99090066 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY "(J"UU(Ply/
CITY OF CUPERTINO BUILDING-ELELTIHCAL P ITNO.
BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESSS� SANITARY NO. APPLICATIONSUBMITTQALQDATI
L)Li IP
_ OWNER'S NAME: QF PHONE: CONTRACI'(IR'S N'A`ME: LIC NO:,�
2wL NIC L.
CONTRO #
- ARCHI'1'EEC(ENGINEER: LIC NO: ADDRESS: ❑
cu rz�J9 PRJgC— �Oiki zo CORPOPAIC CT SJ qFlb
CONTACM( ( PHONeBUILDING PERMIT INFO
30`O �l'r��eNs��IY'1 402)) ❑ Consultant Fres Paid by Applicant(Initial) BLDG ELECT PLUMB MOH
3Z1 -� )00
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
M=Z1 hereby anlnn Ino I elft licensed under pmvishn�x of Cnantcr 9(c,mtmeneins JOB DESCRIPTION
WOC with Section 7000)mfDlvisian 3ofthc Bosinessand[impositions Code.andmy license is RESIDENTIAL:
FSB in full farecand ellen I PERMIT ISsl1ANCE
aFUf— hkcnae Class Lam- 1i,# �OJit 2 ❑SFDWI, ❑KITCHEN REMODEL
WGi Date 9 ��—Cormir •, 147> C&0—
APPLIANCES-RESIDEN'T'IAL []ADDITION ❑PLUMBINGRE-PIPE
❑h ARCHITECTS DECLARATION PAN ❑MULTLUNI'T []STRUCTURAL
~m Z 1 understand my plans shall be used as public records MODIFICATION
p--4—a UPI'0200AMPS [I INTERIOR [I CHIMNEY REPAIR
F-t3 E'ud Licensed profcsalonaI 201-1000AMPS IMPROVEMENT []SWIMMING POOLS
S Y�; OWNER-BUILDER DECLARATION OVER 10W AMCS ❑BATH REMODEUREPAIR [I DEMOLITION
S a d'a I hereby amen that I am exempt fated the Calltraemr'a Licun.c Law for the
a�iV followin S t 70315.Business and Professions Code:An t t ❑OTHiiR
X 3 g reason.Ia ion Y ci y or coon Y SIGNS ELECTRICAL
W a f- which requires a Permit to construct,slot improve,demolish,or repair any someone
0 prlano i is issuance,also requires the applicant for-ch permit m flea signed stammer, SPECIAL CIRCUI'VMISC.
Eby that he is licensed pursuant w the provisions of the Contractor's Licence Law(Chapter9
u1�00 (commencing with Section 7000)of Division J of the Business and Rofessions Cede)or TEMP.METER OR POLE INST. R
0.11.e a that he is escmpt therefrom and the basis for the alleged exemption.Any violation of BLDGIADDITION ❑DEMOLITION
Section 7031.5 by arty applicant for uPermit objects the npplicuntmuavil pnalty of YOWL?It DEVICES ❑TY.NAN'T ❑FOODSERVICE.
!-Z} not more than five humped dollars($5004. IMPROVE�f,�T
6 � I,as ownerofthe Isonso,or my,employees with wages as their sale compensation, SWIMMING POOL ELECTRIC rC(N/Lftw/' �Or
in;L will do the work.anti the structure is not intended or offered for sale(Set.TA ,Business �OTHF,
S 3 m and Prolbsxions Cade:The Contractors License law Jrcr net apply to an owner of OUTLETS TCHIN-FIXTURES
progeny who builds or improves thereon,and who does such work himself or through /
his own employees,provided that such improvements are not intended or offered for NEW RES :NTIAL ELECTR SQ FT - --
.wlalf.how ever,the building or improvement is sold within one year of completion.'he Q.TT:FLOOR ARCA' SISQ.Ff.
cournectruilder will have the burden of proving that he did not build or improve for pur- ,'0 s; ,� •011
prsc of sale), 111 I 1
❑I,an owner of the property,am exclusively contracting with licensed contractors to TOTAL: FIN
1
comvuct the project(See 71W.Business and Professions Cade:)The Commune,s Li. II f•J (� 1 I
cense Law does not apply m an owner of property who builds or improves themon.and QTY. PLUMBING PERI �FTF. 2 1 1997 UI 1
who mntrmu for such pnjau with n aontmcmrtsl Ecensrd purxutnn m the Comracoo, U I
License Taw. PERMIT ISSUANCE t� A
❑I am exempt under Sec. ,B&P C fonhis reawn
_
ALTER-DRAIN&VENT-WATER BEA)
O 1 -' +--'✓9 1
WORKER and COMPENSATION DECLARATION BACK PLOW PROTECT'.DEVICE
hereby affirm underr Penalty of perjury one of the following W Worker',
m:
0Ihuvc provided
nforb inection3W of the Ladmir Code,for the
Compcm DRAINS-FLOOR.RO(I' RE ST O . ION
cation,as pmvidnl!m by Section l]W of the labor Coda for the Perfonnancc of the
work for which this permit is issued.
1 hate and will maintain Worker's Compensation Insamnce,ns required by Sectio
J]OB of the laMa Code.lonhe Perfnrmnnce of the work for whwhths Twono is issued. - OU ,ETS OCC.GROUP //^ A
My Workds Cum Zion Insurance cam r and Policy nu
comer: 11,2�%knu'T .ItJ�vnr y � `aItt e�J3093 A .Svc
CERTIFICA'Ili OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE RCA. ST BUILDING DIVISION FEES
(Tbiswe non necdnolbeerrmplmed iftoc permit is fnronclmndreddollars(SIM) F
or lea.) ANCHECK FEE
Icenifythxt indeperfonnarneefthe work forwhichthisperwit i0ssucd.],hot]
nnl employ eny person in any manna M: uhjeawthe Worked Compcn- ENERGY FEF.
7 0
,7.r ration Iin to I tc `n
ZApplicant u - a - e� .L I GRADING Fiili
NOTICE,TO APPLICANT:If,after making This Cmo cam of Exemption,ywu ehauld :Mll'REATING Com" SOILS FEE nmone,subject m the Worker's Cwupensntion pmvioo ns of the Labor Grdc,you must
forthwith comply with such provisions or this Permit shall rte demned revoked. WATER SERVICE
caa a0
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,FT. PAID
U O Iherehy off red that there ixmm�ewellnn lending ugetmy fonM1e pvrfnrmancc of Dom RecnptM
Pthe work for which this permit is issued(Sec.3097.Civ.CJ
Lenders Name TOTAL:
U landeirABdreas TOTAL:
F- 0. 1 esnifY tom 1 have read oris appGcabon and mala tom the above nommoalion is BUILDING PEE
U7N colied.)agree it)comply with all city and county ordinances and state laws relining to QTY MECHANICAL PERMIT FEE
Zbuilding construction.and hereby authorize representatives of this city m enter upon the SEISMIC FEE
abovetneadomed property for m,fismion Iampoms. PERMIT ISSUANCE
(We)agree to save,indemnify and keep Includes,the City of Cupertino against GLECI'RIC FEdi
Iiahi lifie.s,j udgntente costs and expenws which may in any way accede against said City ALTER OR ADD TO MECH.
PLUMIi1N FfiP
in xyue of he UNDERSTANDS
of to Pemtit.
APPLICANTTcUNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLINGUNIT(TU IILUq CFM) MECHANIC ME
SOUp
R iGU1.ATIONS.
X.�i AIR IIANDLING 11N11'(OVEN 10,00OCTM) CONSTRUCTION t Is
Signitureof ApplicancrContmmor Use ! EXHAUST HODD DVrDUCT) HOUSING MITIGATI I
HAZARDOUS MATERIALS DISCLOSURE
Will the applieantor pared,building necupaal store or mndle ha.amnur material HEATING UNI'I'(TO 100,000 B U)
as defined by the Cris nitro Municipal Code.Chapter 9.12,and the Health and Safety
Code.Section 25532(.)! HEATING UNIT(OVER 100,000 BTU)
0 Yes V- VENTILATION PAN(S INGLE RP SID) PAID Date Receipt '
Will the applicant or future building occupant use equipment or devices which — e
BOILER-COMP(3HP OR 100,0s)emit ha mdour,air enno tiomets as defined by the Bay Area Air Quality Management 100,0s)BTU)
I
District) BOILER-COME(OVER 10J.000 BTU)
[3 Yes No
1 have read the hazardous materials requiremems under Chapter 6.95 of the Cali- AIR CONDI(IONER ISSUANCE DATE
farm.Health&Safety Code.Sections 25505,8533 and 25534.1 understand that if the NEW RESID'EN'TIAL.MECH. SQ.FT.
huildingdoer not currently haves,unint,thm it is my reyamat ility tonality thecompnt % Z -7,4 (T
oflhe mnoverchn I I anui wane of a Cm,is eoI Oc Funey. r /
� '1 , e 9 9-99
vcr'�tim aired agent Ume TIYI'A1.: Issues BY:
OFFICE