99100079 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY IO
Cli•Y OF CUPERTINO BUILDING.ELECTRICAL. PERMIT NO
4 APPLICATION/PERMIT PLUMBING.MF,CHANICAL.
BUIIDIN(i DIVISION BUILDING PROJECT IDENTIFICATION
"ooOl
SANITARY NO. APPLICA'T'ION SUBMITTAL DA'1
ItUll"DING AG lkl!SS.
7S S /N Bo r sem/ io-is`—t
OWNF.R'.'NAME: PHONE: CUNT RAM OR'SNAME; LIC NO: NIC CONTROL»
�ARCHITEL IHNGINEER: LIC NO: ADllkf•_xa: Go ❑
CONHAMT. PHONE: BUILDING PERMIT INFO
��G /'G /f ❑ Consultant Fees Paid by Applicant(Initial) BLDG Iil-EcT PLUMB MECH
/ T /d (, ❑ $4 ❑ ❑
LICENSED CONTRACTOR'S DECLARATIONQTy ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby aRrm that 1 um licensed under prevision%Of Chapter 9(commencing
W=Z with Scafw17(XXooI❑ivisian3ofthe Nminess anJ Professions Code.and my license i. RESIDENTIAL'
W C)c in full lin«anA cllccl.� PERMITISSUANCE ❑SFDWI, ❑KITCHEN REMODEL
�acQUU Liccnu Ch`��/��. L,��Y —Lie.» APPLIANCIIS-RE.IDINTIAL. CADDITION ❑PLUMBING RE-PIPE
yQL Uma tantmuor 4..-.� _ �MUhThUNI'I' [I STRUCTURAL
ARCIII'fEL FS DECLARATION / 1'ANIi1.5 STRUCTUR L
•pzyz jury plan%,hall he us, us poblicncards 111"IU 200AMI'S
0IN'1'Elitok ❑CHIMNEY REPAIR
E✓t3 f",{Qil Lacucd 11 1'e......ul 201-1000AMPS IMPROVEMEN9' E]SWIMM INC,POOLS
OWNER-BUILDER DECLARATION OVER HXXIAMPS ❑RATH REMODFUREI+AIR ❑DFM01.1'I'ION
C
C Ci 1 hmror u(Sa,,that 1 mn eBusin s an the Coxion,C's License Law lin the ❑O'I'I IIiR
1 P.U Bellowingdness,Worth
t 711JL5.Business and improve,
demolish.
Code,:Any wt nr ummY SIGNS Ii1.liLTRICAh
3 4.N¢ whim mildness permit re um4mle mmr,improve,demolish, file
repair any twment
102 A�
thiormsl0.isensed pursuant
anyo the provisions cant
forthe such Conductors
mires igned aw(Chapter9 SI'IiC1Al.CIRCl11T/hIISC. Aylo r
f,W that be ending wit pumtion70he of Division
of the C.mmness ii«nwlaw(Chapmr9 FR 1 -ff
R'0C (commencing with Section 7000)of Uivisi.nJof the Business wd Profeizi.ns Cade)or TIiMItMETER UH POLE INST. V
a I1 cC that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NIiW BLDG/AQUI ION ❑DEMOLITION
�MN
Section)031.5 byw,applicant for.permit z.injects the repplicint 1.a civil penally of POWER DEVICES TENANT ❑FOOD SERVICE
not more,than Eve hundred dollars(5500). 1P OVIiMGNT
=Q ❑ 1,us owner of the Cv+pcny.Or my employees with rages as their role compcnsmion, SWIMMING POOL ELECTRIC ❑OT
F- will dtrahework.Cdtheatmctuniators,Livens or Use
does o,apply to a..Business
6 3 m and Professions Code:TM1e Contrucnrts License Lax'does not apply In an owner Of OUTLETS-SWITCHES-FIXTURES
propcny who milds or improves thereon.and who does such work himxlf or through NEW RESIDENTIAL HL[CfR SQ FT.
his own employees,pry.vided that such improvements ate net intended ur.Rend far ;Q TOUR AREA YSQ.ET.
sale.If,however,the building or improvement is sold within one year of completion,the
ownicar-builder will have the burden of proving mat he did not build or improve for pur-
pam nfsale). TOTAL:
❑ L as owner Of the property,am exclusively contracting with licensed contractors to /
coast mcl the project(See.7044.Bu.incss and Pmfc,ocre,Cade)The Contractors Li- /
xc law does not apply to an owner of property who build,or improves thereon.and QTY. PLUMBING PERMIT FEE
who contracts lin such projects with a u+mmcmgs)licensed Pursmmt m II"Contractor's
License I,uw. 11I7RMI"1'ISSUANCE
Ej I.nI e,enlpl under See. ,B&P C foo this rwwrn
ALIT:R-DRAIN&VI?NT-WAI'F.E TEA) VALIIAI'ION /
�wner, Ualc Q V
WORKHR'S COMPENSATION DECLARATION BACK FLOW I'ItOTEC'I'.DEVICE
I band will
nn under rymuhy oe perjury one of the inosefollavon,declarations.
Ihuvc•und will mninminuCcrilicmc.f Cnnaenl to sell-innurc for Worker's Cnmpem DRAINS-FLOUR,ROOF.AREA,CONU. SIO 1i5 'I'VI'E CONS'1'HUCI'If
nnhn r,us fooMed far by Scene.371X1 of the Labor Code.for the IcRormance Of the
w..rk to,which this pem+il is ismcd, FIXTURES-PER TRAP /
E]1 have and will maintain Worker's Compensation Insurance,as required by Section 1
3700 of the Lor Cnde,for the perfismeance ofthe work for which this permit is issued. GAS-HA.SYS'I'P,SET
I-I INC.4 OUTLETS ICC,LOP AI'N
My Workers Car asation Inst tic tri it Policy number GAS-EA.SYSTEM-OVER 4(iA) N q
Carrier: is,NO_ �-- „ 2�(�0 /
IEWHE,CATE0 r k� PT ON FROM WOR ERSGR[ASIUINDUSTRL WASTE INTERCEPTOR
COMP IN NTION INSURANCE BUILDING DIVISION PEF'_S
("is seaj'on need nut is vamClcted ifthc pemtit is fm one hundred dollars(SIW) GREASETRAP PLANCHECK REE
kssJ
I certify that eathe any nwaster oftheoast work for which this permit is irsuednted.I'laill SEWER-SANITARY-STORM EA.200 FT ENERGY FEE
not onLaw,any CanoniDamanner so mbeyW+c/ •WOrAeri Compcm
O,� sminn Lawn of Californiaa.llac _(,�—T WATER HWTFiR WNENT/ELLCTR GRACING PEG
z O Applicant
iaON(ITICE TO APPLICANT.If,afteIML1101 flil,Ccnificate of Exemption,you should WATER SYSTEM/BEATING SOILS FEE,
a7
Iccome,.bieet to the Workers Comycnsotion provisions of me Laarz CMa You Inst
limhwitheamply with such provisions Or this Permit%hall he deemed revoked. MRESIDH�IALPI,MB.
y0
CONST RUM ION LENDING AGENCY B. SQ.19'. PAID
UzconstoictDwe Receipt p
UO karwhich thilM1,,,aither isrOd(Ser.3097,CO.agcncYfor lheperhmuncaofthe work Thr which Nix permit is IxsuW I5cc.3(197.Clv.C.)
Lender,,NameLander',Addrcxx 'T OTA1,: 1I comfytt I have read trisapplication and smic tbel the above i.1t nnutlan isl U] VINO 9iH4 r rect.l agree locmply with all city andeounty Ordmancesand state lowsrclutiogtaL PERMIT REE FEE
U z building co Olmetion,and herby wmanirereprcsemutives of this cityto enter mpn the
abmclncntioncdprnpany lninspecoonpurEcees. ,iCIkIC INIi j 5 ' 99
(We)agree,to save.indicatory and keep harmless the City of Cupertino against
liabilities.judgments.costs and expen%vs which may in any way accrue against said City ALTER OR At)])TO MECH. U.UMBING FEE
in cor,esparrod Of the granting of this permit.
APPLICANT UNDIiRS'1'ANDS AND WILL COMPLY WITH ALI,NONTOIN'T =BTU)
G UNIT(TO 10.000 CFM) NSIANICAL FTE
SOURCE REGULATIONS.
�i G UNI'f(OVER 10.000 CFM) CONS I'R
Signaue of ApplicinJContnorm Dte OD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIA ISCLOSURE
Will the applicant ar future Wilding occupant store or handle hazudnus material IT LTO IOIL000 BTU)
as defined by the Cupenia.Municipal Cede.Chapter 9.12,and the Health and Safety IT(OVER 11%1.000 BTU)Gide,Section 25532(a)t
YenMNo N FINN(SINGLE RESID) 1•AID /
//�` Uma Rttei p
Will Ibe applicant or future building Occupant u.se equipment or devices which BOILER-COMP QHI.OR 110,(X10 BTU) TO
emit haranlou.s air sommainanm us defined by the Bay Arca Air Quality Manage'or s
Dionet, BOILER-COMP(OVER 100.0001 BTU)
yes
AIR CONDn'IONER ISSUANCE DATE
1 ha,r rend IM1c hvnNnus ntamrialx reyuiremcnN under Ch.ptnr 695 of the Cali
taenia Ilculth&9al'Gy Q+XIC.S ctinns 25505.25533 anJ 25574.1 unde:xnmd Ihm if the NI?W It851U1!NI IA I.MECH. SQ.PI'.
Building Airs nm currcndy n:tvO ummm,lhathi.s my scsponobility mnbti'y the cupmn
vh\uirc Fair
Aiclun net prior til issuance of a CeniGeyml )kyr
f �/�
'•IWhurimJ%gem t ate TOTAL ISSUE)BY�`�e.
OFFICE