Bay Area Air Quality Management TOTAL:
District l a� BOILER-COM P(OVER 100.007,BTU)
❑Yes {�No
I base rend the n ors,Sp ion,25505,25533
5 r,25533 ma aorta Chapter 6.95 ol'the it he
AIR CONDIIR)NER ISSUANCE DATE
fbmlu,doesnSafety
l,ha Scdinns25505,2s933and25531.I aI lilydLhait the NEN'k1iSIUEN'I'IAI.MliCli. SQ.IT.
,I do,reams no,cum:ich host bit e 'all Mut 11 L,my re III a Cally m nofdy Mc.xcopvm V
of the requircmanls which most he mm prior nr Iswantts nl n Ccdificum ol'(kcupunuy.
TOTAL: ISSUED❑Y:
Owner or authorized agent
Dale
OFFICE
Yrf
O 1� 17O �q i 12.
ISL A Al
L
2x 64
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.r
PWT p� Mid
FD. 137
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L-v,_._..._._.__.. .:. ° VON
1991
offib"E C011py O�pG- 60 pF