99080012 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RUILDING-ELECTRICAL N
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.-MECHANICAL
BUILDING PROJECT IIXEbGDFICA'rION
BUILDING ADDRESS: * SANITARY NO. APPLICATION SUBMITTAL DATE
ficwk � z- 4 9
l 'WNlilt'S NIIIAMIi: PH NE� , COM'RACTOR:S NAME: I I LIC NOO, N/C COMAOLIf
CIIITF,C IENs.INEIi LIC NO, ADD IiSS' 7 f( ❑
Co., Cr: Q I n / /Q, p PHONEBUILDING
�/y� 9 BUILDING PERMIT INFO
m Y1 lil9(M [e`�•�-16)_Il� U I/� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECCH
�C
LICENSED CONRACE OR'S DECLARAION QTY ELECTRIC PERM IT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
W d'Z with5ation700Bofoivision 3 name Business and Professions Code.andmy license is RESIDENTIAL
WOO PERM1'1'ISSUANCE � �
F WD in full fits,end.1811. ❑SFDWL S- TCIIENREMODHL
License Cl. a en Lica . APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING R&PIPE
GU1o,I Dam colnmaor_
ARCHITECTS .CLAN ❑MULTI-UNIT [I STRUCTURAL
ZQV=iZ sends. dray plans Il h,dad as Pahl orfs PANfil.ti
MODIFICATION
OZ�O 0 i UP 10200 AMPS
El INTERIOR ❑CHIMNEY REPAIR
I.icemcJpm4ssinnnl i h 201-1000AMPS IMPROVEMENT ❑SWIMMING POOLS
may$-1 OWN$ -11UILUli ECLARATION OVER IINpAMI'S LYBATH REMOD REPAII{_❑DP.MOLITION
y5 Q 1 herthy aRnn that I am exempt rum the Contracto s License Law for the C'/--'p
X;1 U following reason.Station 9031.5,Business and Professions CWC Any city or county SIGNS ELECTRICAL ❑OTHER
W lis vFi which requires u permit to con.tmcr,alter,improve,demolish,or repair any surname /✓
u'04t
prior o its issuance,also requires the applicant for such permit to file a signed smmmenI SPECIAL CIRCUIT'/MESC.
�Ny that he is licensed puuuentwtheprovisions oftheComracrorsLicenxLaw(Chapter 9
W no COMMERCIAL:
lest he
(commencing h basis her
menet rasand Pro'esCM1asum.11 TEMP.MINER OR POLE INST.
6 a e tY that he is exempt thercfrom and the basis for the alleged cacmption.Any violation of (1 NEW BLDG/ADDITION El DEMOLITION
Section 9031.5 by CC,.,Plicunt for.pcmritsubjects the application,a civil penalty of POWER DEVICES ❑TENAYT ❑FOODSERVICE
not more Shun Use hundred doll.,($500r
Q Fl
IMPROVEMENT
= I.as owner of the ppy.enor my employees with wages as their role compensation. SWIMMING POOL ELECTRIC
W F.O willdothe work.andthe.wcture issot intended oroRered for,Te(Sec.9064,R....i— ❑ ER
W�'m and I'rdesaons Code',The Contractor's l.iecn,se Low does not apply m rot owner n1' OUTLT?'fS-SWITCHES-FIXTURES
pmpcny who hull&or rmpmves Ihctron,and who does such work himself or through A
his own employees,provided that such improvements are not intended or ane for NEW RESIDENTIAL ELECfR SQ FT. ($
sale.IL hasever.lhe buil ding or improvement is sold within one yearof completion
the IS
lJ .FT.Foir)R Q.FT.
erbuilder will have the burden of proving that he did not build or improve for par-
pose of,IC.j
❑1,as owner of the property,ant exclusively contracting vi It licensed cnnowho, ,, TOTAL: AUG 2 199
answct the pi(Sec.91006,Business and Professions Cnec)Tout Contractor's ri-
nseLaw does not apply toana%net of Iterpeny who builds or improves thereon.and QTY. PLUMBING PERMIT FEE Jf
who contmets for such projects with a wamctorO)license(]pursuant to the Contractor'. Q
License law. PERMIT'ISSUANCE kJs/
❑1 am,stamp under Sec. .B&P C for this mason
ALTER-DRAIN&VENT-WAS ER(EA) VALUATIOK
east Darn
WOR KF.R'S COMPENSATION DECLARATION BACK FLOW PROTEGE DEVICE I�
I hereby affirm under penalty of perjuryorwof the followin,dedarmna: / 5
I have and wit l mainSam a Cnnifiene of Chosen(lCAlf-nature 6r W.Ner'a Cnmpen- DRAINS-FLOOR.ROOE..AREA,CONDSTORIES TYPE CONSI'RUMON
tion.as provided for by Section 37p of She Luther Code,for the pedam once of th ,/
work for which this permit is issued FI%TVRES-PER TRAP K
❑ I have and will n o urem Wnrkcr's Cnropunsatimi I...ranuo.as required by Section
37M afthe Labor Code.for the performmoe of She work for which this permit is issuM. GAS-ISA.SYS'I'IiM-I INC.6 OUTLETS OCC.GROUT' / �I'N Q
My Worker'.- sari In rat currier and Policy p�.(�C���y1C,�¢,. /J, tO
Carrier Palicy Na.:�' -G / GAS-EA.SYSTEM-OVER 6 SEA) El O
(PICA I'E% PITON FROM OR ERS'_V GREASUINDUSTRL WASTE INTERCEPTOR
COMPP,N$ATTON INSURANCE: BUILDING DIVISION FEES
Thi-,,tion neor not he mnrplemA fthepennit is for ane hundreA rallnra 151001 GREASE TRAIT
or less) PLANCHECK PER
I cenify that in the performance ofthe work for which this permit is issued.I shall SEWER-SANITARY-STORM EA.RISE FT.
oat mnploy airy'ersnn i n any haumr so user Income subject to the Worker%Compcn- ENERGY HE.
O Z ,tion Laws of California.Das WATI7R HEATER WNENT/ELECIR GRADING FEE
Z O Applicant
y NOTICE TO APPLICANT:It,doer making this Ceniocme of Exemption,you shoulJ WATER SYSTEMIIREATING
F ' become subject to the Workers Compensation provision%a1'the Labor Cade,you must SOILS FEE
Lakl forthwith comply with such previsions or this permit shell be deemed revoked WATER SERVICE
G CONST'RUCT'ION LENDING AGENCY NF,W RESIDEN'T'IAL 1'LMB. SQ.FT. PAID
7 Z pate Receipt a
U O Thereby affirm tom there is.Construction(coding agency Gosh,perfnrmarrce of
rat
the work fohich r wthis pomp is issued(Sec.31P)9,Civ.C.)
0 ILender' TOTAL:
s Name TOTAL,
LE 1<nd,rs Address '
} y 1 Certify that T base read this application and state that the above information is BUILDIN FEE
Corneal,Iagree ter comply with all City and aunty art Choose, ad ,are Tmv—daling nr QTY. MECHANICAL PERMIT FEE
V Z building Construction.and hereby duthariie representatives of this city to enter upon the SE 'M 'PELT
above mentioned property for inspection purposes. PERMIT ISSUANCE
(Wu)agree to rev,,iado holy and keep harmless the City 01'Cupcnlno against
$LEC RIC F:E
IiabilidCajuJgmems,Costs and expenses which may in my way accrvc against said City ALTER OR ADD TO MECIL
PLUMBINII;E
in consequence of the granting of this permit,I
APl'LICAN'1'UNDF.RSTANDS WILT.COMPLY WITH .L NON-PO T AIR HANDLING UNIT TO I(I,INXICFM) MF.CIIA LFEE
SOURCE REGULATIONS. OQ
l ,�j� j AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCED.'TA%
Sigwmre of V actor `�'�/L Date EXHAUST HOLES)OVIDUCT) HOUSING MITIGATION FEE
icaH RUOUS MATE IS DISCLOSURE
the upplis horfmurchuilding cupam.storcorhandlchv.blaronr ial HEATING ONES(TO I00,000 BTU)
as defined by the Cupeni no Municipal Edo.Chapter 9.12.and the Health and Safety
Core,Section 25532(x)9 HEATING UNIT'(OVER 100.000 RTU)
❑Yes I'Nal Vi LATION SAN(SINGLE RESID) PAID' -
IIT
Dom Rcceip p
Will the applicant or future building occupant use eint or devices which BOILER-COhP(3HP OR 100.(X0 BTU)
emit air Contaminants as defined by the Bay Arca Air Quality Management
A
District'
00
❑Yes ]N. BOILER-COMP( H ) L
I have rear the bae.urdous materials requirements under Chap tar 695 of the Cali- AIR CONDITIONER r��Tww ISSUANCE DATE
fomia Health&.Safety Care,Sections 25505.M533 and 25536.1 understand met if the NEW RESIDENTIAL Is iCH. SQ.FL Y
Shirring does nm currently hove n,thmdis my......ibil' notify
.r the oup
ccant J
nthe requires rrI,wh d,son a pilar m issuance inamcnfOjp a
Owner a arttnzcd ag Dm TOTAL: ISSUED BY:
OFFICE