00010099 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPIACATION/PERMIT PLUMFING-MECHANICAL
BUILDING IBOJECIIDENTIFICATION
BUILDING ADDRESS: • SANITARY NO. APPLICATIONSUBMITTALDATE
10216— lo&S Pink C1✓cte � . 6LLKP H"° lza - 20(:>0
OWNER'SNAiEkLc C� PHONE: COSTS LIC LIC NO'.
o(,(/N`h�F/'U\ NIC CONTROLp
UICIIITid:77 GINEER LIC NO: ADDRESS: El
SZ) C 1 -7 l ob $ 204w k&"c�5CV L.A".a .ewe'at 4fd Q14.17?
CONTACT PHONE. BUILDING PER MITINFO
�kLIIA) CJI O:r ((;10 ?S I'L 1irO ❑ Consultant Foes Paid by Applicant(Initial) BfL/D�G// ELECT PLUMB MECH
LICENSED CONTRACT ORS DECLARATION QTY. ELECTRIC PERMIT FEE
1 herchy affirm that 1 am licenxd under provisions Of Chapter 9(commencing JOB DESCRIPTION
Zwith5cction 7mXhOl Division 3ofihe Bnsinmcand Professions Cade,dorm,license is RESIDENTIAL:
WO, PERMIT ISSUANCE.
F�.. in full Lncc..d dfcct. OSFDWI. p.IP1eTCHEN REMODEL
aZW License Class Lick APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING REPIPE
NQ6 Date TrS DEtor
'D. ARCHITECTS DECLARATION PANELS OMULThUNIT ❑STRUCTURAL
Z O n Z 1 understand my plans shall he used as public records MODIFICATION
OZ—C UPT02MAMPS [I INTERIOR ❑CHIMNEY REPAIR
��.F+W Licensed Pmfesslonam 201-10(M)AMPS IMPROVEMENT C]SWIMMING POOLS
J OWNER-BUILDER DECLARATION
C a' OVER ImX)AMPS CLAA'FH REMODEIIREPAIR C1 DEMOLITION
6 1 hereby affirm tM1m 1 um exempt from the Comrnetor'e Liceme Law for the
X 3 6 V following Oc mn.(Section 7031.5.Business and Prodsoin.s Code:Any city or roomy SIGNS ELECTRICAL ❑OTHER
W LL y which requires a permit to construct,aIle,improve,demolish,or repair any strvemre C A
Prior to its issuance.also requires the applicant(orsuch Permit in file a signed statement SPECIALCIRCUR/MISC.
f of that he is licensed pursuant to the Provisions of the Contractor'%license Law(Chapter 9
Wap0 (commencing with Sell nYIX10lot Division 3 of the Bovines and Pndessions Cod0or TEMP.METER OR POLE INST. COMMERCIAL:
P'. ca Ih d N,,vava P,therefrom and the busts for the alleged oxen auto Any siolatlon of 0 NEW BI.DG/ADDITION 0 DEMOLITION
I N Section 7031.5 by any applicant Into pcnnh schy",Ne applic:mt to u civil pcnthy of POWER DEVICES ❑TENANT 0 FOOD SERVICE
� not more than live hundred dollars woo). IMPROVEMENT 0 ]Lazmvner of the progeny.or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC 00THER
F will do the work,andthcswaure is nm imendM or olfemJ lmsale(Sa.](]44,Business
L3 m and Professions Codd:The Cco rectors License Law docs not apply tO ea owner of OUTLETS-SNITCHES-FIXTURES
1 property who builds or improves thereon,and who does such work himself or through
his Own employee provided that such improvements are not intended or uttered ler NEW RESIDENTIAL ELECBne
FT,.le.it.hnwcvcq the huiliingorlmprovcmuut issold withinnnc year ofmmplctimn the SQ.PF.lq,00R AREA ISQ.II
builder will have the burden of proving that he did not build or improve for pun- (� ��V, Il
wale.).
r of the progeny.am exclusively contracting with licensed contractors to T AL:
Ile .0
construct the project(Sec.704ua,Business and Professions Cnde:)The Contractor's Lb F.I Q O 2000
Once Law does nm apply to an ow nor of property who builds or improves themtm,and QTY. PLUMBING PERMIT 1`I (.I
woo conmoas Lnsucn
Uo,eco.1ts uttmmuctnr(s pursuant mine Cnnwctor'%
hicenu Lt VERMI'I'ISSUANCE
❑lam exon %Jen Sur. ,B&PC for this rens...
Oxnc ` Dae ALTER-DRAIN&VENT-WATER(EA) tJy_ VALUATION_
oSr
WORKERS COMPFNSATION D .ARATION BACK FLOW PROTECT.DEVICE (+��
I hereby afGna under penalty Of perjury one a following declarations:
l have and will maintain a CeniticateofConsem to self-insure for Worker'%Compen- DRAINS-FLOOR.ROOF,AREA,CONI). STORK 'TYPE CONSTR ULTION
_cation,m providial fur by Section 31(X1 ofthe Labor Core,for the porb oosome of the
work for which this femur is isoed. FIXTURES-PERT kAV
❑ I have and will maintain W'orker's Compensation Insurance,as required by Section
3700of me Labor Code.for the performance ofdo work for which this pemtit is issued. GAS-IiA.SYSTEM-]INCA OUTLETS OCC.GROUP � �E
My W'orker's Compensation Insurance curia and Policy number am: J
Cameo Policy No,: GAS-IiA.SYSTEM-OVER S(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GRiiASFIINDUSTRL WASTE INTERCEPTORCOMPIINSA'TION INSURANCE BUILDING DIVISION FEBg
(Th-coinn need not he c.....ptrend i l the permit is lar one hundred dollar,($I W) GREASE'I'RAI'or less) PLANCII I?CK FIiP.
Icertif,,uu inthe perfomtance nfthe work for which this pemdt isnubd,Isbell SEWER-SANITARY-STORM EA.20011'.
not employ any person in any manner so as to became subject to the Wadwri Compen- ENERGY FL•E
O Z scion Laws Of California.Dam WATER HEATER WNCNT/FLECTR GRADING PEE
.Z Applicant
.N. NOTICE'10 APPLICANT.If,attar maAing this Cenifeme of Exemption.you should WATER SYSTEMNREA'1'ING
a '
becomebjeco thm
e Wa U.-Cnpenaaioa ao,Olons oldie lobo,Code,yoonrwt SOILS Ie,?E
mn
lonnwith comply with such provision%..,In,pcnnh%hall be derned revoked. WAFER SERVICE
Q
Z) Z CONSTRUCTION LENDING AGENCY NEN'RESIDENTIAL PLAIN. SQ.FT. PATO
V O IhertFY off nn that there isaamswaion lending agency Earth,perfonnanee of [)are pt
Receis
Dr F the work for which this permit is issued(Sec.3097,Ci,C.)
TOTAL'
OV Lender's Nonni
WLeaderTOTAL:
Leader s Address
y 1 rendy taut 1 have rend this application and alum that the above infmnmnian is BUILDING Illi
to correct.l agree m comply with all city and county ordman...and state laws editing to QTY. MECHANICAL PERMIT FEE
V Z building construction,and hereby authorise represenutives Of this city to enter upon the SEISMIC FEE
abtwe-mentioned Ptopeny for ire,croon pin"ses. PERMIT ISSUANCE
(We)agree or cove,indemnify and keep harmlms the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expends which may in any way accrue against said City A LTER OR ADD TO M ECH. PLUMBING FEE
in vm,Nue coltnogruntingoftNx 105 man,
APPLICA RSTA SA f .CO Y W FH ALI,NON.PONr AIR HANDLING UNIT(TO 10,000 CFM) MECHANICALFFB
L.AHON
` AIR HANDLING UNI'I'(OVER 10,000 CFM) CONSTRUCTION TAX
i r
atom APPIicaMCo I run Date EXHAUST HOOD(WIDUCp HOUSING MITIGATION Fl3E
HAZARDOUSMAI'FR1ALS DI ,OSURE
Will the nPPllcam nn fmnre building tmcupvm t orhandleharnNons material HEATING UNIT(I'0100,1X10 BTU)
I us definul by Lha CrTemara Munieilnd Code,Chapto .11 and the Health unit Safety
Cole,Seai...25532(01 HEATING UNIT(OVER 11101X10 B'IT)
0 Ye. 0 No PAID --
VP.NTILATIONPAN(SINGLF:RESID) Date Receipt#
Will the applicant or future building occupant me equipment or devices which BOILER-COMP CHP OR 100AOO BTU)
it haysdnus air contaminants as defined by the Buy Area Air Quality Management TOTAL:
vail BOILER In),000 BTU)
0Yes oNn 3 3 3
Ihaverewlthehanrdnusmaon,S[Smq mi undc,Chapta fi95nftM1e Cnli- AIR CONDITIONER ISSUANCE DATE
r
poor Health fury Cowk, riot 255 25534.1 undmmtxl that if the NEW RESIDENTIAL MECH. SQ.UL 2 Q_ 2_c,O rJ
lmilJin twrrcndY cam t,t art y un msihilitymnotify the occupant
n Uc rty ctmnts hie npnO ofa CcniOcam of Occupancy.
14
Owner.. wan,odagcot u [)are TO'PAL: ISSUEDBY:
OFFICE