99080104LIE
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY .A*--qq u/) (/ 10 L{'
CITY OF CUPERTINO BUILTNG - ELECTRICAL
I'
BUILDING DIVISION APPLICATION/PF,RMIT PLUMB NG
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS:
SANITARY NO.
AP�P,I/�(CATION SUBMITTAL DATE
\Q 1� r1Q. rr �`
�??
OWNERS ME: PHONE:
"iOV O�1
CONTRACT(lR'$NAME: LIC NU:
, ' ns l00
NIC
❑
CONTROLN
ARCHITECIOENGINMR: LIC NO:
ADDRESS:
Jm7 /ngi7*4.4n4 art. 54,441x$
CONTACT: PHONE:
t
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
RID ELECT PLUMB MECH
-IO
ILS zi ❑ ❑
LICENSED CONTRACTOR'S DF:CLARA'HON
1 herehy emote that I am horsed ander provi.htn. of chapter 9 atmnmencing
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
PERMIT ISSUANCIi
with Seetien 9(NNp of Divisimt3 of the Business and lYnfa'wioGnsCec. and my liccsis
in lull Race and SQ ct. I L
C as ,' I Lie. a SS.
License a
Dae -—Comes J•l¢.nT2 Sg-�IS9ri
RESIDENTIAL:
[ISFDWL E3 KITCHEN REMODEL
❑ADDITION ❑PLUMBING RF. -PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR El CHIMNEY REPAIR
IMPROVEMENT 0SWIMMING IDOLS
AFIM,IANCEti-RESIDENTIAL
ARCHITECTS DECLARATION
I understand in, p4ns,folt Waved as public recoNs
PANELS
UPTO200AMPS
Licensed Profinelunal
201-100AMPS
OWNER -BUILDER DECLARATION
I hemby affirm Ili.,I am exempt from the Corromo s, License Law for the
mllowing reason. (Section 0031.5. Business and ProPo.sion. Ede: Any city or county
❑BATH REMOD EPAIR ❑UIiM1fOLITIO
❑ OTHER
OVER IfYO AMPS
SIGNS ELECTRICAL
'
which requires a perm'it to ceostma, alter, improve, demolish, or repair any structure
SPECIAL CIRCUIT/MISC.
�s
prior)I, it,skonaimer, flue.,ficartf 'h ptpail infileti,i'mcd,lamincia
that he licensed pursuant I theprevisions fm Contractor i' I (Chapter9
(Iv toantra$withSect el?000) of DA'sm Sof Ili. Biinusmd Promo -a- Code) I),
that he Is exempt therefrom and the basis for the alleged caauption, Any vtolaoon of
TEMP. MHIY.R OR POLE INST.
COMMERCIAL'
❑ NEW BLDG/ADDITION ❑ DEM01,I1 ION
Section 7031.5 hyany applicant for a immulmhjects the applicant to o civil penally of
IIOW17R DEVICES
❑TENANT FOOD SERVICE
all are than live hundred dollars (S500).
❑I,a% owner of the property, Or my employees with wages as their sole cotnMnsatinn,
will do the work, and the structure is not intended or offered for sale (Sec. ODW. Business
and Pndcssions Cer: The Compositors License Law does not apply to an Owner of
IMPROVEMENT
❑OTHER
SWIMMING POOL ELECTRIC
UILETS- SWITCHES -MIXTURES
NEW RESIDENTIAL ELECTS FT.
- •
pmpcny who builds or improves meteor, and who does such work himself or through
his loan employees, provided tsuch improvements vemts arc nm intended or oifcred for
ohat
Sala If, howoer. thebuildingurlmprovcmenl is cld withinoneyeaofcompletion,the
-builder will have the bade. of proving ohm he did AOI build or improve for par-
SQ. _ RAR A
t
�I J/SQ. PT.
t
li
wsaner
orada).
Prep ,&,memo,ivelyPo.traningCoalicensetnmr,1m
I, mewner of he n
c a (Sec. o04a ane, into door:) The Cs oe's Li -
net
OPAL
� AUG 13 1999
I
wt thco
di is not n of property whosedJsnrlmproves Corton.and
c contrctnsr
pop apply loan
QTY PLUMBING PERM FEF.
L
ith aommemrty
wM cmmrxcfc for such Projects with aconbunnr(s)lieenscJ punuunnm the Contractor
such
I
PERMIT ISSUANCE
Liccnsc Law.
l am axmnpt antler See , 13 A 1' C lior thi'mason
sr
Tk
ALlilt-URAINV
act Datr
/_ O<�
v
'C
WORKER'S COMPENSATION DECLARA'1'I ON
y one f the billowing declarations
1 hereby Affirm under Penalty of perjuro
BACK FLOW IROrEM DEVICE
DRAINS- FLOOR. ROOF, AREA, COND.
Q l have and will maintain aCertlfcamof Consetnm self-imnre frWorkces Compo-
.station, as provided for by Section 3000 of the Labor Coq for the performance Of the
work fee which this permit is issue.
STORIEf
TYPE CONSTRUCTION
FIXTURES - PER TRAP
I] I have and will maintain Worker. Compensation Insurance, a% acquired by Section
3100 ofthe Labor Cee. for the performance of the work for which this permit is issued.
My Worker's Compensall1W¢n Insurance carrier and Policy raytuber art)
Cerricr. Siriti t,t" l, Policy N., \V01 �1
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE U(-0
GAS - HA. SYSTEM -1 INC. 4 OUTLETS
OCC. GROUP
l� o
1/3
GAS -EA. SYSTEM -OVER 4(EA)
GRGSFIINDUSTRL WASTE INTERCEPTOR
I BUILDING Of ON n7 'r
GREASETRAP
(This section need not be completed ifthe permit is for one hundred dollars($100)
nz less.)
SEWER-SAN]TARY-STORM EA. 200 FT
•i I !9J
F,NERG,FEE
( ?1
Icemly that in the perhrromecofffic mk for which this termite, issued. [,hall
not enoploy any persw mn in any manner so as become subject to the Workers' Crimper-
WATER HEATER WNEIS PELECTR
WATER SYSI'EMrrREA'I'ING
Applicants mf California, One
\_
NU110E TO APPLICANCO If, after making this Cenillcate of Exemia.., y,,a shaull
V
GRADI FEE 4)
E'�
beam.. subject n, the Worker's Compensation provisions oftha Labor Cee, yen must
oullovthtontply with ouch pnrvisions or this permit shall be deemed revoked
SOILS
WATER SERVICE
`f
NEW RESIDENTIAL PLMB. SQ. ET.
CONSTRUCMON LENDING AGENCY
I hereby affirm that there is a comtruaion lending agency for the p rflrermmoeof
PAID
Dam Respa"0
TOTAL:
RUIhDING FEE
AN I
the walk for which this permit is issued (Sec. JOY(. Civ. C.)
Leaders Name
TOTAL:
Isbled Address
1 c,md, (bat 1 have read this i ppliemion and state Ill.' the above information is
erect. l agree to comply with all city and county ordinances and state laws mlatingm
building construction, and hereby authorize representatives of this city to enter upon the
QTY. MECHANICAL PERMIT FEE
Is
SEISMIC FEE
PERMIT ISSUANCE
absowmcmioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Calem.. against
ELECTRIC FG
PLUMBING FEE IVA
Iiabilities,judgmmots, costs and expenses which may in any way acme against said City
an t,oplesec oat the grating of this (scrod.
ALIfill OR ADD TO MECH.
AIR HANDLING UNITCIYI 10,(0l
MECHANICAL P E
AlIFLICAN'F UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.000CFM)
CONSTRUCTION 3IIIsK
/I n
`StgnumreofAPPbcant/Cnntra mfor Date
EXOAUS'I' HOOU(W/DUCT)
HOUSING MITIGATION FEF,
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (To 100.000 BTU)
Will thcupplicant or future holding oecupantalore er handle M1malloas material
as ddlmed by the Cupertino Municipal Cade, Chapter 9.12, and the Health and Safety
Code. Section 25532(x)'
HEATING UNIT (OVER 1000.000 BTU)
VF,NTBATION FAN(SINGLE RFSID)
Yes Oloo
PAID -
Dam ReeciptM
BOILNR-COMPIJHPOR 100.000 BTU)
Will the applicant or annum building equipment or devices which
.t hazmdnus air ronmminantsmdby the Bay by the Nayy A Arca Au Quality M1fanagettmm
L
BOILER -COMP (OVER 100180 BTU)
Uistria?
❑Vcs ONO
AIR CON DITIONER
I have read the hazardous materials mouiremcnu under Chapter 6.95 of the Cali-
forma Hmdl, k Satety Code. Sections 25505, 25533 and 25534. 1 tmderstand that if the,
ISSUANCE DA•rE Qat
NEW RESIDHNI Al. MACH. SQ, PT.
builoingdoe nslcumndy it ismy lespnnsihility tonoorymr oa:upam
nrthe 4nirtmrnte whish antra lx m 11'lejw,nance of a CenlOrnm of Oc�
5
ISSUED BY: i l
TOTAL,:
Owner amhnrizeJ atom Dam
OFFICE