99120093I ANTM FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
_9:7__ U % 1 Z_w 7`ti
..PPL C
PERMIT O. —
CITY OF CUPERTINO
BUILDING -ELECTRICAL
APPI,ICKI'ION/PFRMIT
PLUMBING.. MECHANICAL
BUILDING DIVISION
BUILDING PROJECT IDENTIFICATION
I'1'ARYNO.
APPLICA'('1ON SUBMITTAL DAL I
BUILDING ADDRESS:
io s S•. �' Y.
I L
OWNI,R'S NAME: _ NW, CONTRAC'TOR'S NAME I. CNO
NIC
CONI OLM
-'Pit
V G
0
1 l'IITTE iN NEER: LIC NO. ADDRESS: ^ �}A/]/
-/J
1
D S.
li:
PHONE
BUILDING PERMIT INR
CONI'
❑C......Mart Fecc Paid by Applicant (initial)
BLI)cy- EL[Cy PLUS huiC
YJA
LPTJION
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT
FEE
JQRLr'JDfESCRI
1 hereby dfinm thu 1 ono lueemo !under pnrvisions of Chapter 9 (mmmeaeing
is
RFSIDFNTIAI'
wish Snnion]IXNBof Diviaion3of the Businessland Prof¢sionN Code. and boy license
1'ERM11H'ISSUANC�
❑SIUWh [I KITCHEN RIiMOUEI.
in full force and effect. ����//// �,O
Liana: Clans Lic.MJL"/
APPLIANCES-RIiSIDENIIAL
❑ADDI'T'ION ❑ PLUMBING BE PIPE
Dara - 7�} Comrealor Y. (nl� • Lfr^7 M'
Qh1ULT1-UNIT ❑S'1'RUCIURAI.
ARCHITECTS DECLARATION
PANEIS
MODIFICATION
1 umderslo d my pluns,hull he uwd ac puhlic records
Up 10 200 AMPS
❑INTfiklOk ❑CIIIMNIiV RF:I'Alk
IMPROVEMENTE]SWIMMING POOLS
Licensed Proco,iunal 201.1000AMPS
OWNER.BUILDER DECLARATION
OVER IIRM AMPS
[I BATH REMODEI/REPAIR DDEMOLD'[ON
front the Coulmcr's License Law for the
1 hereby a1Rnn that I am exemptm
❑ OTHER
following reassm. (Section 7031.5. Business add Professions Code: Any. city or roomy
SIGNS ELE CAL
whirl y a P n construct. II p d 1 h ,cany orcluall
poor to itsalso reclaims tile "Plimemall h PeralmI IIe a S'Iaed.rt mend
SPECIAL CUIUMISC.
COMMERCIAL:
that he is licensed pa n the provisions of the c I t License Law (Chapter 9
Ieonllneromywih Seen an 70fXpofDi Non3nflhe Business and Professions Cale) or
TEN P.MFI'ER 7, INS
�,`
td M11:W BLDG/ADDITION [D UIiM01,1'f10N
Thal he is excmpl therefrom and the baxin far the alleged excmpllon. Any violation of
Section 7031.5 by any applicant for a peoula-hjects the applicunno a civil Formby of
POWER DEVICES
❑TENANT ❑ FOOD SERVICE;
nut room than live hnmind dollars (55018.
C
IMPROVEMENT
FILosowneraddop..pemy,or my employee, sits wxgcN asmcirsmle corrawasution,
SWIMMING Pr sOLELE
O'fHlik
will do the on, and the suucmre is bol inBnded proffered for sale (Sec. 7lkW. Btsinea
rk
OUTLEI:S-SWITCHES-FIXTURES
i and I'rofesxinns Code: Be'Camtaclors License Law Imus not apply ht ;in owner of
' prall who humid, nr improves thereon, and who does such work houseful through
NEW RFSIDENTIALELECTR SQ FL
SR PT FLOOR AREA
5 SQ. PI'.
his own employees, provided that such improvemenu arc not intended or offered for
sale. 11, the huilding no imLrrvcmem1,sold w morinncynrof ennlplcom
owner -builder will have me burden of Proving that he did and build no implir
(Qrove _
1 �
pose of sale.).
'
❑ 1. mf the pfoLemy,1 1 exahi,ively coal me0mg want licensed nt,ntra,n
construct he pmpal (Sec. 70H. Business and Poop eoinas CldcU The Cnmmcut, s Li
FEE
cen.m Law does not apply no an owner of property who builds or improves Ihc.n, and
TY. R
wilt, comms for such pmj,,I, with it eallracmr(s) licensed Pursuant da the Conlruem's
Liao. law.
❑ I am exenpl under See. If & P C for this moron
VALUATION
ER- AIN & VENT -WATER (EN
Ownar st
WORKER'S COMPENSATION DECLARATI ,IN -
y.0 E ) 1 0
y
000
under penally of one of the following deel:nminn.
1 I botchy at firm f p
On CeniGcamof Cmn.wntlomlf-insurafor Worker's Co
y i
1 ) 0
S'TORIIiS 'i'Y PIi CONS I ItlIMOl
lhavcmdwillmmntan.
nater, u, provided for by Section 3700 of ne Labor Code, for the perfmmancc of me
PER TRAP
work dirt which lois Lenon is island.
Idl%TUBES -
`V
1 have and will umimain Worker's Compensation Insurance, as reclaimed by Section
3]1X1 of the Labor Cole. for the performance of the work for which this permit is issued.
/ GAS -G. SYSTEM -1 INC. 4 OLDLETS
I
rGR(IUP Z�s
(p
My Wnrter', Compcmalion l nwmnce caricr and Policy mandn"arc:
GAS -EA. SYSTEM-0VI!R 411!A
E32
Carrie, Policy No.:
Q 3
CERTIFICATF OF EXEMPTION FROM WORKERS'
GREASUINDUSTRL WASTE INTERCE
FEES
COMPENSATION INSURANCEBUILDINGDIVISION
I'LANCHECK FEE
CDoissecdion relation bocomPlemdiflhepemoilisforonchuarreJdallats(SI(I I GRPA.SETRAP
less.)
Icerlily in the the workit,,which thto the
SliWiilt-SANI'I'ABY-S'IOBM111iA. 21N1IT.
;NIiRGY IBE
Workers' Confhsllined-
batoneuralryLaw any parvor in ado matter so a, m I<emme ant}ee m me wmkerr emmpen-
poi my
GRADING FEE
L nminn Laws of California. Dam WATER IIEATiik WNBNT/ELf:CIT
j Appfieanl
SOILS FIJI
T: after aking this Cenifcme of Exemption, you should TELL SYSTEM/TREATING
NOTICE DO APPLICANIL m
become subject In the Workers Compensation provisions of the Labor Care, you must
/ rl 17 A
! �l
forthwith emorply wim such provisions or this permit shalt he deemed revoked. WATER SIikVICE
CONSTRUCDON LENDING AGENCY
NEW RF_SIDF;NfIAL 1'LMB. SQ. Ell
pt, B)
Dare Receipt
I hereby afGrnuhm ileo, in u mnswnian lending agency tonne peffnrnrnne.of
the work for which this permit is issued (See. 3097, Civ. C.)
'I OTAI�
Lender', Ndnoc
Lenders Address
TOTAL:
BUILDING 17E.17Is
11
I comity that I have read this appluenkma and nate mat the above infunnmion u
SIi1Sh11C 1tiE
-
O s ren. lagrre m comply with all city and county ordinances and state laws relating inQTY MECHANICAL PERMIT -'FEE
K hnildingconstruction, and nertby amhoriecrepmmmmivesof lhlscaymenmrupan the
above-mentioned property for inspection purposes,
PERMIT ISSUANCE IITo
\ `i
1
I!LECI'kIC FEE
( Wel mar. In use. indemnify and keep harmless me City of Capetian against
Hodo0illes.judgm rd,coots and expenses which may in any way acerae against said City
ALTERORADD'I'OMECH. 'TUI
I'LUMIi11NGITF.
'
in ofthe thispermit.
)GEAR
RSIAgof
AI`I'hICANT 11NU1i125TAND5 ANI) WILL COMPLY WITH ALL NON -POINT
PLICANI
AIR HANDLING UNIT (TO IO.IX
h1F'G'H ICAI. I'f:E
SOURCE NEGULALIONS.
AIR HANDLING UNIT (OVER ld, pCFM)
CONST 1C1'ION FAX
.ND USI NS, M I' I'IGATI0N FEE
Signature of Applicam/Comractor Dnlc EXHAUS'P HOOD OVIDUCT) 6V
HAZARDOUS MATERIALS DISCLOSURE
miilding some or handle Initial material
HEATING ON] HILL IB'ID
Wdiffin a"heodl or fare occupant
as defined by the Cupeninm Municipal Code, Chapter 9.12.:, d the Beallh and Safely
HEATING UNIT' (OVER 100.000 BTU)
Code. Section 255320x?
❑Yes ❑ No
F
VEM'l1ATION AN led NGLE RES IU)
PAID
Date receipt to
Will the applicant or future building occupant use eyuipmcm or devices which
BOILER - COMP OHP OR I00.000 BTU)
end( hunudous air mnmninmmN as defined by the Boy Area Air Quality Mutageme n
1^
WHO? BOILER-COMP(OVER 100,00OBTI)
❑Yea ❑No
ISSUANCE DATI!
A] CONDITIONER
I have real the haurdous noac.' reyui Tans unJer Chap¢r h YS of Inc Cali-
funis Health & Safely Care, Sections 25505. 25533 end 25534. 1 uMerstvad Lha if the
NEN' RESIDENTIAL MECH. SQ. FT.
hodldingdoes mm.... ready have a mwm, dead is my respic inll'dy ht notify the Ikcupanl
of lbe requirements which aimed bo mol prior no issuance Of Cenifieale of Occupancy.
Dare
TOTAL:
ISSUED BY:
Owner or authori2d agent
OFFICE