S 4394 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPIACATION/PERMIT PLUMBING,MECHANICAL S 4394
BHILOING PROJECT IDENTIFICATION
BUILDING AHDDRESS. SANITARY NO. APPLICATION SUBMITIAL DATE
/ 0 / 71 Par le 7_ 7_4
OWNERS NAME: PHONE: CONTRACTORS NAME: LIC NO:
1,C60
Og 0 SOW V SA! Z NIC, RO
CONTL g
ARCHI'IECVENGINIiRR: I.IC NO'. LI) V Nose// < <+ ❑
IM CONTACT: PHONE: BUILDING PERMIT INTO
❑ Cansulfanl Fees Paid by Applicant(Initial) BLDG tLECT PLUMB MECH
R.,: o b� /66a ❑ ❑ ❑
LICENSED CONTRACTOR'S D'CI.ARATIONQTY ELECTRIC PERMIT FEF.
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Q0
C' with Scainn 1pfl(Il ofnivisi9n3of the Business and Rofessinns Cole,undmylicenseis RFSIDENTIAL:
WOO PERMIT ISSUANCE
C�' in full trace and eli�'t"t33 V -Z '3 f/ 0SFDWL KITCHEN REMODEL
y U U Liwtue ' sx G Lie.M O
yawn Date Commaor Cc+ 'JY APPLIANCES-BESIDIiN'1'I Al. ❑ADDITION OPLUMBING RE-PIPE
Oy A CHITECPS DECL A ION PANELS ❑MULTI-UNIT 0STRUCTURAL
Z
1-D.
-Z I understand my plans shall be used m public records MODIFICATION
OZ 4O UPT02MAMPS [:1 INTERIOR IMNEY REPAIR
Licensed Pone....ran PBI-IgXIAMPS IMPROVEMENT 0SWIMMING POOLS
?
OWNIR-BUILDER DECLARATION
C Y OVER IPit AMPS 0 BATH REMODEUREPA1R 0 DEMOLITION
C Q 1 hereby affirm that 1 em romapt Imre the Commanr's License Law fur the
X3IL U following reason.(Section 7631.5,Business and Professions Code:Any city ores unty SIGNS ELECTRICAL ❑OTHER
W LL N which re,uires a permit to construct,alter,improve,demolish,or repair any smicmre
E'LLO-1 priori I. 9 thef h 1t In signed yPe SPECIAL CIRCUIT/MISC.
B�yOhio he licensedp u E p fth C t t 'eL 1 (Chapter
CC, (commencing cng with Suion 7(XV)of Dtvisi n?tithe Buetcaa dI' [.. nscode)or TEMP.METER OR POLE INST. COMMERCIAL:
a a e IY that he i,eaempt therefrom and the basis for the alleged csemption.Any violation of 0 NEW BLDG/ADDITION 0 DEMOLITION
�^y
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES 0TENANT 0FOOD SERVICE,
not more than five hundred dollars($501).
IMPROVEMENT
$ Q pLas ow,net oftnepesholor Tyemployees with wages as tcirsole nsmpensation, SWIMMING POOL ELECTRIC
u13will dntlw tions nod theFile c is not Connector's License Law does sal apply o an o err,os O GTHER
w and eny wholo Code:The usesch License Law Jots nm apply s if owner,of OUTLETS-SWITCHES-PIX
progeny won builds or improves such improvement,end who docs sucn work himdeed of anhrough
his own owever.the building tram sucn esoldw am not intended or offered for NEN'RF_SIDfiNTIAL ELECTR
sale.q bmveveemhebull he Isar en at anent is be within one build
or i provetfor the ?Q�, FL66R REA D Q.FT.
pur-M1uilJer will have enc buNen at roving that he did not nogg or improve for bur- '
secof salt.). I 7 1999
❑ 1,as owner of to propenX am exclusively contracting with licensed contractors m TOTAL: JUL L _ - 1sR sec s/
onstrua the project Pol.]IWC.Business and Professions Code:)The Contractor's Li-
uLaw does Own apply it)an owner ofproKny who bonds or improves the¢nn.and QTY. PLUMBING PERMIT I FEE
who contracts for such projects with a commanr(y licensed pursuant o the Contractor's p
License Law, PERMIT ISSUANCE By
Iran exanpu under Sec. .B&P C far Ibis reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of Perjury one of the fallowing declaretione V
❑ I have and will maintain a Ceni ficam of Consent o self-i asure for W'orker's Compen- DRAINS-FLOOR.ROOEAREA,COND. ST RUTS 'TYPE CONS IRUCTION
satin,as provided for by Station 3]1X1 of the I'mm,Cale,for the porfonnnnee of the
ark for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Woders Com scrionon Insurance,as required by Section
3100ofthe labor Code.forthe perhormancenfthe work for which Nes permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Wor QQ rap'(sntitm Iyw a br and Policy ny Eby y
Cmuen,Y G i-T / --sA L/ Policy Na,:("a oo� GAS-P.A.SYSTEM-OVIiR 4(BA)
CEROIICA'1'17 OF EXEMPOON FROM WORKERS'
COMPENSATION INSURANCE GREASF/INDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
Oils scentancednotbecionlaed if the permit is forme hundred dollars(SI00) GREASETRAP
or less.) PLANCIfECK FEE
I certify that In the Performance of the work forwhich this permit is issued,l shall SEWER-SANITARY-STORM BA.21X1 FI',
na employ nny person in any Tanner to as m become subject it)the Workers'Courtin- FEE
� Z saian laws of California.Doc WATER ABATER WIVEN'UFLECTR GRADING FEF:
Z O Applicant
NOTICE TO APPLICANT.If.after making tris Cenifcme of Esemption,you should WATER SYSTEM/BEATING
I-' r become subject m the Workers Compensation provisions of the labor Cone,you must SOILS FEE
WI� fonhwith comply voli powisions ni,this permit shall he deemed revoked. WATER SERVICE
7 Z CONSI'RUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.ET. PAID Receipt a
UC) I hereby affirm that there is a construction lending agency for the verfnmiance of
F" the work Ea which this permit is issued(See.3097,Civ,C.)
C) ULender's Name TOTAL:
W Lender's Address TOTAL'.
Pt I cuT,that 1 have read this application and sunt That the move ioliantation Is BUILDING
F rp cunect.l asrce mcnmply seder all city ung county oNinanees ung sit l....doing in Q1 Y. MECHANICAL PERMIT FEE
UZ building tr amnion,and heabyaor
uthrsse
e reprenttivcsoftnis city to enmrupon the SEISMIC FE.
Abate-mentioned progeny for inspection purposes. PERMIT ISSUANCE
(We)agree of snve,indemnify and keop rAnnless the City o[Cupenino against ELECTRI 'E
IIablliulcs.judgntcnts,aosts aud,s,enw,which may in any way accrue againstsnid City ALTFRORADDTOMF.CH.
in n.n9ucnce of the granting of tris permit. I'Ll1MHING F'C
APPLICANT UNDER TANUS NO W ILL COMPLY WITH ALL.NON-POINT AIR HANDLING UNIT(TO 10.1X10 CFM)
MECHANICALNIC
SOlji)RE i S. _)_-) —qf
��J\ AIR HANDLING UNIT(OVER I0.000 CFM) CONSTRUCTIONTAX
SegnautrcolApplicmi,Co.doe"or O:uc EXHAUST'HOOD(W/DUCT} HOUSING MITIGATION FEE
HA%A RDOUS MA'T'ERIALS DISCLOSURE
Will the applicant or future building occupant store or handle Incautious material HEATING UNIT(TO 106.(0X)BTU)
as defined by the Cupenino Municipal Cale.Chapter 9.12,and the Health and Safety
Cale,Section 25532(x)1 HEATING UNIT(OVER 100.000 BTU)
O Yew ❑Nn VENTILATION PAN ISI NO LE RESID) PAID
Dale Receipt#
Will the.pp anti nr future building occupant use e.Air u on Jwlces which
emit rauNous air amtaminunts as dc6nW by the Bay Area Air Quality Management BOILER-COMP(3HP ON 100.000 B'TU) O
Tl'A
4 D4f�huirvapml,
1 BOILER-COMP(OVER 100."BTUI
es ON.
wered the nv.allous mnt,Wk w under Choler R,95nf the Cali- AIR CONDI'I'[CHER ISSUANCE DATE
equircmcn Ch,
n.,
ih&Safely Code,Sections 25505,25533 and 25534.1 underoad that if the NEW RESIDENTIAL MITCH, SQ.FT. ,7 �� 7
cs not current haveat rat tomtit is myresrymsibilitym notify the occupant
Ts",in
wolf muu tn. tossuanceof.Centfcate.. rano.nthorireJ ngem Date TOTAL: ISSUED BY:
OFFICE