S 1990 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PEST F NO. 1 9^ 0
BUILDINGI- DIVISION A i`F` I A'f10NQ'P:RMPf I'I,uMBING-MF,CIIANICAL J y
NIID.DIN'G PROJECT'IDVIS1IF'ICATION
BUILDING ADDRESS: nSANITARYIACA'I'ION SUBMITTAL DATE.)WNI 'SNAMP' PHUN& C NTRACfOH'SNAMy+' LIC NU'.-7?o22 . P—leV i coNTuol.xRCHITECIIENGINEER: LIC NO: ADD F'SS,
da 47
ONTACE PHONE: BUILDING PERMIT INFO
❑ Consultant Feces Paid by Applicant(Initial) BLDG ELECT PLUMB MECII
a„� asp de �e ID 1:129— ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEC
I hemhy anion that I am licensed under provision.of Chapter 9(commencing
JOB DESCRIPTION
D0Z with lection l00o)ofDivshm 3nfine Business and Pmfecsions Cede,andmy license is RESIDENTIAL:
1— 2 PERMIT ISSUANCE
F W^ in a CI.. dlecL ❑SFDWL ❑KITCHEN REMODIiI.
QutFj License Clnnc' Lic.p
FZw Do, Contractor nl'YLIANCIiS-RIiSIUIiNI'IAI. ❑ADD)"TION $TLT.'RiBING RG-PIPE
to 6 a ARCIII'I ECT'S DECLARATION ❑MUI:1'1-UNIT' O STRUCTURAL
�o,lZ Imul.ra-un+ I hll he used us blirmcmds PANELS MODIFICATION
ZO tn- Ypanasa pu
O IIP T0200 0AAMPS ❑INI'CR[OR VE ❑S CHIMNEY
MINGREPAIR
OOL
Q^GW Licemcd Pnddsiunul 201-IUICANPS RX111R ODI C]SWIMMINGLS
OWNER-exempt Rut the RAtION
C tY 6 hereby uvirm mm I nm exempt from the Contractors License Law Int ince OVER SMAMPS ❑BATA RI?MOIIEIIREPAIR El DEMOLITION
OiU following reason. 111315.Business and Professions G+de Any it t ❑OTIIIIR
xx yean or SIGNS IiLF.C'TRICAh
u13 h. which ret+drac a a.Peru,.,m construct,inner,.,fin e,deprolh parrait t m repair any sharchuell...re
1"u•NOa prim toiu insuanceahareto the the appcasof for Conpctors License aw(Chamem SPECIAL CINCfIII'/MISC.
wE5a, domarrith lie inting%dI Section
to00)ofD.sion 3 he Contractors License Lvw(Chaptur9
waa C (commm�eingxitM1 SectinnllXMB.f Division?nfthe Business and Pmfdvionc Code)or TIM P.MI?IIiH ON POLI INS'llFR I'
110,e C that he is exolnpl therefrom and the bnsis for the alleged exemption.Any violation of ❑N G/ADDll'ION ❑DEMOLITION
Xro¢ Section 10315 M1y uny appli.um hnaper I,wibjectsthevpplua tto a civil penally of POWER DEVICES
u1^h 'TENANT ❑POOD SERVICE
=O nutmorethan live to ]red dallan(S500).
DLas owner ul the Pmpcny,or myempluyecs with x'mges an lM1cirsak am intimation. SWIMMING POOL ELECTRIC TOVF;h1F.NT
F.. willdo the wnrk.and Ifii...am isnot intended or offered for cal.(Sec.7014.Business K H I!R
L3 m and Prof,n%ioms Code The Contractors License Law dtvs not apply to an owner of OUTLETS-SW'I'TCHES-FIXTURES
pmpeny woo builds or militates thereon,and who Arcs such work himself nr tlmmgh
his awn employe,provided that such improv arnumc am not intended or offered for NEW RESIDENTIAL ELECTN S017,
salt.l L M1owcver.the building or ant, cncia is xold.indoor.ysmol unpinon.the SQ.FI'.FLOOR AREA s/SQ.FT.
owner builder will nave the burden of proving thin he did not build or improve for put-
prat of s.l..)-
❑ 1,as owner of the proper,am exclusively contracting with IicemeJ contractors to TOTAL:
mdme me project(Sae 7044,Iln., and Prols m Cale:)The Contractor:c Li-
naLaw does nmapply toanowner ofprrl+nry x'ho builds or improves mercom and QTY. PLUMBING PI7RMIT FEE
who c,nra's hu'larh...aims with a contmeorts)factual pun.am to the Cormai
Licaoe Law, PIIRMII'ISSUANCIi 3,37-0
Q l am.xcn+pt under Sec, .13 A P C forbom...a
AUITR-DRAIN&VENT-\4ATI3
Owner Dam H(13A) VALUATION
WORKER'S COMPENSATION DECLARATION BACK 11-OW PROPECT.DEVICE '
I hereby a1Bnn under penally of perjury oneof phe following Jeclarnituo.
I hove and will maintain a Cenifcne of Cam.anunself-insure,for Worker's ComE,m- DRAINS-FLOUR.ROOF,All FA.COND.1%
ms pnwdvd for by Seen 0700of the Labor d
G .,for the pcme.
rfnrm � of the S'I'IIRIES 'TYPE CONST'ROC'T[ON
work for which his ptimtit is issued. FIXTURES-PER'IBAP
1 haecauld will m n Worker's Cmnpe--ion Iastrame,as required by Sewion
llWof the Laou Cade,aside pcarommncenf th.work for which this permit is iswed GAS-1L\.SYSTEM-I INC.4 OUTLETS UCC,.GROUP A1'N
MurWo a Can �api In ranee oricr;oli P:Niry�mtlyrpq 9lOj GAS-G.SYSTEM-OVER 4(EA)
CIiHT {CA'TI?OP IIXL Pl'ION FROM W-OJH�K B✓RS' b
COMPENSATION INSURANCE GREASEANDUSTRLWASTE INTERCEPTOR
Tlhis xtttion need rot be cumplemd ifthe,ro it,future hundred dollars($100) BUILDING DIVISION FE15
or lesx.l GRE ukSE TRAP
PLANCIIIiCK P[E
Ivmrity plet inthe anysmmerof fie stobekfor whichthis the workers
ui 1,1m1ICoronr- S1?WER-SANITARY-S'IURM EA.2001T
nm employ any person in any manner co as to become subject to the Workers Compem ENI3HGV D•� l✓1 x
Oz ,cJi
ation Lawsof Califomiv.Data WATER I IF.AI ER W'NF,NTMLECTR
Applicant
z n
NOTICE GRADING FF.Ii
NO TO APPLICANT:If,most making this CenlHc:vc of IlxcpmVtian,you should WATER SYS'TEhI/TEE6fNG
become omoo to the Worker's Compensation provisions of the la+bar Cale,you must SOT
Wr„ tnnhwith.,amply with such prm'i,cions or this taurnit nhull be drari re,oked. / WATER SERVICE
I'
U OIf'T Ur uurutww
CONSTROC1ION).ENDING AGENCY NEW RESIDENTIAL PI,MB. SQ.PL PAID
I hereby affirm that hem is a construction lending agency for me psallonnance of Data Receipt#
E.E. N he work for which this lemur is issued(See 31X91.Ci¢C.)
Isnders Name T(TTAL.
Lender.,AJJreas 0'I' A, 0
F" y I ti.rohy that 1 have mad this application and state battle move information is BUILDING FEE
Z) nmeell nsreemmmnly wim all city and county ordinunvc.and vara laws rdaing t° QT'V. MECHANICAL PERMIT FEE
C„) •Z building construction.and hereby onlro mrepresentatives tilhis city to enter upon he SEISMIC PEE
three mentioned property for inspection proposes.
(We)ogre.to cave,indemnity and keep hammuss doe City of Cupertino again,, PERMIT'ISSUANCE ELECTRIC ME z.
Iiuhilitics,juJgmems,cosuvnJ.xlensd whicM1 may in uny wry...mugvina,aid City,mueAUILRORADDIOMF.CH. LD
an cynce of tire gra
e nting of his permit. PLUMBING FEE
ANT
AIR HANDLING UNI F(TO
S(YURIfII11f11(1�DE('TANISAND WIIy( L��{ NON-POINT AIR HANDLING UNIT(OVERII00MCP.M) CONSTRUCTION
TE
C' 7///// CONSTRUCf10N l'A%
Signutu TAppiicanarConmacpn Duro EXHAUST HGOD(W/DUT) HOUSING MITIGATION FEE
HAZARDOUS MAE TRIMS DISCLOSURE
Will ilia applicant or future holding occupi...a mr handle haraNauxmmnal HHATINC UNII'(T'O Ig1.dug BTU)
as deft ed by he Cuprino Municipal Cafe.Chapter 9,12,and the Health and Sathty
Gde.Section 25532(x)? HEATING ONI'1'(OVER 100,00o BID)
❑Ye. ❑Na
VLNTILA'DON PAN(SINGLE HESID) PAID
Will thea la,mu ,,future buddin•ar� Date Receipt x
pp b e B yin ce,An,em ar devices whish BOILER 01{POR I(XI,IXNI R'l11
tit hvvdou.c air ammminanrc a.,Jcfin.J by the Bay Arca Air Quality Munagcmcnl ) MM ,^
i,,riCl? BOILER-COMP(OVER IW,00OBTU) V T l/
❑Yd ❑No
Lad the hmallos rial.,m AIR CONDITIONER ISSUANCE DATE
Salify Calc.Sectio-2550425575 wd 25534.1 undntaodtatifthe NEW RESIDENTIAL MECH. SQ.FTt cutmntly havecnecord,mat it is my msisammility to notify the occu mu�ts which u+-t o m l Pour to inmmceof a Cunificvt.of Occupancy. /J-sd agent Date TOTAL: Jf�J/`��c / Q
SUED BY.
OFFICE