S 2994 APPLICANT TO FILL IN INFORMA ON'#ITM5q LINES USE BALL POINT PEN ONLY
61TYOF.VUPERTINO If I BUILDING-ELECTRICAL PB o.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL.
4P VAXt 1. NI:PROJrC. IMENTIFICA ON r
13UIID1 G UD :SS: 30, SANITA NO. APPLICATION SUBMITTAL DATE
`2
NA S tryAME: GA PHOJA: CONT A R'S NAMM8. LIC NO'.
�• 'Q/1 N/C CONTROL is
C JTGINEER: 1T7 LIC NO: AD FSS: '1W ❑ q�
COUW
NTACT:�rFFPHONE: - -t r -';,BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELE PLU,M13 MECH
LICENSED CONTRACTOR S DECLARATION QTY ` , ELECTRIC PERMIT�. '
Iherehy.ffrm Nat lam licensed undop n. fChapmr9(commencing I,- __ ,..t f '', I ,) JOB DESCRIPTION
WOZO with Section 7")of Divi Jofaie Buwnessandd gyp fessm Cude.ardinyliceisais PERMIT ISSUANCE
�F, F mfull force nit n= (J u ��s SFDWL ❑PLUM KITCHEN REMODEL
QUp❑ license p APPLIANCES-RESIDENTIAL ❑ADDRION El PLUMBING RE-PIPF.
TSUrm
WM RCHITf?CT'S DECLARATION ❑MULTI-UNIT []STRUCTURAL
ZOt`� yPan,s a pu PANELS
IunJeramndm 1 M11lbedxed us M1I¢recoMs MODIFICATION
OZ 0 UP TO 200 AMPS [I INTERIOR [I CHIMNEY REPAIR
F ��W Licensed Proresamol 201-10MAMPS - IMPROVEMENT
ayE'� OWNER-BUILDER DECLARATION ❑SWIMMING POOLS
d C Q 1 hereby effimi Nat I am exempt from the Cnmmcmrs LiccnxI,Low for the OVER IOW AMPS t
BATH REMODELIREPAIR ❑DEMOLITION
x 3 a F following reason.(Section 7031.5,Business and Professianx Code:Any city or county SIGNS ELECTRICAL OTHER
41 Ir. which requires a permit to construct,alter,Improve,demolish, repair any structure1�0
k1. prior to issuance,ulsn requires the applicant for such Permit to file a signed statement SPECIAL CIRCUIT/MING.
2 G� that he is licensed purstood athe pmc,ion,of the Commerce,License Law(Chapter 9
W..00 (Cummeocingwl...Sectinn]WO)afEw...on3nfthe Business sod Professions Cade)or TEMP.METER OR POLE INST.
CUMVIERCIAL-
0.q rG that he is exempt therefrom and the basis for the alleged exemption.Any violation of NEW BLDG/ADDITION ❑DEMOLITION
,a=il,4. Section703 LS by any applicant for a permit subjects the applicantto.civil Penalty of POWER DEVICES
not more than five hundred dollars($500). NANT El FOOD SERVICE
[-Sp ❑1,azowner of Ne propctlY.or myempioyees with wages as their sole atmpensazinn. SWIMMING POOL ELECTRIC IMPROVEMENT
will do Ne vOmk,and the.trocture is not intendedor offered forsale(See.7044.Business OTHER
and professions Code:The Compactor's License Law does not apply at an owner of OUTLETS-SWITCHES-FIXTURES
�' property who builds dr improves thereon,and who does such work blmscR or through
his cisn employees,provided that mah improvements arc not impaled mr offered for NEW RESIDENTIAL ELECTR SO 1'T.
sale.If,however,the building or improvement issold xithinime yesroR'nmplelam.the SQ.FT.FLOOR AREA VSQ.FT
cwn,of Balder will have the burden of proving that he did not buil)or improve for put- o
pose of sOwne U a(pa
I,as owner of the property, exclusively confessions with licensed contractors to
Z T IL i Z
consumer N project(Sm ]030,,B Nosiness unit Professions Cade)Th C tract r. Li-
c .L J n t pply to an owner of property who buddso p e.th n d QTY. PLUMBING PERMIT Ili .i FEE 't'
who c ower pursuer mirriect,with.emuctraorts)licensed IF.. amt the C t t - - - i 'rt :.41 D . /Z&
�c l am exempt under Sea B&P C for this reason PERMI T ISSUANCE
At:]ER-DRAIN&VENT-WATER( - VALUATION
Dam
Nrm under
p COMPENSATION DECLARATION BACK FLOW PROTIiCf.DEVICE
T hereby affirm under Certificate
or ofCou one of the insum for declarations:
❑Ihave andwillfor byneCion 370 of Con sem m Cede,for
forerformsce ofCamped- DRAINS-FLOOR.ROOK AREA,COND. STORIES TYPE CONSTRUCTION
,cion,as provided far by Section 3]00 of the Lnbor Code,roe the performance of the
work for which this pandit is issued. FIXTURES-PERI'RAI'
I have and will are,fi n Worker's Compensation work
hi h require),i Section
My nINe LaMsr Cmlc,limh soonermana ofthe work forpler an
pemiir is issued. GAS-F.A.SYSTEM-1 INCA OUTLETS OCC.GROUP APN
Myder Compcns t m ranee carrier Polley number em:
Carries sooner, 5Y�lye: GAS-EA.SYSTEMOVIiR4(
CEHUp CATS OF XEMP ION FROM WORKERS' t
COMPENSATION INSURANCE GREASEIINDUSTRL WASTE.INTERC: k¢ BUILDING DIVISI[)N F'EIS
(Thlssection need notlecompleted ifthe permit is furore hurdraddollan(5IW) GREASE TRAP
or lass)
PLAN
I certify that In the perfornmdeanr the work for which this permit Is iamul,I,hull d
nor employ my person in any manner so as In become subject to the Workers'Comped- SEWER-SANITARY-STORM EA.2011 FT. ITS
OZ nation Laws of Calif me Date WATER HEATER WN&N'1'IELECTR
Z 2 Applicant V
EE
y NOTICE TO APPLICANT.If.after making this Certificam of Himmpti..,you should WATER SYSTEM/IREA1'ING
a ; become subject to the Workers Compensation provisions of the Labor Code,you must SOILSTIM
[Ll forhwith comply with such provisions or this permit shall be deemed revoked, WATER SERVICE
Q
Uz CONSTRIIC'TION arnon r LENDING AGENCY NIiW RESIDENTIAL PLMB. SQ.IT PAID
C.7O l for
rwhich rni that there i,wcnnswation lending agency rnrthe perfnnnana of etc Receiptp
ILL I� the work far which this permit isissued(Sec.309],Civ.C.) �. O
O LI Lender's Name TOTAL:
r Luakes Address �] AL.
(~ 0. 1 certify that 1 have read Its application d state ret the above ingratiation is - 1. - , BUIL NG
h correct I agree to comply with all city and county Ordinances and nate laws relating m 1
QTY. 'MECHANICAL PERMIT FEE
Ula idoce-matioural on and hereby authon purposes.rntatives of this city to corer upon rhe '1 SETS d
abtwe-mentmnW propcny rind emnifinspecyan l keeph - .. - -
(We)agree m Bova,Indemnify unit keep harndese the City of Cupertino ago irust PERMIT ISSUANCI? P.LFRTR PP.B
liubiliries,judgmem,s,costs and expenses which may in anyway name against said City
inconsequence of the flooding or this permit, ALI'ERORADDTOMECH. PLU NG FEE,
APP ANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT PIR HANDLING UNIT(TO 10.010 CFM)
$ EREGULATIONS. M[CHAN IAL FEE
L,7_31-
� g�C_y/Q/J AIR HANDLING UNTT(OVER 10,0(10 CFM) CONSTRUCTION TAX
Signaure ofApplic and C�Ya�i m/7 EXHAUST HOOD I W/DUCT) HOUSING MITIGATION FEE
IAZARDOUS MATERIALS DISCLOSURE
Will he vppli,manr future huildingwcup...smsot handle hazardous material I117NFING UNIT(10 101,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Haahh and Safety
Cole.Section 25532(x)? HEATING UNIT(OVER 100,000 BTU)
EJ yes o PAID
VENTILATION FAN(SINGLE RFSID) Date Receipt If
win,hpos attrition,main re building occupantuse ea Air
mdevices which BOILER-COMP OR 1WA00 BTU)
unOf hazardous sir contaminants az Jenne)by the Bay Area Air Quality Management TOTAL:
OTAL:
❑YesNo Itt111.P.R-COMP IOVItIt Ifl(1,00 BTU7
I have read the hamohm,mamdals rot is ter 6.95 of the Cali- AIR CONDITIONER
ryiremen under Chapter g111f DATE �k
hamia Heahh&Safety Csde,Sections 25505,255JJ and 2553).I umkrstnnd Nm if Die NEW RESIDGNTIAL MECH. S FT.
hail is ce,xnmcumentlyh ve normal, it is my mxFmsibiI tyio motif the acupmI Q
icquiremenes which a be rad prior to issuance of a Cert icat of
uthor >' a ISSUED BY: �O
OFFICE _r
. 111• -,'(.;'• ' .�
Ls ��� s
i
i
I
i
Inspection Query for a Specfic Permit 8/29/00
OT
*� JSEUW
:FRE
S2995 111029 ISYCAMORE 131 JUNDFLR PLBG 5/24M0 5/24/00 DS IP
S2995 11029 SYCAMORE 31 5/24/00 5/24/00 DS IP
S2995 111029 SYCAMORE 131 IFOUNDATION 6/5/00