99110050APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO I
BUILDING - ELEC'1'R
RUII,DINGITIVISION APPI,ICATION/PERMIT nutr nrvin nleolrcr mvsl
pL�,�c��-•^—r Ara..
NAM11
AtZS 2�a�w.)
CONTACT:
[)DBMS:
❑ Consultant Fees Paid by Applicant (Initial)
1 hereby uffinu that 1 non licensed under pmvisloov Id Chapter v Iconunewing
OCZ wish Senion](XMq of Uivlsinn3of,hc Business and Profcvsinns G,de. and myliccnse is
F0,0 in full ficccamde I. 4
,Xu l- License Class �'24 Lic. x
F-ZW Dae 7 �1 Comms
m 6 a ARCHITECTS DECLARATION
f -m Z 1 understand my Plan%shall M used as public records
OZ=O
r ors ., i ccncd Note ..innul
<R2 OWNER.HUILDER DECLARATION
C G 1 hereby alHrm ILaI 1 am exempt Gam IM1e Cnnlmunds License hew lin the
3 4 U following reason. (Seel ]1131 S. Husinexs end Notcssiotynv Code: Any cier coumy
which requires a permit to conria. alms improve. Jannlish. or of any sWcume
F-LL'0¢ prior to its issuance. also requires the applicant for such pennino file a signedstatement
i y that he is hcensw palmation to the Provisions of the Comrectors Licence law (Chapter v
9 6 =GO2 (commencing with Section ]IXIB)of Division 3 nf,hc Rosiness and Professions Cade) nr
6 e OL that he is exempt therefrom, and IM1e basic for the alleged exemption. Any violation of
y Sectinn]831.5 by any aPPlicart for a Perini[ suhiects the applicam In it civil pcoully of
y tat'tare than fisc bundrcd dollen ISSOB).
��< ❑ Lav owner of the prnpety, or any employees win, wageau their sole cnanpensaniun,
SaF� will Jo the work.and,be Interact is nm intended a npered for sale (Sol. Boorms%
ty 3 m and Professions Cock The Claimant's License law Jocx not apply to an owner of
property who builds or improves these', and who docs such work himself or through
his own employees, pmvidcA that such improvemenry am not intended or offered for
sale" If, however, the building er impmvemem is sold within one year of completion, the
er-builder will have the burden of proving that be did not build or improve for pun
pow of sale.).
1, as owner Of me prnpeny, um exclusively contracting with Ileensed contractors to
instruct the project (Sec. ]OW, Business and Ptotessions Cale:) The Cori memrs Li-
xt,Lew docs not apply to an owner of property who builds or i inpmvev thereuq and QTY
who contract, for such Pmjed with u em.luam (s) licensed purmunue the Conlrwlor's
Liccnw law.
1 am exempt under Sec. . B & P C far this noon
Owner Dae v:
WORKER'S COMPENSATION DECLARATION
I hereby atiirm under Penalty of perjury one of the following declarations:
Cl
� I huvc pe,v,d l mmmmn a Cenifiwm of the Luf mCodenfurche pediWorkcr'xCnmryn-
.vhtinn, m provide) fur by tiatiinn 391X1 of the hnM,r Gxlc, for the perfunnancu of the
Is k for which this N .... it ix Issued.
I have and will maintain Workers Compensation Inwmnce, as required by Section
" I ) of the Labs Code. for the performance of the work for which this pcmael is issued.
My Warinsatiollslnsurence artier and I'ulic��G-05.� _«�
Camcc C Policy Na
CERTII COMPENSATION
OE SATIONII N PROM WORKERS'
COMPENSATION a Imes is
(lnis.uctinn need not rte complcmd iflhe pcmnil ix u, one hutdreJ dollars ($ 100)
le".)
1 employ
any mel in Be pc,fnature, orate wed, for which this permit is issued, Col shall
per-
nol ennplor any pens or I, nature, sn as In necmne snnjem In one wmkor. emnpnn
O Z s.,am laws of Cdola ice. Decca .
Z 0 Applicant
N.a NOTICE TO APPLICANT: IL after making this Cetificme of Exemption, you should
>become subject to the Wads/.v Compensation provisions of the Lana, Codc, your mad
forthwith comply with such pmvision or permit shall b , )caned mvekcd.
aQ
CONSTRUCTION LENDING AGENCY
I hcrcny nlfinn that Share is o wnrtmdlun handling ugcncy for theperfinananac it
W- the work for which this permit is Issual (Sec. 311)], Civ. C.)
C U Lemdcrs Name
rU I<ndcrs Address
1 1 certify that 1 have read this application and state Ill., he above information is
FN rormcl" I agree R, a,nnply with all city and county ordi,mnces and slate taws relmiag m
U Z building con:wctinn, and hereby umhaDe mpmw,nativcs Of this city to enter upon the
show -mentioned property for inspection pu,posev.
(We) a,,. weave. indcmmfy and keep hunnlcax the City of C.,scra , igain',
liabilities,md,mvn, eons and ex,e,O, whichnmy in any way accrue again y
WILL COMPLY WITH ALL NON -POINT
I ZARUOUS MATERIAIS DISCLOSURE
N'ill laic: turf o builJingoacuPam uorc or handle hazardous material
as Jefinc l by t Cu no Municipal Code. Chapter 912, and Inc health and Safely
C'u It. See
❑Yea ONo
Will be applicam nr fuwrc building,ecup:,m me cqu,pmcut or devices whall
mit mountains air commitments as defined by the Bay Arca Air Quality Management
District'
❑Yes 0 N
11 1 Ibc h:nardous mam'Ws nyuircmems under Chapter 6.95 of ,he Cali-
li,mia He 1 uldy Ctxlc. Seeu 255115, 25533 and 25534.1 undersand the( it the
huildime it let...ualyla"ca .marl i'll,y is"oneinllay mnolil'y Om l'cnpmn
(ELECTRIC PERMIT FEG
PF.RMI'IISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP TO 20f AMPS
OVER IBMAMPS
SIGNS ELECTRICAL,
SPECIAL CIRCUITIMISC.
TEMP. METER OR POLE BEST
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETT S -SWITCHES - FIX 'I URES
NEW RESIDENTIAL ELECIR
PLUMBING PERMIT'
PERMIT• ISSUANCE
ALTIER - DRAIN & VENT- WATER (SEN
BACK FLOW PROTECT DEVICE
DRAINS- FLOOR, ROOF, AREA. COND.
FIX'I'URBS - PER TRAP
GAS -IEA. SYSTEM -I INC. J OUTLETS
GAS - EA. SYS'I EM -OVER J (CA)
GREASEBIH)USTRL WASTE INTERCEPTOR
GREASE TRAP
S IIWER-SANI"I ARY-STORM F.A. 21X1 IIK
WATIEK II RATES WNEN'1'/ELECI'R
WATER SYS'TEMOREATING
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ. PT,
TOTAL
QT/Y.
MECHANICAL PERMIT
/ PERMIT ISSUANCE
I I ACfER OR ADD TO MECH,
AIR (IAN OILING UNIT (TO I O.Byl CFM)
AIR HANDLE NO Cyst r (OVER IILIXX) CFM)
FEF,
INK
BUILDING PERMIT INFO
NL❑TlG li 11 PLU❑MH htloan i
JOH DESCRIPTION
RESIDENTIAL,
❑SPDWL
❑ KITCHEN REMODEL
OADDITION
❑ PLUMBING RI PIPI!
❑MULTI -UNIT'
❑STRUCT'URN.
MODIFICATION
11 INTERIOR
O CHIMNEY REPAIR
IMPROVEMENT
❑SWIMMING POOLS
❑ BATH RIiMUOIAJRBPAIR
❑ DIEMOLI'I'ION
0 OTHER
L
COMMERCIAL;
❑NEW HLDG/ADDI'T'ION
❑DEMOLINON
❑TENANT
❑ 1'001) SERVICE
IMPROVEMENT'
OO'1'HER
I I EXHAUST HOOD(W/DUC) I I
HEATING UNIT (TO IBQO(XI RTU) +,
' HEATING UNI 'F(OVER 10O.BB) BTU11�K
VEN'I'II,AI'[ON FAN (SINGLE RE -SID)
BOILER -COMP (3HP OR 101111 G 1
I IBOILER- COMP(OVER I011010 B' 1' U) I I
I I AIR CONLAITONER
N17W RESIDENTIAL MECIL SO. PL
NOV - 9 1999
E
BUILDING DIVISION PIAS
PLANCHECK hili
ENERGY II?li
GRADING FEE
SOUS FLEE
PAID
Du¢ Rucip,k
BUILDING FEE
SEISMIC hili
ELECTRIC 12I:I1;
PLOMRING FES?
MECHANICAL THE
COFSTRUCHON FAX
HOUSING MI'DGATION ITE
PAID
Dam
ISSUANCE DATE
// 8 ? �,
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