99110042 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY l k O 0 1-f�
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APIaLICATION/PF,RMIT PLUMBING-MECHANICAL
BUILDING PROMICT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. KATION tlMITTAL DAT
/L y0 NARf t itN o�f /�oAd �i� -
WNERSNAME: PIIQ. ': CONTRACIOII'S NAME: y- LIC NO:
DSC S C 8, NIC CONTROL or
C HITECTMISGINirit LIC NO: ADDRESS: ❑
.217/0 �6✓E�tIS C C 13 I��.�(O
CONfAC'1'. /(/ 1PHONE: IJUILUING PERMIT INFO
�� •e AIBRR/•// ` ofj 267-2 /oo ❑ Consultant Fees Paid by Applicant(initial)
BLDG EL�EyCT/PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I herebv affirm Nat 1 am licensed under previsions of Chapter 9(commencing JOB DESCRIPTION
OCZ wlm Section Division 3offle Bminc.cs and Pn,I...m,Code,andmy license is RESIDENTIAL;
WOO PERMIT ISSUANCE,
CWE- in ren Come and effect. 97 zY5 ❑SFDWL 0KITCIB?N REMODEL
QUCy h¢eunCl ss Lim.X APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
F Z W :)are Colo.
hQ4 ARCIITECI'S DECLA A ON (D MULTI-UNIT C3 STRUCTURAL
F7� PAS
MODIFICATION
ZOOZ Iunderstand illy plans shall M used as public records
OZ-W UPTO300AMPS El INTERIOR El CHIMNEY REPAIR
F,N)t'W Licensed l'mfeacionil 201d010AMPS IMPROVEMENT C]SWIMMING POOLS
ec OWNER BUILDER DECLARATION
C Q UJ I hereby affirm tore 1 um exempt from the Contractors License Law for me OVER 1010AM1'S [I BATH RIiMODF;I/ItEPA1R [D DEMOLITION
3 F following reason.(Scairn]03 L5.Business and E•n+feairn.Cole:Any city or county SIGNS ELECTRICAL ❑OTHER
which rapums a fermi)u+cnn. r ,label,imp so.demolish,m repair any smmmre
Fu'oI prior to its issuance.also re4uier,the applicant for such purmlit)rile a sigood statement SPECI AL CIRCO I IrMISC.
acy�,T that he is licensed pursuant m the provisions of the Contractors License Law(Chapter 9
�f�p0 (commencing with Section VONB of Division 3 of the Business and Professions Cods)or TEME METER OR POLE INST COMMERCIAL
d d e Ihm he is eeempl Ihe.drrm and the basic for he alleged.xemptmn.Ni,v....... al SU NEW BLDG/ADDITION ❑DEMOLITION
K"
Section 7031.5 by any applicant for a permit subjects the applicant in a civil penalty of POWI7R DEVICES TENANT ❑FOOD SHRVICE
F Z i ^ill more than five hundred dollars(S5t0p IMPROVEMENT
1- I,as owner of the pmpcny,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
F. will do the werk,andmegmaureismol imendednrnfl'crd Casale(Sri.]IW.Beinns ❑OTHER
LL_ and Professions Code:The Contractors License Law rias nm apply m an owner of OUTLET'S-SWITCHES-FIXTURPS
L 3.. property Iho builds or improves thereon,and who does such work himself or through
his own employees,provided that ouch Impreven+cals am not intended or offend for NEW RESIDENTIAL ELECTS SQ IT.
sale.IL hoses,the huilNnBm improvement a mld withmareyearol romphnio^,the SQ.ET.FLUOR AREA S/SQ,FT.
crrd
builder will have the buco of proving that he did not build or improve for par-
`
eaof.sdea.
❑1,to.owner of the pa+perty,ren exclusively comr^eling wird licensed contra net ask L'
construct the pmjca fisc.]IW.Business end Professions Cde:)
ccnm Law does not apply to an owner of pmpcny who build or ire FEE
who contracts for such projects w all a centurions)licensed pursuantt e t
Lircnm law. PE I C
-� ❑I an exempt model See .It d P C for Nis araC.
\, ITne - VALUATION
mar WORKER'S COMPENSATION DECLARATION ( (yT 1'.DLVICIi
1 hereby mmrm under penalty of perjury one of the(allowing declare
I have and willmuintam a Couldicamof Consent to sd6lnsare for Workers Co I - ( STORIES TYPECONSTRUCIOI
.vark f as which
this
for by Suction 39W nllhc Luhur Cods,for tiro i,
work for which Nis permit is issued,
❑1 have and will maintain Worker's Compensation Insumace,as re S
P]0lof the lanurCde.for Eire perfornnmce of mvwnek for which m: s. e . A-BA.SYS'fLM-I I�'C.401IT1.ETS OCC.GROUP - �APN
My Worker's Compamatien Insurance carrier and Policy number are:
Camey. Policy No.: GAS-IiA.SYSTEM OVER 4(EA)
CERTIFICATE.OF EXEMPTION FROM WORKERSGREASFANDUSTRL WASTE INTERCEPTOR
COM13ENSAI ION INSURANCH BUILDING DIVISION FEES
(filikile inn neednof hecnmplered iohe ryrmit is for terse hundred dnllatx(S 100) GREASETRAP,or less.) PLANCHECK FEE
I certify that in the performance ofthe work fix which this permit is issued l shall SEWER-SANITARY-S'l ORM EA.200 FI'.
not employ any porton in any manner so as to became object m the Woders'Comps^- BNERGV FEE
Z ...ka.U.,lof Coshfrnia.Date WATER HEATER W/VENT'/ELECTR
Z GRADING PEE
Applicant
NOTICE APPUCAN'C N.after making this Certificate of Eacmplinn,you should WAI HE SYS'I'EM/TREA'FINC
SOILS PEIi
> forme object to the Worker's Compensation provisions of do Labor Croke,you must
W forthwith comply with such previsions or Nis pcmtit shall bee dared revoked. WpT17R SERVICE
C'
CONS'1'RUCI'ION LENDING AGENCY NIiW RIiSID1iNTIA1,I'LMN. SQ.FT. PAID U Il, Rccript X
I hereby affinnthauhem iso commerical lending agency[.,,he perfmmunceof
U
the work for which this permit is issueJ(Sec.3097.Civ.C.) t
C) U lend. .' I(YTAI:
.Name f,\ 'I'OT`L: r�
} W lender's Address '
r G EE
0. 1 certify that I have raid Ellis application and.state that the move information is
BULLI II-
o-Hi UJ correct.Ias=it)complywithallcityandcountyordinancesandsmrelawsrelmingto QTY. MECHANICAL PERMIT FEEJBIMEEE7
NOV - 9
U sz huilJing con.vuctlan,and hereby uwhurier roprasenlntives ill this city m corer upon the 1994
ahovemcntin^d property lir inspection proposes. PERMIT ISSUANCE
(We)agree to save,indemnify and kap harmless the City of Cupertino against
li.lehlic,judgmend,costsand expenses which may in any wayaccmeagarcosaid City Ad17R OR ADD TO MIiCH.in +nseyvenceof the gruntingof obi,lemon.APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI,NON POINT AIR HANDLING UNIT(TO 10.000 CFM) I•EE'-' --
SOUR�C��y1�'11��/GGCDN.ATIONS.
� � AIR HANDLING UND(OVER 11,1100 CFM) CONSTRUCTION'TAX
Signature ofsopplmnntlContmcmr •56A ale EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Willme applicant III 1.1.1.brikupolaised store nr handl.haondommatcrial HEATING UNCI(TO 0C.IXIO R'IV)
as defmd by me Caperton Municipal Cde,Chapter 9.12.and the Hca1N and Safety
Code.Section 25332(a)^ HEATING UNIT(OVER motion B'IU)
Yes ❑No V[IN'I'ILA'I'[ON FAN OSI NG 1.13 BITS Go PAID Dal, Recciptp
Will the applicant or furore huilJing occupant use equipment or devices which BOILER-COMP GHP OR 100,0111 BTU)
it hmardnos air contaminants as defined by the Bay Area Air Quality Management T L;
JLwriaP ❑OILER-COMP(OVER IIN,IYO it rut
0Yes C]No
I have must the huzudous materials accumulators under Chapter 6.95 of the Culi- AIR CONDITIONER ISSUANCE EAT
fomiu Ileahh N Safety Coal"Sections 25505,25533 and 25534.1 understand mal if he NEW RESEBiNTIAh MIiCH. SQ.El'. / ��
bil
uJingJasn tmntlynavcamnant did is my resrym mnrnify roe«mlwtt
aide,hm mill hi seat l e I m issuance Golf f r ancy. !/
sed a8ent / Ualc TOTAL: ISSUEDBY:
OFFICE