99100019 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING•ELECTRICAL11 PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT Now
PLUMBING-MECHANICAL. Soo 01
BUILDING PROJECT IDENT'IFICAT'ION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
199-83 ievnAV4PC?A n�€, k5w"v4 0 •
-. OW FiR'S NAME; PHONE: CONTRACTO`RS'NAM/Pf 49610 LIC NO:
�� �4N `,�� NIC CUNTROLp
RCHrTEC1ENGINEER: I NO: ADDRESS: ^ Elc�
�-a "3o 2sn'I� l b 014 e"Vil ,.- SS
CONTACT I ` I PHONE: BUILDING PERMIT INFO
/VI jAf 2aQ7053 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MT:CH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby emrm tnm I um licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
a%z doSection700(hidDivisionSofthcltosinessundProfessionsCode.andmylicenseis RESIDENTIAL;
u100 wh PERMINSSUANCIi
EE n full fm r rout(�eeccL.� ❑SFDWL ❑KITCHEN REMODEL
U(F(] License Class_l�_�_Lic.# 4b720
zD1 Dmc Ce— c1m Comm '1?Ae APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
<MDori —T0•�e� ❑MULTI.UNI'T ❑STRUCTURAL.
ARCHITECTS DECLARATION
z o ori zzz - I understand my plans shall M umd rc public records PANELS MODIFICATION
Oz4O UPT0200AMPS [I INTERIOR ❑CHIMNEY R17PAIR
F��FW Licensed Professional 201-IgOAMPS IMPROVEMEN' []SWIMMING POOLS
5�,�-I OWNER-BUILDER DECLARATION OVER I(NX)AMPS G BATH REMODEUREPAIR El DEMOLITION
L �' 1 hcrehy affirm um 1 am Ommpl froth the Cumnevers License Law for the
6,�e0 G.U following reason.(Section 9031.5,Business and Professions Code:Any city.r ounty SIGNS ELECTRICAL. ❑OTHER
W O y which moldiness o permit as caosaucL.Iter,improve,demolish,or repair any stmcmre
priohn its issuance,ulsorequies the applicant for suchpermit to rile asignedaa¢mem SPECIAL.CIRCUIT/MISC.
;yW!�} Hari'cis licensed pursuonno the provisions of the Connectors License Law(Chupor1)
IyapO (commencing with Seeti.n7000)of Division 3ofthe Businessand Ponfeasions Code)or TEMP.MITER OR PULP.INST. COMMERCIAL:
dk�cq that he is exempt therefrom and the basis for the alleged exemption.Any vinlmion of ❑NEW BLDG/ADDITION ❑DEMOLITION
iEIN Section 7031.5 by any applicant u permit subjects thcapplicam to a civil penalty of POWER DEVICES ANT ❑FOOD SERVICE
WW non more than rive hundred Dollars(5500). IMPROVE
F=0 1]1,as ownerof the property,or my employees with wages as their vole compensation, LAMING P001.ELECTRIC
will do live wnrk,.nd the amount is nm intem0edoroRerelfn...le(Set,701 Businesa ❑OTHER' M
and Professiom Code:The CUntmcurs License Law does not apply a in.wrier of O TI 'S-SWI' HES-FIXTURES V
6 3 p openy who builds or improves thereon,and who does such work M1imulf nr Nmugh
his own employees,provided that such improvements are not intended or offered for .IDENAs,TIAL ECTR SQ Fr.
sale.IL however.the building s improvement is sold within one year of completion, SQ. TFLOOR AREA $/SQ.Fr.
er-huilder will have the huden of proving that he did not build or improve for par,
posy.f.1c.), TOTAL:
❑1,us owner ol'the prnsmy,am exclusively contracting with licensed commons u
conumm the project(Sea 7044,Business and Professions C..;,Fhe Contmemrs Li-
cense Law does not apply tow owner of propeny who builds or improves the¢on,and QTY. I'L GING PERMIT FEE
who contracts for such projects with a conuactinds)licensed pureuant to the Commerce.,
License Law. PERMH ISSUANCE?
tom exempt undersec. ,B&P C for this reran
ALTER-DRAIN&VE W VALUATION
Dine
WORKL'k'S COMPENSATION DECLARATION BACK 10.000 PR(IFEC Q D
I hereby affirm under penalty of perjury one of the fork.....okclaetiom:
I have and will maintain a Certificate of Consent to self-iasure for Workers Couper. DRAINS-FLOOR.R00E ARE ORIES TYPE CONSTRUCDOh
satins,as provided for by Section 3700 of the Lubar Code,for the pethoure ce of tiro
work for which this permit is issued FIXTURES-PER TRAP
'g�1 hove and will maintain Workers Compensation Insurance,as required by Selection%X)of the Labor Code,for the pertonnance of the work for which this permit istouaf GAS-EA.SYSTEM-1 INC.4 OUTLET OCC.GROUP ,^AI'N, x
My Wm4:e/s ComtR carton lnsimt cwonerand Policy�npP�'�r V fs�T�
Cartier, ep/y��.A-� Policy No.:C'^- GAS-EA.SYSI'L'N-OVER4(EA)
s �-�= 'CRTIFICATE OF I?XEMITON FROM WORKERS' GRCAAVINDUSTRh WAS'IP.INTIiRCLPi'OR
COMPENSATION INSURANCE. tlU11.DING DIVISION IEdcv,
(This It..mend nm Wecor,leled if Ne permit is Boom,hundred dollura($lot)) GREASE'1'INP
ser less,) PIANCHECK FEE
I certify that in the performance of the work I.r which this permir is Issued.I shall SEWER-SANITARY-S'1 ORM EA.200 FT.
not employ any person in any manner 1 gg m hecnme uAveel to the Workers'Compen- ENERGY WE
,� mtionlnesofC,�.r 'r.Date —l4� WATER HEA11iR W/VEN'1/1?LECTR
zQ ApplicutlF a GRADING IEE
NOTICE TO I'after mal this Cenificate of Exemption,you ahou d WATER SYSTEMITREA'I'ING
(• `N-' betaine subjee to the Werke s as tion provision of the lumbar Cole,you must SOLI S FEL'
Wforthwith comply tpmvionox m,h ix permit shall W deemed revoked. WATER SERVICE
0.
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMU. SQ.IT. PAID
V O Iherebyef onflo them isacsmmumiun lendingagency forrheperfomtarcenf Da RfeCiplM
u'sF the work for whicht 'ap.rmit is issued(Sec.3091,Civ.CJ
Lenders Name TOIAI.:
0{Ura Lcndcrs Address A TOTAL'°
y 1 certify that I have read is upplicminn and state that the.bnve information Is BUILD -F.E
V) correct.l agree to comply with all city and county onfinances and slate laws relating to QTY. MECHANICAL PERMIT FEE
z building construction,and hereby woman ropmuntatives ofihis city to enter upon the SEISMICF t
r dMve-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)r,mc,to save,indeaily and kcap banaless Ntino
e City of Cuperagainst E
mLECTRIC
Iiabilkics.judgments,costsond expenses which may irony wayacemei,prom mid City ALTER OR ADD TO MECIL
in consequence of the granting of this permit PLUMBING F'E
APPLICANT UNDERSTANDS AND WILL COMPLY W11'11 ALL NON-POINT AIR HANDLING UNIT(10 by"CPM) MECHANICAL :6
SOURCE REGULATIONS, AIN HANDLING UNIT(OVER 10,1X10 CFM) CONSTRUCfIONTAX
Signet re g t cher firm IxHAUST HOOD(W/DUCT) HOUSING MI'I'IGATION FEE
OUS MATERIALS DISCLOSURE?
t theappheard or(utum building receptor store or handle nodous material HEATING UNH'(10100,000 BTU)
as defmW by the Cupertino Municipal Code,Chapter Q.12.and the Ileahh and Safety
Code,Section 25532(a)1 HEATING UNIT'(OVER](a),"BTU)'
(]Yes ❑No VENTILATION PAN(SINGLE RFSID) PAID
Date Receipt#
Will the air conte or future handing occupant use es Air Qui at devices which BOILER-COME(THE OR 100,0(X1 BTU)
.tit h.xadnus air contaminants as defined by tM Bey Ams Air Quality Management TOTAL: 1
Owner? BOILER-COME(OVER 100,0)BTU)
[IYcs E]No
I have read the huradess materials requirements under Chapter 6.95 of the Cali- AIR CONGO IONER ISSUANCE_WTE
fomin I acrd,&Safety Code,Sections 25505,25533 nn 1255 W.1 undershmrFT.
d that if the NEW BESIDES MECIL SQ. / O _ C/�sslJsssy�i ��
building does not cumend have tenant that,. is my responsibility to notify the needlessre hich mush metprinrtn ismmee of.Cenifhcateof0ccupmmy.
Owner or and 8 t IS` 971 TOTAL: ISSUED BY:
OFFICE