99110149 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
APPLICATION/PF.RMIT PLUMBING-MECHANICAL, p
BUILDING DIVISION BUILIANG PROdECE IDENTIFICATION sono
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
o Sc o s g9!lD � -2
OW�'ER'S NAME: _PRONG - cog 'S NAME: LIC NG.
G _ NIC COZ,-
RCH F,CT iNGINEER: LIC NO. ) ..S: ^ o �, / ❑
J rF
CONTACT: T;eU At
k sC7 J/_P PHONE: O J—vll BUILUING PERMIT INTO
\/ ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELIiO'r PLUMB MfE�CH
LICENSED CONTRACTOREl'S DECLARATION QTY ELECTRIC PERMIT FEE / /
1 hemby alarm that 1 ant larrunJ under Enacroms of Chapter 9(commencing JOB DESCRIPTION
{�{yy pO with Section]mX)of Division3ofthe Blumv,eand Profession6s Cqtdc,andmy liccmein VERMU ISSUANCE? RESIDENTIAL:
FyW0 in but onectnd ce- 1 LrLe /// 0 // ❑SFDWL. ❑KITCHEN REMODEL.
QUU License Class CCii ..JJ Lic.N W APPLIANCES—RMIDFNTIAL ❑ADDRION ❑PLUMBINGRE-PIPE
usz W Dam Comment,
Om ARCHITECTS DECLARATION PANELS ❑MULTIUNIT [2 STRUCTURAL
~ Z 1 dersJ my plans nhull he mal ns public rcanres MODIFICATION
O 201 AM $
OZ` � unutn❑ INTERIOR 11 CHIMNEY REPAIR
9�2~W L.iccn.ed Pmfcssinnal h IMPROVEMENT 0SWISIMINGPOOLS
g4f; OWISHR-BUILDER DECLARATION I l ❑BADE REMODELIREPAIR 0 DEMOLITION
%Q I hereby affirm that 1 nm exempt from the Contractor's Lien.
iq5 2.U following mason.(Section 7031.5,Badness and Profecsimte Coln:Any et y lir atm S O� ❑OTfIL'R
u+LL W y which requires a permit to construct,alcor,improve,demolish,or repair any s care
prior to its issuance.also millums the applicam for such permit to file a signed from AJ112 _ -
� � that ev is licensed pursumnuo the pr ovens,ofine Commons,License law( ler AA
Q� be oncom,x'ill,Scams 700(4 of Division 3 of the 11 ocasand Is l'ehsimns 1 AI' � �U Q Q
d that be is exempt therefrom ani the basis for the alleged exemption.Any vie a u 1 ❑NEW BLDG/ADOITI N ❑DEM01,1'I N
oi Section 7031.5 by any applicant fora permit suhjats the applicam m u E It
not more than five hundred dollars 155(X1). ❑TENANT ❑FOODSERVICE
h+7a i• a IMPROVEMENT
M ❑ L,usownrtd0lnpmvrc,mrmyempinyecswilh Wages istheirsn S GI 1
I. will Jo the work.and the structure is not Intended oroffcmifor smle(Sc El OTHER
W oke and Professions Code:The California's License Law does out upply to an owner c E II_ Fl
6 3 pmpeny who build.lir improves tM1ereon,and who Jns such work himself or Ihnor
his own empinyces,provided that.such impmvenumn arc not me or offered for NEW RESIDENTIAL ELECTS SQ FF.
sae,If,however.the building lir imprmiNm
oveent ld within one year of completion,the SQ.Irl'.FLOOR AREA $ISQ.FT
owner-huilder will have the burden of ornimil that he did not build ur improve for pur-
pn.¢of sale.).
❑ I,as owner of,he pmpeny,am exclusively rontmaing wish licensed cmmmnors to TOTAL:
e tae Lo the es not (See.o on Business unl ny who
buN ds or improves Tho Com hereon,Li- -
%be,c Lpwdtsforsapply man nwnaofpmpeny whensed sort tothe otton.and QTY PLUMHING PERMIT
who commeb forxuch pmjems with a commemr(s)licensed pursuant n,the Gtmmnor's
License Law. PERMIT ISSUANCE
❑ I oat exempt under Site B&1'C fmnhls oullom
Owner Date ALTER—DRAIN&VENT—WAt'HR FA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE401 /�/')
I lecehyuffrm under penalty of perjury one of the following declarationsF�90t 4-0
❑Ihnve unA will ntainminu Ccnific:ve of Consennnsclbinsurofor Warkers CotmpL'n- DRAINS—F[-OOR.Ro OEAREA,COND' STORIES 'TYPE CONSTR UCI'ION
cation,us provided for by Section 37W of the Labor Code,for the performance of the
,far which This permit is is ted. FIXTURES—PER TRAP
WE have and will maintain Worker Compensation Insurance,as mquired by Section
3700of the Lada Code,for the peffmmoncc I,] he work for which t his permit is Issued. GAS—IIA,SYSTEM-I INC.d OU I'LETS OCC.OROUP AIN
My Work C yo run erzlerand Policy�P,N�`rY�:6�ZS-1Q GAS—EA.SYSTEM OVER4(P.A) n
Carrier: Iicy No.:z y � .�
CI:RTIFl ON FROM WORKERS'
COMPENSATION INSURANCE GREASPIINDUSTRI,WASTE INTERCEPTOR
BUILDING DIVISION PHISS
(This sccdonneed nor belmnapEwd iflhe permit is Racre hundred dollars 1$100) GREASE IRAP or IcxM1J PLANCHECK TEF.
I certify that in the performance of the work for which this permit is issued,l shall SEWER—SANITARY—STORM EA.21017..
not employ any person in any manner sat as to become subject fm the Walkers'Compem IiNERGY FEE
,z cation laws of California.[)are WATER IIHAFHR W/VENTTL, 1,
zj O Applicant 1 GRADING FEE
q .N. NOTICE TO APPLICANT:If,after making this Certificate of Eacmption,you should WATER SYSTEMG RFATING
(—' hecnnm mb'et m the Workers Com tion f the Lahr Code,you must SOIL9 F'/s,
pence pownionsn ^ �.� Fit forhwith comply with such provisions onhis permit shall he deemed revoked, WATER SERVICE J n�
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PUMR. SQ FU l PAID pate Receipt
L)QW
thereby alfimtthanhcre isu construction lcndingagency fordo,perfnrmnnce of
,� the work for whichad,permit Es island(,Site3097,Civ.C.) '
Lender',Name U L
4 Lender's Address TOTAL. BUILDING IEE
1 certify that 1 have mad his application and state that din aNice infatuation is
Uq comet.I agree to comply with all city and county ordinances and state laws mlmingto QTY. MECHANICAL PERMIT FEE
U � iducengmaimadt ion,art barmetsumirc rcprcsemmivcs of this city rat enter upon the '.tSIi ISMIC hIiE
ahnvrt(We) gJproperty fur itantly apurposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cuperinn ugoinm ELECTRIC FEE
liabilities.judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in cartttquenee of the granting of this permit. PLUMBING TEF.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT('1010.000CFM)
MECHANICAL FF.F,
SOURCE REGULATIONS.
AIR ILANDLING UNIT(OVER 10.0110 CFM) CONSTRUCTION TAX
Signature of ApplicpnVConvannr Date EXHAUST I IOOD(W/DUCT) HOUSING ME'PIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store oat handle haaxNous material HEATING UNIT G 0 I(I0.0W BTU)
as defined by the Cupection Municipal Cad,Chapter 9.1: and Ote HeuIN end Safety
Code,Section 25532(a)? HEATING UNIT(OVER]Ed."Err,)
Fl Ye Nn
VENTILATION FAN(SINGLE RESIDE ('AID -
Dme Receipt N
.Will ate applicam future building t use equipment of devices which
mit hvnnlaus airconmmininann as defined by by the the Bay Amu Air Quality Management BOILER—COMP(JIiP OR 100,000 BTU)
TOTAL
District?El Yes Fl No BOILER—COME(OVER 100.0(100 ITU)
AIR CONDIDONER
1 have mad the hvardnos materials nquirtments under Chepmr 6.95 of Ne Cali- ISSUANCE.DATE.
fomia HaolthffiSafety Code,Sections 25505.Ivoryrmd2.5530,I loroand that NEW RE$IDIiN'TIAI.MACH, SO Er // 9
huilAing oesalth&Safety llyCo have a mnan2 50 it2553 rexptmsi ilil,34.1 to nmsYnd that it arnot
the /
of the tmmenu which mutt be met prior a iswance of a Certificate of Occupancy.
•/r or A *du
1i t j OO( -lY-9�
OsGncr or udthadi.cJ agem Daa, TOTAL: I ISSUED BY:
OFFICE