S 4353 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPE RTINO Bull'DING-ELECTRICAL ERMIT NO. 4353
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
ItGILDING PROTECT IDENTIFICATION S
BUILDING ADDRI!S': SANITARY NO. APPLICATION SUBMITTAL DATI
1 � ar a 170 S0/
OWNER' NAME: .- PHONE ONT NESNAM LIC
.^Cl 77
NIC CO�ON�BUL#
C "/IiNGINEP :.GLIC N)'. ADDRESS: ❑ J / G/
CO, AC AW,`-'0^•(n1-'H L': BUILllING PERMIT INFO
f (/j ❑ Consultant Fees Paid by Applicant(initial) BL ELECT PLUMB MECH
P.o. ary►rn c re 2' ❑ ❑ ❑
LICENSED CO TRACTOR'S UECf.ARATION QTY ELECTRIC PERMIT FEE
I hereby aRrm tM1ut I um IicenxJ unJer provisions of CTapter 9lcommencing JOB DESCRIPTION
OaZ with Section WN10)of Division 301he Business and Professions Code.and my license is RESIDENTIAL:
WOO P-RM1I'ISSUANCE
CSF- in full fora and eRec ,_ • OSFDWh ❑KITCHEN REMODEL
CUU innbut la. Lica APPLIANCES-RESIDENT IAL ❑ADDITION ❑PLUMBING SE-PIPE
f z w Date C o.mutnr
Dm nRCHI TECI"S 1l-Cl.A ATI❑ I'ANEL5 ❑MULTIUNIT ❑STRUCTURAL
I'alZ Iunde....nd my p)....hall M used aspublic rtcor MODIFICATION
OZ`a I31'T02MAMPS ❑INTERIOR OCHIMNEY REPAIR
I-En F'LL Licensed Proleacimcl 201-IINXIAMPS IMPROVEMENT ❑SWIMMING POOLS
ac
OWNER-HUILUER DECLARATION 1000AMPS O BATH REMODEUREPAIR ❑DEMOLITION
C Q I hereby affirm that I am exempt from the Contractor',Li¢n,c Law for the
x70Ial�Walr h6.F following reason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHEk
I- wh'mn ralnir,u panni.to construct,at,,,i pions,demolish,or mpair any,imcmm
-1 prior to its issuance,also requires the applicant for such permit file a signed statement SPECIAL Cl RCUIT/MISC.
f tas�t3Y unit he is licensed poonammm
son pvi,ionc of the Canmuenrt's License Law(Chain,,9
COO Immm,ramll aim Section'BXNoof Division 3ofthe Businesand Proremions Caarra, 'IEMT MEI'ER OR POLE INST. COMMERCIAL,
61 p that he is exempt therefrom and the basis for the alleged exemption.Any violation of O NEW HLDG/ADDITION O DEMOLITION
W^ Section 7031.5 by any applicant for a permit subjects the applicant a civil penalty of POWER DEVICES ❑'TENANT ❑FOOD SERVICE
ZG
no.more than Five hundred dollars 055(0). IMPROVEMENT 0hmowncnJthe pmpcny,or my enrpinyec with w.Hc,ue their axle compcnsminq SWIMMING POOLELECfRIC
[I OTHER
F. x'ill do the work.ani the sunamrek ince inrenJeJurortercd for,,de(Sec.70Lt.Business
13 re :nW Prides.!,..Code:The Conn.,, 's Licenw Low doe,,am apply In na owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his into employees,provided that such improvements are not intended catenated for NEW RESIDENTIAL ELECI'R SQ FT.
sale I. h the building improvement IJ oro Y f id t ,the '` r1, 'U.FT)_pj.00 REA ��/SQ.Fr
ernld will have burden fp proving JJ not improve f put v p .'0 ^0 U
El 1.a:1 , � JUL 1 91999
co 1 0 oc nth pr pony m exclusivelycontracting 'Ib licensed contractors nr Tll /�V
ruu nersomacca ply orm Ii and err 1 C or.)Th v t c Lo-
cense law Jsns nm apply ns an owner of pmpcny who builds or improves Chuan,and QTY. PLUM61 'G .RMIT FEC
who,nova,,fur ash pnr,jeutx with a amtracmr(s)Iiccnsvd pursuant tmhc Conwctork
License law. —�J PERMIT ISSUANC Q
1 a eannpt ander Sec. ,B&P C for this reason e p
ALTER- VE - (i?A) VALUATION
Urine, Date
WORKHR;SCOMPENSA'HON UECLARA'I'ION RACK FLOW P;eE7CbF.VI Z 3 O OO
I Inrchy anion under Nualry of pe jury one of the following dalnauonz: 2—
IhaveandwillnatintuinuCertificateofConsenftovelf-lnvurc lar Workers Compen- DRAINS-FLUOR,ROOF ND.OSTORIES TYPECONSTRUMTON
.anion,as provided for by Section 37M of the Labor Cale,for dm pcdurmunce-the
for which this permit Is issued. FIXTURES-PER TRAP
wo 1 have and will maintain Workers Compensation Imam..'.as halmoc l by Section
37 the labor Code, Performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLL-I'S OCC.GROUT' APN
hfy Work ,CompensaJnn Insurance carrier and Policy n m
Carricr: Puncy No.: rt o GAS--A.SYSTIiM-OVIiRd1EA)
CF JCATATii(IP EXEMPTION IBOM WOR KERS'
COMPENSATION INSURANCE GREASF/INUUSTRL WASTE INTERCEPTOR BUILDING DIVISION IBES
(@isra,inancedndN,-annpleled if the pmnit is formae hundred dollars(5110) GREASETRAP
orlon) PLANCIICCK PEE -2— S'
I ccni fy thin in the perfoona.cuofthe work for whichthis permit i,issued,I,hall SEWER-SANITARY-STORM EA.200 FT.
no.employ any Person in any manner m as to Wemne subject nr the Workeri Comm, ENERGY FE
Z. satin.laws of California Ilam WATER HEATER WPVENT/L'LGCTR
ZApplicant GRADIN
NOTICE To APPLICANT:If,after making this Canlficotc of Eacmpmon,you should WATER SYSIEMOREAI'ING SOILS
ua > neconre comp m Inc Worker's vismPematwn Provision.of the farad Code,you mac.
W
forthwith comply with such provisions or this permit shall l+c Jeemcd revoked. WATER SERVICE
O
UZ CONSTRUCTION LCNDING AGENCYlwr, NEW RESIDENTIAL I'LMB. SQ.Pit PAID pant Receipt a
U 0 IhereM1y affirm thunM1crc is aconarvcunn lending agency for Mrfnrmunce of
D. P the work far which this permit i.issued(Sec.3097,Co,C.)
QU 1<nJcr's Name
r Lenders AJdres, T 1.'
4 1 candy thin 1 have read.M1is application it state that the above mflaccuu n is BU11.D1 , 'E
y runcm.1 agree to comply with all city and cnunry ordinances and ante law,relating m QTY. MECHANICAI.PERMIT FEE '7 O
U building construction.and hereby audience mpmsenmtives ofthisciry menmr upon the SEIS :FEE �y
utxrvenncn.inncdprolxnyfnr impaction Irl"ca, -P-RMI r ISSUANCE. D S Q
(We)agree to save,indemnify and keep harmless the City of Cupertino against ii. RIC E
Iluhilities,judgmem.cco..ts and expenses which may in any wayacemagain,said City ALTERORADDTOMECH. PI K G
(IN
c
c of the granting e ng of thus Permit.
APPLICA5101i UNDERSTANDS AND WILLICOMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.0IXICFM) M'C ANICAL FEE
Piton
O I
C AIR HANDLING UNII'(OVIiH 1gg0 CPM7 CONS UC ION TAX
plicant/ o act r nc EXHAUST HOOD(W/DUCE) HOUSING MITIGATION PCE
HA"'/.A US -RIALS DISCLOSURE applicant or future building occupant store or handle harmdum material HGA'1'ING UNIT(TO IIN41MI1 BTU)
as defined by the Cupamin,Municipal Code,Chapter 9.12,unit the Health and Safety
Cod,Scalia.45532(,)? BEAT INC,UNIT(OVER I WINO BTU)
OYc ON. VENTILATION PAN(SINGLE RESID) PAID Dam Reccifm0
Will the applicant or future building occupant use equlpmeot oT devices which BOILER-COhtl'DHP OR 1 ander"
BTU)
it hamNous air contaminants m defined by the IL,Area Air Qualify Management O L-
4,�,dol
BOILER-COMP(OVIiR 1 W.000 BTU)
❑No
thin, d the h:vnnlnusm:neriaL rtquircmen.e unJer CTapmr A95 of Ne Cali- AIR CONDITIONER ISSUANCE DATE
HeSafety Cade.Sections 25505.25533 and 255341 understand Nm d the NEW RESIDENTIAL Ni SQ.PI t r-2—
cumnan., nt it iso ymsrymsibilitym notify eceapumts whicv . c. arta i. ofaCCard Ilut ISSUED BY:
OFFICE