99080006 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 9 '/VYOU6
CITY OF CUPERTINO Bull,BNU-ELECTRICALPI'
BUU.DIN IRVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT MEN 'I IFICA'I'ION
BUILIA'NU�'j 1 , _5 M26)� � SANI'(ARV NO. APPLICATION ^���ATE
OWNER'S SI! )y13a�7 C T4" R:SY. I lqc O47)-1
� NIC CONTROL#
RCHEI EC PENGINEER: TIC NO: !1� ❑
I l/J'
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB Mecx
O L;zP = Z7S �-07 L 11d ❑
LICENSED CONTRALTOR'S BE
AAARATION QTY ELECTRIC PERMIT FEE
1hereby afhrmthI1 an,' ....d d p .nrCh.pt 9 Lemotonctient, JOB DESCRIPTION
2aZ m$ f 71ro0)of0 3 fnc Bus Il f,.rinn:C 1 d yI1cL.-yr RESIDENTIAL:
,,� nt full form;md effntc �rL PERMIT ISSUANCC
���. � T ❑$FOWL ❑KITCHEN REMODEL
QVO Ltare R LIc.N APPLIANCES-RESIDEN'I'IAl. ❑ADDITION [I PLUMBING RE-TIFF.
S,Z ec IJwc ConDFCL
d A CHI'I'ECPS DELLA ATION ❑MULTI-UNIT El STRUCTURAL
(-�a N PANELS
Z p m Z_ 1 understand my plum shell be uncA as public rental. MODIFICATION
OZ-A UP DO 211(1 AMPS
F4I..CW Finwd Prord.n2(11
nnl Ll INTERIOR CCHIMNEYREPNR
-IBOOAMPS IMPROVEMENT C]SWIMMING POOLS
OWNER-BUILDER DECLARATION
�..C Q M1crehy aPnm Ihnt nm exempt frim the Grntracmr' Liccnnc Law for t'¢ OVER I[N)0 AMPS El BATH RBMOIj�VIjEPAIR ❑DEMOLITION
a F following revwn.(Semon 9031.5.ISusineno and Pmfission,,Cote^.Any city or amity SIGNS ELECTRICAL C OTHER �r�
N whmh regwms u senna a.eons¢uct,alter.Improve,demolish,in repair any.vlmcture
,i
prior.......... ce,rlro regnircx thwtppllcanl french Pcrcablol leaairadmitement SPECIAL CIRCUIT/MISC.
that he is licensed pursuanuo the proviaionsofine Contractors License l.aw(Chnptery
r�C (urmmrncng wah Scott( 7(X00)(d Division 3 ofthc Business not Professor,Calc)or TEMP.MET ER OR POLE INST. COMMERCIAL:
d y eG unit he is exempt therefrom and the hvsis for the alleged«mnpion.Any violation of ElNEW BLDG/ADDITION -1 DEMOLITION
X ui. Section 70315 by troy...:cunt fora proud nab r,N mid aHth am to a civil penally of POWER DEVICES
W 1 (_1 TENANT CFOOD SERVICE
nor more Ihsn five hundred dollars($510). IMPROVIMIiN'T
�y6 Lsx owner of the pmPcng ornry cnnployces witM1 wngec sx their sole mmpenxminn. SWIMMING POOL HLFCTRIC
�py� will do mhewurk,acdmhcamumciscmmmcd,domftrcd fursvlc(Sec JOVQ Business C1 OTHER
W3 m and Profm.iom Code:The Convectors License Law does not apply of an uwner of OUTLETS-SWI"I'CHFS-FIXTURES
copcdpve
y who hudd or Imros Ihered ,and who docs such work himself or through
his own ennplayees,provided that such impmvelnndx coined intended or offered for NEW RESIDENTIAL ELECTR SQ
4.1, ,M1nwever,the building orimpmvement isnnld within one yeurnf<nmplclion.the S Pf.FLOOR AREA $ISQ.FT.
cr-buildearen
rwill have the hdof Pro ing Ihw he did em bald m Improe Far Par
porale_).
❑ I,as owncrof the propmy,um exclusively conuauing with liycnsed u usual rs m 'TOTAL:
ms'tmrn We prq..t(Sm.Tri Brsiano and Professions C's")The Commoners Li-
reWwdoe,.col apPlY m:m owncrof Pmneny who nuilUsorjimprmvx..croon,and QTY, PLUMBING PERMIT FEE
who contracts for such pt jects with a contrvcrods)airman]puoprnm untie CunmmcmrY
License l.uw. PERMIT ISSUANCE
❑ I um exempt ander Sec. ,B&P Cfo,datneason
Owner DACI'ER-DRAIN&VENT-WATER EA
IO
( ) VAhUATION
WORKER'S COMPENSATION DECLARATION 13e\CK PLOW PROTECT.DEVICE D
1 M1ncby altinn under penalty of pejry uone of the following declarations
'
I have and will maintain u Cenccmu of Consent e sell-insure for Workers Comped- DRAINS-FLOOR ROOF,AREA,COND_ ST ILS TYPE CONSTRUCTION
smion,as provided for by Seaton 3700 of the Labor Cud,for the purfortnance of the
work for which this pound is Issued. FIXTURES-PER TRAP
I haveand will maintain Worker's Cmnpensatton Insurance,as required by Smion
.TMl of the Wfxtr Cod,fin the performance of the work for which this perm: is issued. CAS-EA.SYSTEM-I INC40U'1 LETS OCC GROUP AlIr3
My Wo 9gqlns .C,and POMC) 10.
� GAS-EA.SYSTEM OVER4(EA CUA
Cvnerc�= �YG nSPohcyNo.N� �� 'pld� )
CERTIFICATE OF EXF,MPI'ION FROM WORKERS'
COMPENSATION INSURANCE GREASEIINDUSfRL WASTE INTERCEPTOR
n his worion cost not be completed Lite permit is Britain,hundred dollars GI I(d) BUILDING DIVISION hHiES
I RAP
orbs_) SEATS-SANT PLANCHECK FEE
loyaltympeGambu any..annerofs1c,bekfor whmh rot ninhe Worker,
$IeWER-SANITARY-STORM L'A.2110 FT
not employ any person in any....roes so as w hcenmu subject to the Warkyrs'Cnmpen- ENERGY FEE
O Z .ration Laws Of Cd,lod m.Dam WATER BEATER WIVENTIELECTR
Z 2 Applicant GRADING FEE
h NO7HCF.TO APPLICANT'.IL aficr nmkmg tills Gaihcnle of Exemption,you sb..uld WATER SON,EMOREATING
hcmmeanhjcct..In,WurIke-Compensation prnvisionsof theLabor Code,youmaa SOILS FEE
forthwith comply with such provisions or this permit shill be dremed revoked. WATER SERVICE
a
CONSTRUCTION LENDING AGENCY NIIW RESIDENTIAL PLMB, SQ.P1'. PAID
V herebywh,himauhercir med( ee 3097,C-
ugencyf nilspedormnnmof Date Receipn%
LU � Errol kfurwhenthis pencil is inxued(aye 3119],civ.CJ
O Lenders Name
I(l1AL:
Lender's Address I TOTAL _
ly Iemeethat 1have with
and counandacrethan the shove iws relating i. BUILDING FEE
N nmrccm.I agree it)comply with ill city trod mtnnmy nngnanm,.an(]nem laws relating no QTY. MECHANICAL PERMIT FEE
V Z budding commotion.and herein,andnnic repremnlnnives ofthiseimy m enmrupon the SEISMIC IEE
abovo-mcctioned paperty for'no"non i PERMIT ISSUANCE
(We)agree ht saw,indemnify and keep hum;l—the City of Cupeninu ogainsl ELECTRIC FEE
tiralitics.judgmcnts,costs trod sxpcnscs IF may m any way accruc ngainxt said Gty
in n'u'ance,of the granting oflhis permit. AhTIiR OR ADDTO MP.CII. PLUMBING I'IiI3
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT NR HANDLING UNIT(TO Imk01H1 CFM)SOURCE REGULNI IONS. MECHANICAL FEE
V AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION'1'AX
Signature of ApplicvnVContmcnrr Dem EXHAUST HOOF)(WNUCT) HOUSING MI'TICATION FEE.
HAZARDOUS MATERIALS DISCLOSURE
Will theupplicvmm(uturc huilJing occnpum smrc nr htrnillc hvalloux mal.Yim HEALING UNIT(TO 100000BTU)
os defined by the Crpeamo Municipal Code,Chapter 9.12,and the Health and Safety
Code,Scmbn 25532m)? / HEAT IN'G UNIT(OVER 100.000 BTU)
❑yes QNn PAID
VENH'II,AI'ION PAN(SINGLE RES ID) Dame Receipt#
Will the applicant ia furore deficegby the B esu ea Air a lily M ce.which BOILER-COMP OHP OR 1 W.OW B'TU
In[hazardousair comaminana us JeOnal by the Bay Area Air Quality Munugcntcnl )
Domed fr l(YIAL:
�Yu awj BOILER-COMP(OVER I00.00(113TU1
I have read the LaIndons ntaten'ulsre ms under Chime 6.95 of th,Cali- AIR CONDITIONER ISSUANCE DATE
9 p
Barra Health&Salcly CodSections 255052556d2sil 1understandtictTraH.c NEW RESIDENTIALMECSQ.Ertlhuild gJ I ruvlyl m I Ihut
it ) .p :Nf yl notifyd cupam
of til y ' L'which b Updunc .. cola Cen'T:
Owncr m rum rived age.. ate TOTAL: ISSUED BY..
OFFICE