99120047 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY / I d.06q-;L-
• CITY OF CUP
BUILDING,-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATIONXERMIT m.umnlNr,-hiecnnNlcAl.
ItU11.U1NG 1'RODlCT IDENTIFICATION
SANITARY NO. APPLICATION SUBMITTAL HATE
BUILDING ADDRESS
9 59 1i6i- Aje-N 2- 7-(39
OWNEKf NAME: I PHONE: CO ACTORS NAME: 1 LIC NO:
f�a4N" n t 5Jr1 pf �Rp I p v NIC CONTROLp
191RCIIITIiCf/FNGINEI7R. LIC NO: AUDkE. ❑
•p e37 $f fla Qne..
Ffulifomc
PHONE: BUILDING PERM1TIT INFO
❑ Consultant Fees Paid by Applicant(Initial) HI.DG ELECT PLUMB MECH
❑ixieSlIECLARAT1pN Q'{•Y ELECTRIC PERMIT Il3E
LICENSED CONI RAC OR uinn ohm 1 sen fieerxw tragi previsb'hhx or Chapter9 ocanahlolrg J013 DESCRIPTION
Boz onsa,ae.andmyhaomxeis R -ID�� ENTIAhPERMIT ISSUANCCI_ nand effect. ❑SFDWL ❑KITCHEWWP REMODEL
aUU hiccnsc Clara Li0.N APPLIANCES-RESIDENT'I AI. ❑ADDITIQN SRI!-PIPE
ln Q i Umc Conutcwr
ARCHITECTS DECLARATION PANEIl ❑MUl:fl-UNIT ❑STRUCTURAL.
~.z Iundersmnd my plane,hall Masada,public record, MODIFICATION
OZ`=S UPT02(YJAMI'.S [I INTERIOR ❑CHIMNEY REPAIR
F W Liveried l'm.re"knd 20I-IPNXIAMPS IMPROVEMENT 0SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER I"AMPS ❑RAT II REMODEUREPAIR ❑DEMOLmON
C 6 I hereby affirm that I am exempt from the Contractor's License Law for the
3 a U lidlowing return.(Section 7031.5.Hocimo and Profession,Crack:Any cityof cuunlY
SIGNS ELECTRICAL ❑OTHER
y¢ which requires n pernh m construct,alter,Inapmvc,demolish,or oTmr ony slmcmrc
�'�QS prionoib iuuance,also inquires the applicant for such Permit m file a signed statement SPECIAL CIRCUIT/h1ISC.
WsS4SS4`�} that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
fLOp Isafnmmming with Section 7(NNp of Divlslmh7mf the Business and Prnfcssiom GNe)or TEMP.METER OR POLE INST.
It d e C that he u exempt thcrd'mm and the basis I'or he alleged exemption.Any vinlminn of ❑Nf:W BLDGIADOITION ❑DEMOLITION
XONSection 7031.5 by any applicant for a permit subjects the applicant m a evil pcnallY of POWER DEVICES TENANT ❑FOOD SERVICE
I mo¢than five hundred dollars($50R. IMPROVEMENT
��v I,as owner of the rt.nrm Ie ccs with wu Mclr snlc cote tion, SWIMMING RX)L ELECTRIC
G 0 props Y YcmP Y ,erns penia QTIIfiR
N will do the work,and the swemm is not intended or offered for sale(See70H4.Business OUTI,L'TS-SWITCI{ES-FIXTURES
3 c and Profession,Cwt Toe Ci mmcmrx License nLaw doesorapply m an owner or
0. property who builds or improves thereon,and who does such work himself or through NEW RESIDENTIAL ELECfR SQ Pf.
his awn employees,provided that such imprnvemen¢are not intended m offered for S FG,FLOORAREA $/SQ.IT.
sale.If,however.the building or imprnvemen)Is sold within one year of completion,the
r-builder will have the beadm of leaving thin he carrot Wild or improve for put- D
INwc of ruled. TOAL
1,vx owner of the property,am exclusively commeting with licensed nsnraitor,to
construct the project(Sec.70,14,nosiness and Profexdnes Code:I ire i-m rucmrs Li- DF
c a law does not apply m an owner of Prnpeny who build.,or improves thereon,unit QTY. PLUMBING PERMIT FEE C
whocomema%forsuch peajeces with a commcants)licensed puremm to the Contractors IN 1^
Liccnsc law. PERMIT ISSUANCE 99
I am exempt under Sec. .H A P C for this ration
Doc ALTER-DRAIN&VENT'-W'ATER(CA) VALUA'll0
(teener i
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 herchy af0nn under penalty teperjury one of the following decWorkwe in a
Ihavc unJ will muinmin aCcriOmm of Cnnumto self-insure for workers Campo- DRAINS-Iq.WR.ROOI'.AREA.COND. STORIES TY PCONS'I'ROCTIOt
nation.as provided for by Section 37W of the Labor ewe.for the Performance of an,
Is which thin tenni,Lcleshmd. FIXTURES-PER TRAP
• 1 have ant will maintain Workers Compensation Insurance,a,rcyuireJ by Section
l.CTS'
3700 of the LabotCwc.fay the performance of the work for which this permit is issuedGAS-EA.SYSTEM-]INC.Y OU"1. OCC.GROUP p^AI'R
My Wnr 's Coml'enxam In nonce ca 'er and Policy nu e) qJ
C'arri,n Policy No.'. Irl 1)N 174 6 GAS-EA.SYSTEM-OVER 4(EA) A/
CERTIFICATE OP EXEMPTION FROM WORKERS' GREOMNDUSTRL WAS'IE INTERCEPTOR
COMPENSATION INSURANCE BUILDING[)]VISION I BIS
(This section need nor be completed if the pere it is forone hundrwdollan(S 100) GR17ASElRAP PLANCHECK FEE
or lot,)
Ia,im,persamhe perfimmnt.as
harmork ne,.hetnio the Workers'ued,Camper-
per-shall SEWER-SANITARY-S'IORM 13A.20F FT ENERGY PEE
not enhploy any person in any manner m ac nh become suhjecuo the Worker'Compen-
Z ration Laws of California.Date WAT13R HEATER WNENT/ELECfR GRADING FEE
ZApplicant h
!n NOTICH IO APPLICANT IL after making this Cembeaee of F,acmption,you should WAd ER SYSI'ENUTREAI'ING SOILS FEE
F Novenae subject want Workers Compensation Provisions of the Labor Cade,Yom must
�+ � imhwilh comply wifhsuch provisions.1'his permit nhallMdecmed revoked WATER SERVICE -
0. Q
=' CONSTRUCTION LENDING AGENCY NEW RESIDFNHAL PLMIL SQ.IT. PAID
,U z Il:nc Iiccclptp
L) I hem by aRnmhatmerc isaro (Six.30 len Jing agency funhe performance of
the work for which this Permit is issued(Sec.J(19].Civ.C) TOTAL
I~ Lenders Name 'IOIAL
O :
r GUq Leadch Address BUILDING FEE,
y 1 certify that I have read this application and%rate that the above information is
(Z) correctl agree w comply with all city and county ordinances and state laws relining to QTY. MECHANICAL PERMIT FEE SEISMIC FEE
U Z Wildiagrenarucdon,and hereby andmi're representatives ofehis city teenier uPar Na
abovrnhomionW DmpenY for inspection purposes. I'IiRMIT ISSUANCE ELECT RIC Plili
(We)agree to save,indemnify and kap homeless Ibc City of Cupertino against
liahil'nies,judgmems,mils and expenses which may many way uceme against said City g1.TF,R OR ADD TO MF,CH. PLUMBING FLC
nagmcnw of the gnoming al this pernul.
APPLICANT UNDERSTANI NDW OMPLY WITH ALL NON-POINT AIR HANDLING ONTI'('1'0I(kt%XI CFM) MECHANICAL PGC
SOURCE REGULATIONS
AIRB ND LING UNIT(QVFR IU.(1110 CFM)
CONSTRUCTION TAX
S Appli nVConuacmr Date E%HAUST HOOD(W/DUCD HDOSING MIT[CATION PCC
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building mcupam.anrc or hanAle bwuNnux material HEATING UNIT TO I Be.M RTU)
as defined by the Cupcnino Municipal Cade.Chapter 9.12,and the Health not Safety 1{FATING UNIT(OVER 1(10,0(X1 R U)
Code Section 25532ta)P
❑Ye, nNu PAID
VFM1TILA'I'[ON PAN(SINGLE R[SID) [-)are Receipt N
Will the uppllatm or fmum building a it t use equipment or devices which BOILER-COMP(3111'OR 10fi( X)It UJ)
mit hazardous air conmminams as defined by Ne Bay Area Air Quality Management T(YI'Ah: f
Disrme" BOILER-C(lMP(OV[R IOO.UIII)BTU)
❑Yee ON.
AIR COVIN DICK ER ISSUANCE DATE
1 have rea he h ode.Sections
c ma¢ri 55 re.25533 an under Chapter6.950l the Cali-
fomiaHeank,itse,&Safety Code.eadore25505.25533aw853i.1uweretaw that date NEW RESIDIiNTIALMLCH. SQ.1.7. / Z
bailJhhg memaoenmrcrty have mne,Fri
it is Lia ce of
bilirymnooify'he occulam / e
of rbc nyuircmcntx which mux)W incl prior to issuance of r Ccnificvfc of llccemvncy.
Owner or amborn.ed.gent Ilse TOTAL: ISSUED BY:
OFFICE