99070078 APPLIQANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY "700
CITY OF CUPERTINO BUILDING-ELECT8ICAL PERMIT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL
BUILDING PROJECT IDENT'IF'ICATION
BUILDINGADDRPSS: SANITARY NO. APPLICATION SUBMITTAL PATI
21 IiWO T0%L 4%,201 Z, 2 9
W SNANIE. PHONE CONTRACTOR'S NAME: LIC NO:
T NIC CONTROL#
441,
CHITECT/1!N,INFER: LIC NO: ADDRESS' Ol��I A I ` ❑ -
CON'T'ACT': PHONE: V 1 wJ BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BID
L-yG/ ELECT PLUMB MECH
E! ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION Q'PY ELECTRIC PERMIT FEE
1 hereby affirm That 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
OocZ with Section 900H)nf Outs...3afthe Businessaad Parficinn:Code.and my license is RESIDENTIAL:
ul0 PERMIT ISSUANCE
=wp in fall force and cfByct 42aAl ❑SPDWL ❑KITCHEN REMODEL
QUU hr"°nx Cl s°_�� Ls'# APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING REPIPE
N Z W Pale� i 1`+T Can'.Clar
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL.
Z O ol Z 1 understand my plans sM1all be used as puhlie«roods PANELS MODIFICATION
UP TO 200 AMPS ❑INTERIOR 2ieHIMNEY REPAIR
Q Sd 2; Licenced lkufc siuool NII-IIgYJ AMPS IMPROVf?MI,NT 0SWIMMING POOLS
y�0', // OWNER-BUILUIiIt DIiCLARATION OVER 10N)AMPS ❑HATH RIIMODEIJRF,PAIR ❑DEMOLITION
C y' I har�y affirm that I am icmpl firma the Contractor's Licenee I.aw fill the
W U follnwmg reason,(Section 7031.5 eBu.ineas and P lost I,Code^.Any city or county SIGNS ELECTRICAL Q fYl'1113R
3 6 N which mloires a Permit it)construct,alter.improve.demolish,or repair any structure
LLo5 PriooitsNsu:ince.also requires the appicamloroohPemir
rtnmeasignedsm¢nanl SPECIAL CIRCUITIMISC.
W }00i rt
that he is licensed pursuant In the provisions of the Contractors License Law(Ch9apmr
u�1�a (nrmmcnci.g with 5ection?OW1of Divisinn3oftbe Nosiness and Professions Csde)or FRO ..
a aC that he is exempt therefrom and the basis for the alleged exemption,Any Valmion of U BLDG/ADDITION ❑DEMOLITION
X^u' Section 7031.5 by any applicant for a permit subjects the applicant to a civil Reunify of WJrR D601(27 NT ❑FOOD SERVICE
ad at' not more than five hundred dollar,Who), IM OVEMENT
=6 I,as owner of the anPe.y.tinny employees with wagcsmtheir role compensation. SWIAIMI LE' C
�(..,� will do the work,and the structure is not intended oroffered for aale(Set.96pi.Business ❑O 111 m and Profev ions Code:The Comment's License Law does not apply to an owner of awff s0kiifft-FL%TU
f I
property who builds or improves thereon,and who does such work himself or through ,
his own employees,provided that such improventmns are our intended or offered for NEW RESIDENTIAL ELECTR SO FT.
sae.Il:how'ms9 the M1uilding orimpnrvemanl Ls sold within nuc ycnrofcnmplmlon,the SU FI'.FLOOR AREA SIgQ,FI'.
owner-builder will haIL
ve c hurdcn of proving Ilial he dW not build or Improve for pur-
p .of salol.
❑ L as awn r of the property,am exclusively contracting with licensed contractors m '1 OTAL'.
mstmm the project(See 91144,Business trod Pto'essam,Crxle;)The Contractor's Li-
wme Law does not illanowncrnfpmperlywnobuild,orimpfovesthemon.and QTY. PLUMBING PERMIT FEE JUL 2 g 199
it"commas for such projects with a comrdcmgs)licensed pursuanuo the Conlmeam"
Licence Lu'. PERMIT ISSUANCE
1 am exempt under Sec. .B&P C for oris Raven '
Af I ER-DRAIN&VENT-WAIIIII VALUATION
Date 3
ncr WORKERS COMPENSATION DECLARATION HACK IT OW PROTECT.DEVICG
1 hand v affirm under penalty of perjury one of the irsom following rker s ns:
Ihave andwledor by eCion 37re of theConsent
I-aor actde.for the workers of the DRAINS-FLOOR.ROOF.ARF.A,COND. S'1' IF,S TYPE CONSTRUCTION
smirk,as provided or by Section 79(10 of Latin Coda far the performance of the
^�klwhichth':Pe Y .:' J PI%TURES PER TRAP
2 I I d will utum,in Work.,',C .fe,valion notmanne,as required by Section
3900 l Tic Labor C lie f 'hepd 'c t(be workl whih This permit is lssucd GAS HA.SYSTEM-I INC.4 OU'1'LETS OCC GROUP �/` 1
My Word}± C�u�nPensmiorin:as is II I Y yrbo f0 �,J
Currier:L'.Y1IILWnor on GeJ'( Policy Nn.: /�Jf01 �� GAS-EA.SYSTEM-OVER 4(BA)
CIiI TIFICATEOPH%IiMIT10N1;ROM WORKI!RS' D�
COMPENSATION INSURANCE GRI?ASOINDUSTRL WASTE IIOERCEPFOR BUILDING DIVISION FEES
(Thissccti"""ttdem LrearmprodlillMPennit is oronchundredddlan(SI00) GREASETRAP
sir less) PIANCHP.CK FEE
I cekifythm in the peRommnecafthe work for which this permit is ivaed.lvhall SEWER-SANITARY-STORM EA.200 ET.
not employ any Person in any manner so a%to become subjecuo the Workers'Compen- ENERGY FEE
Z sari".laws of California.Dam WATER HEATER w/OCNT/F.LECTR
Z 2 Applicant GRADING FEE
oq NOTICE TO APPLICANT:If,after making this Cenifieme of Exempamn,you should WATER SYSTE-"MTREATING
> I¢cone subject nr the Workers C"mpereation provisinm ab
of the Lor Cede,you mull SOILS FEE
foahwith comply with such provisions a Ibis perunu.,hall be deemed revoked. WATER SERVICE
Q
� z CONST RUC'TIUNLENDINGACENCY NEW RESIDENT TIALPLMB. SQ.P1, LAID - -AT,#
Uula
U O (hereby affirm(hat there in a amslmcoon lending agency for the performance of
the work for which this permit is issued(Sec.3097,Civ.CJ
0 UJdNa...
Lcns NaTOTAL:
U.1 Lender's Address TOTAL: BUILDING FEE
6. 1 certify that I have read this atildenoon and state mature above information ix
F rn correct.l agree to comply with all city amt county ordinances and spite laws pending to QTY. MECHANICAL PERMIT FEE
r'7 Z building cmwn.
mveina"d hereby author ire repreunmtivcs of this city m enter upon the SEISMIC FEE
above-mentioned pnrpe"y far inspection Puryoses' PERMIT ISSUANCE
(WI)agree to save.indemnify and keep hamdcss the City of Cupcaino against ELECTRIC FEE
liahi lilies,judgments,costs and expenses which may in any way accent against said City ALTER OR ADD TO MEC11
in consequence of the granting of this Permit. PLUMBING I'EE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 111,0X10 CI'M1
S(lI1RCP � CATIONS, MECHANICAL PEE
AIR HANDLING UNIT(OVER I fod CFM) CONS'IRUCI'[ON TAX
it � pll"a ¢amov� Date E%IIAUS'1'HOOD(W/DUC'q HOUSING MI'I'IGA'1'ION PEE
IIAGARDO AI'BRAIN DISCLOSURE
Will lheappllcanl or-fin p Idingreeupmu a tom or handle hazardous unt HEATING UNIT TO 1001101 IIT U)
as AdincJ by the Cupc.if.M t(vgad Code,Chapter 9.12,and th<Heahh and Safety
Code,Section 25532nd? HEATING UNIT(OVER 100,000 BTU)
❑Yes ON. PAID
VENTILATION FAN(SINGLE RE.SID) Date Receipt
Will the applicant or future Wilding occupantuseequipment or device which
ilana?N"us air ronmminantsu JeOncJ by rite Hay Arca Air Quality Management BO ILER-COh1P(JHPOR IOO.IXp HTU)
TOTALA
Uiaria? Yes 0N BOILER-COMP(OVER 1011(Nq BTU)
AIR CONDITIONER
rn dme ha d - t Ere1 t. ChapterIr695 nuc Cal; ISSUANCE DATE
firma IIvaill ailh Su@ty Cote.Sections 25505 2.1.933 and 25594.I tutuorard that if the NI?W RESIDENTIAL MECH. SQ FT.
build' gI umentlylidocater,oul,mat11 it Illy l ibilh,to TrIlih?th apo" 2 �—
report which mu�mel.dam atattss sc of Letlihrate o(Oceupa sy.
Owne g me 'I'01'AL: ISSUED BY:
e
OFFICE