S 1895 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO Bun,RiNG-ELEcruiCAL PE fT No
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHAwcnl. 18 9 5
BUILDING PROJECT IDEN'TIFIL-A'I'ION
BUILDING ADDRESS: SANITARY IS APPLICATI NSUBM TTN.DAT
o3s S .r� 7�3� V//, 99
OWN(' 'S NAME: PILO ;. C AC- R'SN LIC NO
NIC CON'BULn
• ARCHITECUENGIN13ER: LICNO: .SS'. ❑
CONI'ACP PHONE: BUILDING PERMIT INFO
❑ Cons Ur Fecs Paid by Applicant(Initial) LI , ELECT' PLUMB MECII
7.)-/ 2,F.S' ❑ ❑ ❑
LICENSED CON IRACTOR S DECLARATION Q'py ELECTRIC PERMIT FEE
QgdZ
I hereby aln in.,1 am licensed under provisions of Chapter 9(commencing JOE DESCRIPTION
with Soa 700 3oDIm Budnn••a or essions Ctae- dntyliccnscis RESIDENTIAL:
F- O full lnrcc.a B+e PERMIT ISSUANCE
ymF:, '" v ❑SPDWL ❑KITCHEN RI!MUDI!I.
1-ZW Dura t Cc. APPLIANCES 11 ADDITION ❑PLUMBING RETHT
mQa ARCHI'I'IiC' .. • ' ❑MOI:I'1-UNIT ❑Sl'kUCfl1RN.
F�`�' ✓ PANELS
zo-Z understaadmy pletcehvll be used aspublie m,( 1, ��17 MODIFICATION
O Z- UP TO 2fN1 AMPS
1- E-'M Licensed 1'ndcssinnal ❑INTERIOR IIMNF-Y REPAIR
< , 201-1000AMPS IMPROVEMENT SSW. MING POOLS
may$, OW NI 3R-BUILDI!RDECLARAIION OVER 1000 AMPS ❑BATA REMODEUREPAIR E]DEMOLITION
�Ow
Q I hereby olfimt tM1m I um cxrntpt from de Cuntrumnr's Licvnsf Law fur ihe
W 3 LL F following reason.(Section 90315.Bu•inenc and Prnfez•inm Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
N which requires a permit to construct.ulcer,impor demolish,or repair any structure
or pdonoI,,i...fare,ul•u myuimthe e applicant for such proud to file a signed statement SPECIAL CIRCUIT/MISC.
Eby that he in licensed pari anhc mentor,oftbn Cotara n Li.....Law(Chapter 9
W CLO (commencing with Sealant 7000)of Division 3 ofth,Business and Powvsion.•Cade)or 'FUMP ME'I'Hit OR PULE INS'I'. COMMERCIAL:
G.a e C that by is vxvarg therefrom and the basis for the alleged com ptinn,Any violation of ❑NEW BLDG/ADDI'DON ❑DEMOLITION
Section 9031.5 by mry applicant fare permit subjects the efficient to a civil peril POWER DEVICES
a^rn t than Five hundred dollars(5500). ❑TI!NAN'1' E3 FOOD SERVICE
a moa IMPROVEMENT
_Q 01,as owner of the property,or my empbyen with wages as their sole compensation, SWIMMING PDOL ELECIRIC
' p.0 will do the work,and the snucmre isnot intended or utlered for.sale(Sec.70Li.Business ❑GTHIiR
i m and Pro ions Cn If,ante C....or ur'x Urease Luw aloes not apply n,ua owns,of OUTLETS-SWI ICHIS-FIXTURES
propcny whit build,far affec a thumm,and who Jars such work himself ar through
his own employees.provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECrR Sp EL �'"'•
sac.If.lour the buildinger improvement is sold withimone yearof completion.me t .F.00R 3A SISQ Irl'.
0 r-builder will have the hu en of proving that he did not hai1J or improve for pur-
1.a,ocia TOTAL- ApR 1 9 1999
❑1,as owner of the Ser.7W,am emlus and contracting with,)rom C contractors iif.
nxmuct the Project(sec.7(MB,nosiness and Prelessionx Cwlr.)'rne CommemrS Li-
xhseLaw mmenotapply maoowner ofproperty who mildorifirthereon.and QTY. PLUMBING PERMIT FEF-
ocomer,forochpmjec with v comncoas)l icensed posmad e+the COmmOern
larvate I... PERMIT'ISSUANCE p"
Fj Lun uxcvu,e under Sc¢ ,B&P C for this mason DI
Owner Doc ALTER-DRAIN&VENT-W'AI FR(EA) VALUATION
. WOR KERS CO.MPENS SOON DECLARATION BACK FLOW PROTECT.DEVICE
I hemloyal"i order penalty ofperjury oneol lie billowing dechwatial
❑Ihavc anA will nntinminv Cenifevm of Consent to•elf-inwue for Wnrkcr's Compen- DRAINS-ILOOR.ROOF,AREA,COND. STORM'S 'I'YI'E CONS'CRUCfl01
cation,as provided for by Section 3701 of the Lahr Curls.for the perfort"ancc of the
work far 'hi h this penuir.,I...caL FIXTLRES-PER TRAP VA// _ /
[21 I' t ''ll art W k C nap t Insurance. required by Section /V//(�
M eft Labor Cmle,f fa Ph1ly IIynPal, GAS-HA BYS'TEM-I INC q(lU'ILEfS
7 OCC/Gy/OUP AI'N
GAS EA.SYSTEM-OVER q(EA I ///� ^ 5- f
C:Rlilq NG OFEXEMPHON FROM WORKERS' 'C` /
COMPENSATION INSURANCE GREASE1NDUSTIIL WAS'T'E IN]liRCEI'FOR
Obissectmia toed not Mcompleted if the permit ix forone hundred dollen(5100) BUILDING DIVISION LES;
oflea'.) I GREASE TRAP
PL,1NCIIECK IE13
I eerilythat inthe any mannerrso theas t wok Bn%objectch tpernat o the Works'Conuarnued.I SIiW1iR-SANITARY-STORM P.A.Ztq Ff.
no,employ any person in any manner ro as become subject m the Wnrkerr'Gmmpcm' ENERGY FEE
pZ cation laws of Culifomit.Date WATER HEA! W/VHN'T/ELECTR
Z Applicant GRADING FEE
(= N0fICF;'TO APPLICJN"DIf,hoernukingthis Cenifione of Har,attion.you should WATER SYSTENUTRGAi
> hcaonw subjmt m aha Wo,kcin COmpvnwtion pro kions or the Labor Coaly,you muw SOILS PEE
wid
LrJ forthwith comply r,ma provisions audit,perand,iall be deemed revoked. WATER SERVICE In U
9L
o-7- Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLbIB. SQ.FT PAID
V 0 lherehya heat rive is aconsvuaion lending ngfnfy of the perfamtanceof D eceiptM
the work lin which Niserm
pit is issued(See3097.Civ,C.) ..- -"" "���
F LotdeFs Nenc
p U l(HTL:
Isndvr'I Addax
1 codify that I have read this application and moo that the pave iws rel
rnr :run"is B 'G IEE
Z) crvnwith agree xtall sont and county ontinanres and clawn lating to QTY. ME.CIIANICAI. I
PqRMPF
V Z buil Ji ng cunsiraetion,and herchyewhorize representative'of tho oily or entcrupon the i �. 513 PEP
ebwementioned pmpeny for inspection puq+necn' PERMIT ISSUANCE r`k
(We)agree tosses indemnify and keep harmlus the City of Cup<•nino agora EI. ;E
Iiabiliti Jgnema.coaxand expemu which may in any way accrue against said City AUNIR OR ADD
MF,CH.
In
•cyucnc of the ganong dtbE permit. PLUMB( F•+
I'C ANT NDERS"IT ' COMPLY WIT ALLN N-POINT AIR HANDLING UNIT IB,IXXIC�RT'
:OU C' t • v t..N M1IECIIANICALFBE
Alit HANDLING UNITB)VHR 1 D'000cPM) CONS'CHUCI'ION TAX
.Ignaturc of App fant/Cnt cmr Dam EXHAUST HOOD(W/DUC) HOUSING MITIGATION Fl
DOGS MATERIALS DISCLOSURE.
will tire applicant o,future building occupant store of handle Imummu.mntcrial HEATING ON]'r(TO I00,00d,RT U)
,is defined by the Cupertino M is pal CoM,Chapter'9.12,and the Ileahh and Safety
Cole,Section 25532(a)'! HEATING UNIT(OVER 100.000 Bl'U)
❑Yen
VENTILATION FANS INGLii RPS(Of PAID
-� ° Will the nppliwm fun building occupant use equipment ur ch%fee%which Dam RtteiptM
mithvmdnus air conumin nts. formal bythe Bay Arca Air Quality Managcmcnt BOILER-COMP OHI'OR R,pod RFU)
DisuicR YrA
yes BOILER-COMP(OV13R 100,003 BTU)
In - the ha MO.: b6;1,acquire
mfro'
under Chapter 6,95 of the Gall- AIR CONDITIONER / ISSUANCE.DATE
li+ v Ileahh Sa' eR '+551J and 2553q.1 unJefx and that if the NEw RESIDEN'r1AL MECH. SQ.IT. / L
i fling r early cunt.mat it i. yresponsihil'ym mad
ona upam 7
C uir cwhi t rut prion 11 can of C {if)veis try.
Owncror"nth ed agent }m TOTAL: s
ISSUED BY
OFFICE