99110042 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY C/q 1/00 qZ
CITV OF CUPERTINO BUILDING-E LEcTRICAI, r
BUILDING DIVISION APPLICATIONITERMIT PLUMBING-NIKCIIANICAL
BUILDING PBUJECTIDENTIF'ICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATF
CU rI 01
OWNIik'S NAME; PHONE: CONTRACT ORSN
' AME: LIC NO: LIP
G (406 6- 86 1 / O N/C CONIROI.
• ARCHITEC17ENCINEZER: LIC NO: ADDRESS: EDOSA s FEA Q
CONTACT: PHONE: 6UILUING PERMTTINFO
❑ Consullanl Fees Paid by Applicant(Initial) BLDGELECT PLUMB MECII
CNAN "W4146 0 -G59 (�' ❑ ❑ ❑
LICENSED CONI'RACIORS DF;CLARAI'[ON QTY ELECTRIC PERMIT Fly
I hereby affirm mal 1.lin licensed under ow,i.oca,of chapter 9lmmmrm ing JOB DESCRIPTION
Fwon wish Sanian 7lNM))on)ivision3of the Rosiness soli Profvoiam Crile,nnJ myliccnwu RESIDENTIAL:
CC in full form and effect. Piik Ml'I'ISSIJANCE
afWF 1 Jp ❑SFDWL ❑KITCHEN REMODEL.
QU'ZUW License Class Lic.p APPLIANCES—RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
yd6 Dan it" B !9 Conn��efo���ooe 67.4C
(..7y ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT' ❑S'T'RUCTURAL
Z O ti Z I andennnd my plans,hell tae medics public records MODIFICATION
pZ--0 UPTO 2110AMFS Ll INTERIOR 11 CHIMNEY REPAIR
1—�Lw Licensed Prnl'esummil 201-1000ASIPS IMPROVEMENT SWIMMING POOLS
CSF.; OWNER.IIUII.DER DECLARATION OVER IINOAMYS ❑BATH REMODEIIREPAIR El DEMOLITION
C C Q I hereby affirm that I am exempt from the Contractor'.License Law for the
W 3 CLU following nuu n ISeent 7031 5,Business and Profession.Code:Any eiy m county SIGNS ELECTRICAL []OTHER
Wy which requires a pennii to construct,miter,improm,demolish,or repair any saucture
.F.^CQ prio,to its issuance,aha requires tire applicant bn such"our flleamlgnedaawmeni SPECIAL CIRCUIT/MISC.
had heisliccnsedpmsuxm tofhepmvixiomofthe Cmnneorsl.icense Law(Chapmr9
WaC�O (commencing with Sect Lon 71X0)of Di vision 3 of the Business and Pmfrssions Crde)or TEMP.MECER OR PO .INST COM CIA:
d S CeC mal he is exempt therefrom and the h sic for the alleged cxcmphon.Any violation of EW BLDG/ADDITION ❑UIiMOLITION
XroW Section 4031.5 by maYapplicaul for a Permit subjects me applicant n)a civil Penalty of MOWER DEVICE
W^rq '1'IiNANI' ❑FOOU SERVICE
m mom man rise t h pros dollars y cimpl IMPROV IiMENT
Sp OLn the mornflhepmpculor mYenintended or offered
osale(Sm.compensation. SW'IMh11NG OLT:LECI'RIC
p. will Mihcwons Ind(hein,C.reiram',License
or wdos o.,pecJOYt.Business
W 3m and Pndessiuns Code The Convector's Licenx Law Jas no apply err.n owner of OU'D.h -$WI'ICIIliS-I'I%rIJR1iS
A' prvperty who bunds or improves iheram.Ind who does such work himselfor if-.
his own employees,provided thin such improvententn arc not mLum,d or nffcreJ Bbr NE LSIDENI"IAL ELECPB SQ IT. r/ 010
cdc.If.however.the buildmgnr impn,ever.l LsablJ sabirome yerne'comple.ion,me IT.FL HA VSQ.IT
qua,builder will base the burden of proving her he did not boll r p
of side).
❑ L m'owner 0[thc pnrl*'aIS am exebrvivcly mnlracting with li iav r tar AL:
consumer the project(Sm.]BW,Business and Professions Cost r100,
crow Law docs not apply to an owner of perry whobuildaorinrpus,Ii Iher, L,and FE
whocomracni...ch projan win acommeorts)Iian.wJ punusnno Coat, r
License law. I A
❑ I am exempt under Sec. ,RReP lir shim
A)
Owner VALUATION
Uarc
• WORKER:S COMPENSATION DF,CLAR CK FLOW PROTEC1.DIiV 4q
I hereby aw
frror oer 1znm11y ofperjury one of the Sol I /L cn, MJ ab
El I have and will maintain.Cenifiemeof Consent nisei(-ins AI - ( F STORI ; TYPECONSTRUCTION
-tion,m provided fur by Snaion 3]Bn of me LuM1nr Cade,Be I
wad fur which this peril is issued.
Khave and will mummin Worker's Compensation Insurance as required by Section
)of the Lubor Calc.for the icrimmum of the work for which this peril is rsard, OAS—En.SYSTEM-1 INCA OU" HTS
OCC.CROUP APN
My Workers L',bttybe stir Insumnmcamerand Policy�ag ! ��
Canicc ry� ICG Policy No.: OA 9�/�' GAS—EA.SYSTHM-OVERq : ) IG
Q?KrBICATE OF EXCMPIION FROM WORKERS'
COMPENSATION INSURANCE GREASEAN'DUSTRI,W rE INTERCEPTOR
(This section real not hearmple al if the permit is nature hundred dNlmn($100) BUILDING DI V IS(ON e
or Icxc) GREASE rRAP PLANCHECK Il?E
lecrifythal intoe perforcrecofthe work horwhichdo,Permit is issued,[shall SEWER-SANIT Y-STORM EA.2W FT.
not employ any person in any mannerso as to Mame subject to the Workers Cc L,.- ENERGY ITEC) Z .noon Laws of California.Date WATER IIF, iR WNENI'RiLECfR
Z Applicant GRADING FEE
y
NO][CF.10 APPLICAN'n 11,after making this Cel ificam of Execution. yor should WASERSTEM/1'READN'G
Menne subject Io the Worker's Compensation provisions cd IM1e Labor Code,you must SOILS FEE
I-I hdwhh comply with such provisions or this Permit shell Ie deemed revoked. WqT. SERVICE ^
5 z CONSTRUCTION LENDING AGENCYW R 31DGN IAL PCMB. SQ Ie1'
[hereby ammo firm mm ei_.a comlruaion Iendiag agency forthe am
e ncrorme mf Recti t
!L - IM1e work for whicti this Permit is issued(Sec.3097,Civ.C)
C) I^ Licndera Name IOTA 1.
G tender's Address TOTAL:
y I certify Thal I huve read 11n,appiication Lord once mat the show mI,inforation ILDING IEE
.F'. v1 comel.l agree ro<amply with all city and county oninnncesrmd state laws relainglo QTY. MECHANICAL PERMIT FEE
UZ buildiigcunstruction,and hereby aummue repmsenmtises of thiscity mentma,mn the MIC FEE
ahw f Ip 'tryf :pe pRx P[RMITISSUANCIi
(W) b t J fy nil keep h ameCt) fCugnnn agent .1;E CPL'E------
liabilities
liabili :j d6 t. c J p xh y in an,say secure ),lirnerid City
in aexaquence of die granting of ALTER OR ADD TO MECH.
gn peril. PLUMBING IFF.
APPLICANT UNDERSTANDS AND WILL CONIPLY WITH ALL NON-POINT AIR HANDLING UNIT(1010, MI CFM)
SOURCE REGULATIONS. MECHANICAL FEF,
AIR HANDLING UNIT(0VER 10,1X0 CFM)
8 CONSI'RUCI'(ON TAX
Signa ren1'Applicianc inlmaor Date EXHAUST-HOOD OVMUCr) HOUSING NU LIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hasmadoum material HEATING ON[T'(TO I Nk N0 BTU)
I,,refined by Om Cupcmao Mr eipul Cud,,Clmger 9.12,and the Health and Safety
Gdc,Section 25532(.)? HEATING UNIT(OVER Irif1,1Nx 'U)
❑Yes ON.
VENTILATION FAN(SING .ItgSID) PAID Dam ReceiptI
c Will me applicant is future building by the by A ea Ar Qct or Tesla which
mil hemrdous air cnmumiwmm Its Jefinel by me NUY Area Air Ouulny Munugcrrn,nl II)ILERANER �
)11 13 TO)
Diamie:' 'In'rnL: A
El Yes E]Nu BOILIiR ERCU)
I base read he hnmrdoru'rnatcrialsm ewer Chapter 6.95 of IM1e Cali- AIRCOHealthy25533" p ISSUANCE DATE
fomitegdoes ktcurreafety Ca lc,Spnbns,muni,is toyand25534.I t red yff that iftits N11WRSQ.FL /� Q
building JOrn not currently havcn¢mm�,mat it is my resgrnsibilitytonotifyme ,upanl / '-Ago i
indwrequire Is h mm....,,s,una'.of n Cedifiri of(k'iI /
✓ �� �00
Oteacr-nr J IJ,TrII One Ly TOTAL: ISSUED BY: �b
OFFICE