99100150 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY 9 /l'7O O
CITY OF CUPERTINO BUILDING-bl1.EC1'RICAL PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJI?CTIDENTIFICATION AWRMW
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
2/ 7/0 iPA/Nf3ow (�2 6 . 27—
iiel
OR'SNAMEE: NIC CONTROL#CAIAXIALS ��� TACM
rbcw
4RCHITECTIENGINHER: .IC
NO:: ADDk ESS �� �a `-\le ❑
14
CONTACT N i9-V`V•` F PHONE:�1-�^ BUILDING PERMIT TNI°O
N11_LQ S-D S /(�� ❑ Consultant Fees Paid by Applicant(Initial) BLDG. ELECT PLUMB MECH
G L ❑ ❑ ❑
LICENSED CONT RACION:S DECLARATION QTY. ELECTRIC PERMIT FEE
E hereby afrna that I stn licensed under provision.of Chapter 9 uninmenciag JOB DESCRIPTION
WOO izzwith Section 7000)of Di ' nn 3ofths Business and nfcwiona Code.and to,brea.a is PERMIT ISSUANCE RESIDENTIAL:
F�� in full force and eRea.� 0$FDWL ❑KITCIiF:N REMODEL
aUU hiccn�lT E.ic# RILE APPLIANCES-HIi51DENllnL C11 ADDITION [I PLUMBING RF.-PIPE.
p.Z fy Detc Conuncmr
F j h ARCHITECTS DECI AT ) PANELS ❑MULTI-UNIT C1 STRUCTURAL.
Z p m Z I understand my plans shall he used as public records MODIFICATION
OZ11--0UP'IX)20K)AMPS ❑INTERIOR C1 CHIMNEY REPAIR
1-13~.W Licensed Pmfe,amal 201-1000AMPS IMPROVEMENT ]SWIMMING POOLS
ECLARATI
C C Q 1 hereby action that
OWNER-BUILDER amexcmptfrolm me C naarors License Law for the OVER 10o0AMPS E3BATH REMODEI/REPAIR EJ HON
x�x
0,
U following mason.(Section 70313,Business and Ponfic,ions Code:Any city nr count, SIGNS ELECTRICAL ❑OTHER
W 3 4 y which requires a permit to coesmet.alter,improve,demolish.or repair any structure
I MM}rt primmifi...ance.also requires the applicant for such peseiato file esigned statement SPECIAL CIRCUFUMESC.
f mut he is licensed pursuant to the provisions of the Contractor's License law(Chapter 9
� (Lmnmencing w'Ih Section 7000)of Di vision 3 at the Business and Prefcasions Code)er TEMP.METER OR POLE INST. COMMERCIAL:
Ea.alb C that he is exempt therefrom and the hasis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION [I DEMOLITION
U.
Section]031.5 by any applicant for a permit subjects the applicant m a civil Penalty of POWER DEVICES [I TENANT ❑FOOD SERVICE
t more than Eve hundred dollars(1500). IMPROVEMENT
=Z0 1] I.as owner of the prmleny.or my employees with wages as their sale compcn.smlen, SWIMM ING POOL ELECTRIC
f... will Jit the work.end lhcswcwreis non intended or offered fur sale(Sec.](W4,ituxincss ❑OTHER
W 3 m and Profe,ices Code:The Contrm:mr's Licenu law does not apply m an owner of OUI'LE'TS-S W ITCHES-FIXTURES
popery who builds or improves thereon,and who does inch work him e f or through
his awn employees,provided that such improvements ore not intended or offered for NEW RESIDENTIAL ELECE'R SQ FT.
sale.If.however.the building or improvement instil]within one year of completion.the Pf%Q.PI'.PIAOk AREA E/SQ.FI'.
caner-builder will have the burden of proving that he did not build or improve for pur-
psmc of>alc.l.
I]I,a of the Inuperty,n exclusively contracting with licensed contractors to TOTAL:
construct the pmjcet(Sec.7094,Business and Professions Code)The Contractor's Li-
oceseLaw does not apply toanowner ofprnpany who builds or improves Neon.and QTY. P IMBING PERM IT FEE
who contracts for such projects with a comemeals)licensed pursuant to the Contractor s
Licaov.Law. PERMIT ISS
xaf
1 am exmnpn under Sec. .B&11C for this¢anon
AI.TIiR-DR IN& -WATE lA) VALUATION
Owner Date
Win Qsr'S Catty of SATION DECLARATION BACK PLOW PkOTE LCB �/02/ OOo
1 hand w#limn under penally to perjuryone o['he insure for tlerker's ar
•,mm..as and will maintainaCiam 37(e of the[.[.We
too for Workers Compcn- DRAINS-ROOB.Re F,ARE D. STORKS TYPE CONSTRUCTION
.anion.as provided for by Senior 3]110 of the labor Axle,for the performance of the
work for which thrc pertain is IssucJ, FIXTURES-PER TRAP
❑I have and will maintain Worker's Compensation Insurance.a,required by Section
3700o1fthe laborCeds.prime psmarmancerifthe work forwhich this permit is issued. CAS-EA.SYSTEM-]INC.40UTE., OCCGROUP AP� j3
My Worker's Compensation Insurance carrier and Policy number rte:
Cartier'. Policy No.: GAS-EA SYSTEM-OVER 4(EA)
CEBTIFICATEOPE%EMPI'IUN FROM WORKERS' GREASEINUUSTkI.WASTE INTERCEPTOR OO
COMPENSATION INSURANCE BUILDING IN FEES
(This section need not ba completed ifthe Permit is for one hundred dollars(SURE GREASETRAP
or Ices.) PLANCHIICK FEE
Event, tainthepeifonn' ceof the wmkfnrwhich thispennin isi,sucd.l shall SEWER-SANITARY-S'IYIRMEA.200Ff
nm employ. Wh.at�fiecuo the Workers'Co.,.- ENERGYFEE
0 Z ,union Le ,( " 11 WATER HEATER WNENTIELECfk GRADING IEE
Z, Applicant n n a. vIvilift
.y = NOTICE T< A .I T:Ef,#testi eking this Ccttilicmc of Exennpnion,you should WATERSYS'TIlM/IRPATING
F heeome tab•a o the kers Compensation provisions of the Labor Code,yen mast Sons FEE
LaTa� forthwith comp v with such provisions or this permit shall be deemed revoked. WATER SERVICE
a �
niteac
CONSTRUCTIONLIlNUING AGENCY NEW k131DEMflAL PLMIf. SQ.IT PAID
U Iherehy afamn Nta there ifaonswnion lending agency for the performance of Date kcmipl#
!L P the wick for which this Pemnin i,,,,.cd(See.3199,Civ.C.)
TOTAL:
0 U lender'.,Name
lends,',Address I TUI'AL: //-\
O. I cattily that 1 have,'sad this application and slate Nm the above information is BURIOMG FEE /lin
FIn oxncefIa,,.m comply with all city and county ordinances and state lows rcmting a Q'ry. MECHANICAL PERMIT FEF r
U Z building ei suuctien,and hemhyudhoiu repicsemutives of this city m enter uptm the SE ],ruE `
above-mentioned prnpeny for impection puTosoa PT:RMI'I ISSUANCEp
(We)aj save,indemnify and keep Mites,the City of Cupertino against EL REC FIE / lir QQ
liabilities.judgments,costs and espensox which may in any way accrue against said City AIT ER OR AODTO MF.CH. PL PING FEE
in consequence of the granting of this permit.
APPLIANT UNDERSTANDS ND WILL COMPLY WITH ALL NON-POINT AER HANDLING UNIT(TO 113.000 CFM) MIJCRNICALFEE
SOU E ULA" NS. r
L AIR HANDLING UNE I'(OVER]0,000 CFM) COOPAT N3'AY— —
Silayplifiqns/Courtat f plc EXHAUST HOOD GSMUCI) HOUSING MITEGA'I[ON FEE
IIA7�ARDOUS MATERIALS DISCLOSURE!
Willihe applleanlor finite building occupvmmnre nr handle haranlnustnateriil HEATING ON]'I'(1'0100,(%10 BTU)
nc defined by the Cupertino Municipal Code.Chapter 9.12 and the Health anti Safety
Cads.Station 25532m)! HEATING UNTT(OVER Joh ME BTU)
El Yes ❑No VENT]ELATION PAN(SINGLE RESID) PAID
—Dam Receiptp
Will the applicant or future building occupant use equip ucia or device,which BOILER-COI
P Ofil•OR Ioo'noo BTU)
mil he archms air contaminants m de mal by the Bay Am.Air Quality!dmagemevt TOTA
#
D"na? BOILER-COMP(OVER 100,000 BTU)
❑Yes ElNo
have readthe hvaNw. mtenaE requirements under Chapter 6.95 of the Cali- AIR CONDE I'ION ER ISSUANCE DATE
fomes H Ith&Safety e.Sis 25505.25533 sad 25534.E understand that if the NEW RESIDESTIAL MECH. SQ,Ft. 1 9
Mold' say e rant.marreannre,wnsmdaymneeryNe,eenpant /n ' 2
c en0w e t enam.thnn isnyrespfaCnt� rtetf( yncy.
Own s n dugcnt Intel TOTAL: ISSUED BY:
OFFICE