99120098 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY Z QO
kll'I'ILDING
UPERTINO BUILDING.RLECfRICAL PERMIT N
G DIVISION APPLICA'I'IONIPERMIT PLUMBING-MECIIANICAL -
BUIIAING PROJECT'IDEN1 IFICAITDN'
7N,1CGIRY NO. AI'I'LICA'I'IUN, (TAI.DATE
DRESS:
`VN��N,�(rf �n,•PII)NI::__�M CONT 9111R'i;AME: - ' 1 1 ll G CUNfROLM
an,
R CHITHLT/ENGINEER: l'((YUU vx7 No
tA, ADDRESS: 11�' - J
—� C0 Cl10
CONTACT': NUONLI BUILDING PERMIT'INFO
Pr,�'�I �gyp6� FG/2�y ❑ Consulmnl Fees Paid by Applicant(Initial) BLDG / ELECT a NIA❑MH MECIi "
LICENSED CONTRACTOR S DECLARATION iw QTY ELECTRIC PERMIT FEE rl_Y�/ JOBDESCRIPTIONLrhX/
s 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
0PeZ Ili Sectinn"IINX))ofpivision7of the Buhine.—ad 'mRssion,Cale.and my license is RESIDENTIAL
DENTIAL'
rl0C, .Ih SocIiva7dc ] 1 PERMIT ISSUANCIi
1, 0SPUWI, El KITCHEN kIEMOD1El.
ofUf License lass H Lich APPLIANCES-Rf$IDFMIAL ❑ADDITION ❑PLUMBING RC-PIPIT
v¢a Data Contractor k
ARCIIITIECPSDECLARATION
PANELS ❑MULTI-UNIT' ❑STRUCILRAL
~N Z I unJersmnd my plans shall be road as public rcrords h1UDll'ICA'I'ION
ZOm— UPTONMAMPS ❑INTERIOR ❑CUIMNIiY REPAIR
I"��W hiccnxJ Professional 201-IIX0 AMPS Ih11'ROVF.MIENT 0SWIM1Ih11NG p001S
�•af E; OWNFk-BUILDIER DECLARATION OVER ISMAMPS ❑HAT((REMODELRITAlk ❑DEMOLI"PION
%=Q 1 hereby alfimt mm 1 am exempt from the Curnowo',License I,aw lin me
fL,�0 a U following reason.(Section]071.5.Business and Professions Codd:Any city or county SIGNS FLECD?ICAI ❑Of HER
LL13 LL 1"' which s ' p illConstruct, II impdemolish. p' y.I elarc
f-LL+oI pr ort I c Lv q" 'Ili ppl uII Ip 'n II 6 J.I trnrt SPECIALCIRCUII'/
f } math I sed pa.uanO Ili p fm c I Ir:L I (Ch PeTv COMMERCIAL
I CApO (commcmmng will Sodiun]mNHof Division 3 of me Business and Pmfessons Code)or TEMP.METER OR POLE INS'.
%y e C Thal he is exempt therefrom and the basis f"or the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
X-m Section 7031.5 by any applicant fora permit objects the aPlAi'annu a civil penahy ml IIOWIER to
q3 FKANF El FOOD SERVICE
not marc man five hundred doll.,($50). IMPROV 1EM EN T
fS0 ❑L as owner of the pmpeny,or my dmployces with wages as their sole enmpcnxation, SWIM1I M1IING PO(')LELE C
P• will do the work.unit lhextrocmre ix nal intended or faced frxalc(Sec.?04......inc.x Dal HER
W 3 o and Professions Code:The Contractors License law dos not apply m an owner M OUI'L1!I'$-SW (CUES-111
ITT
pmpeny who builds or improves thereon,and who docs such work himself or through
p y provided that such improvements I intended or offered far NEW RISIDENTIAL F.1.ECTR S T. Q Q
has own dm ve eche pmvi rt is old s are net 5 .FI'.FLOOR ARI!, SIS .IT.
Sala ILimider will have
.den ofpro int toldwithinoneyearof improve
and
-huilJdr will have me harden of proving mm he did eta build or improve for pur-
q:w of roto.). TOTAL:
❑ [.;1,owner.1 he pnspeny,tun cxclusivdly u:mn:aing who liccnscd amu.mors m Chi
construct the project(Sec.7W4,nosiness and Prdossions Cod,)The Cminm ua's Li-
censelnwmnsnmapplyns vet owner of property who builds or improves there .and QTY. .NIBING .RMIT FEE
who contracts for such p sl with a Contractors)licensed pursuant o the Commcmes
License Ltw. PERMIT ISSUAN6.
E)Ivo exempt under Sec. ,B&P C lin Isis reaves
ALTHH-DRAIN "NI'- .TER(ITA) ,{ VALUATION
Date .((}{J{{�p�5 �� I-r,^
WORKERSnePenalty
COMPENSATION UCCLARlcusinN BACK FLOW Par YI'ECT.U: I ,1 Sol ]U
serIhereby il lmaiunderpenallyofofCoyone of the inmieorWuaarc Co; 11 (/`�J
(have and will maintain aCenificate of Cononnn self-inzure for Workers Compen- DRAINS-FLOOk.RWP.AHFA,COND. S'IOHIIS 'TYPE CONSTRUCTION
smien,as pr-ided for by Section 37X1 of the Labor Code,fur the performance of the
work for whiCh this pc.if is,,trod. FIX'I'UIlES-PER T'RAI'
C]I have and will maintain w'orker's Compemation Insurance,as required by Section
37M ill the Labor C:dc fin the performance of the work for which NiJx permit is issued. GAS-ITA.SYSTEM-I INC. OUTLETS OCC.GROUP �IN� D
My Work r� Cunt tsalinnI f5,cul Poli,tun r 1 dg GAS-BA.SYS'IPM-OVER4(EA)
C.mer. 1 x(ALIFRGIAIA kau lkUj.�YY Pnher No.: (5
CF:RTIFlCA'IE OF t%Eh11s1'ION FROM WORKERS' GRF.ASF/INDUSTRL WASTE INTENCEPTUR
COMPENSATION INSURANCE BUILDING DIVISION PIi1S
('I'bis.cection needmm bcmmpleted'dthe permit is for I almaboddoilam($IW) GREASE TRA('
PhANCIIIECK FRi
in Icss.l
lay any"Tea
in mnanymnmersome wodfor which this the Wivesuegislall SEWER-SANITARY-STORM1t EA.200 Ff,
noI cnnploy any person in any manner vents In bmunm wM1Jdet m the Wurkcrn'pmlpdm ENERGY PTi1S
Z xation Wwsufcaliliurem [)are WATLRHE6TIIRWN17NT7ELIECTIt GRADING FEE,
z 2 Applicant I
NOTICETO API9.ICAM':If,after making mis Certificate of Exemption,you should WATER SYSTIiMITR ATING SOILS REE
no,omcsnhjC,l ,,the Worker's Cnngwnx:roan provisions of ilia Labor Code.you nmsl
aQ lunbwim comply with such pmvi.uans to this permit shall he deemed revoked. WAIHR SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMR. SQ.FE PAID
U z Unto Rcccipt N
V 0 IhcrcnY nfGnn that isaconxtmainn lending agency for the perfonnanaof
U. the work for which mis permit is inarad(See YN7.Civ.C.) 'Fy1'AL:
Q U Lender'.,Name TOTAL:
} U lend..'.Address r� BUILDING FEE �..�..,
I ccrdfy Ism 1 have rend mis nppli,amem and staid that the dowc infummtinn I'
F Correct.I soct,ascnmply within l cilyandemanymili...ce remixmclewsrelaiinglo Q'TY MECHANICAL PERMIT FEB.,1
U rp Z building construction,and hereby avmori.e repowertatives ofthis city to enter upon the U SEISMIC FIEB I I f s1'
aboveancndoned pmpeny fieri us'e'd....proposes. !ALTER
RMIT ISSUANCE ��' IT CIRICFEE I t.
(We)agree m save,adenmify and keep harmless the City of Cupertino againstFIL
.-. Iiabilities,judgmems,costs and expenses which may in any way accrue against said City OR ADD TO MECH. I -F Ein Consequence ofthe granting mf this Fannin.A'' CANT'IJND17RS"ANDS ANI)WILL COMPLY WI"fH AL1.NON-('DINT R I IANDLI NG UNI'1'(1'0 10,IXX)CFM) MECIIANICAL PHI?}f(h)jIILN�y`L AT]M i`,�� V'Il �v�� j/J &-MR fiAM)LINGUNIT(UVLR IB.INp CPM) h`/ CONSTRUCTIONTAX f
Si Amureof Applcard"' mcmr `i ((D/arn / F.XINUSTHOOD(W/DUCT) HODSINGM1IfrICATIONFEE�"'I
HA RDOUS MATERIALS DISCLOSURE
Will the applicant or future Willing accupamsmm or handle heaanlal,mmcriil HEATING UNIT(TO 100,1X10 BTU)
ox defined by me Cupe.dno Municipal Coda,Clocue 9.12,and the Ilcmlm uad Sucty HIEAIING UNIT(OVER 1(0100X)111 U)
Cade.Set ion 25572(a)?
C]Yes ❑NoPAID
VFENTILATIUN FAN(SINGLE kESID) [)ate ResciptN
Will the applicant or lunare building occupant use equipment or device..which BOILER-COM('dnp OR I W INN(Iff,
emit hazardous air mnmrnmer,as defined by the Bay Area Air Quality Management 'ICTAL: ��
District? BOILER-COMP(OVER 100,001 B'IV I
El Y11 F)No
1 have read dm luzmdom
us aclials requircmems under Chapter!95 of the Cali-
Alit CONDITIONER ISSUANCE DATE
calm&Safety Code.Sections 255115,25573 and 25577.I understand thin if the NEW RESIDENTIAL MECIL SQ.17.
mildingdsmsfelt.manly have.on that it is my respn...hility unlmify deiwuupnnl ��/� ( r
of mmm e requirements which must be prior to issuance of a Cea ificaOccupancy e ill .
Uwtmr nr nnmurireJ agent
Data TOTAL: ISSUED BY:
OFFICE