S 2976 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO Bill I USING-ELECI'RICA, PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUNIIIING-MECHANICAL
(BUILDING I'RodECf IDEN'I IFICATION S 2976
BUILDING ADDRESS: a � SANIL\RY NU. APPLICATION SUBMITTAL DN
n --� s � 1 �� �Z
(IW NE "NAM((,\ I'IIONG CON'N(C' R'. NAAfIi:
1`'
NIC CONI ROLIf
.ARCIII'PC'1'IENGI NEER'. r LIC NO: U ESS'. / ❑
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CONT(p,Cf: 1 PHONE: BUILDING PERMIT INFO
u `�J�V ` •', �� ` 2G ❑ Consultant Fees Paid by Applicant(Initial) BLDGIfLECTPLUMB MECH
O` 9-/ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY PLECTRIC PERMIT FEE
1 hereby abuse row I nm licensed under provisions of Cbapm,9(commencing JOB DESCRIPTION
=W a'L wnbSatiun 9a))t ornivisioniol me Business and i'n,fessi)n,Codc.mdmyh,uwi` RF.SIDF.NTIAI:
,,p PERMIT ISSUANCE
Fed_ mfense Class elfed. ❑SFDWI. ❑KITCHIEN REMODEL
aUU hiccnsc Claw Lick
APPLIANCES-RESIDEN'UAL ❑ADDITION [I PLUMBING RI PIPE
in C W Did Contmctm
Fpy ARCHITECI'S DEC ATION PANELS ❑MUI,T611Nf1' ❑STItUC'1'URAL
O Z=O I and ersdanmy plana,hal I he used u.public,ecord_` MODIFICATION
llPT0200AMPS [I INTERIOR [_1 CHIMNEY REPAIR
(-�F-W Licensed Professional 201-10N)AMPS IMPROVEMENT DSWIMMINGPOOIS
Y Qew
OWNER"1{UILDRIi UIECLARA'fION OVER 1000AMPS [I LAID REMODEL/REPAIR ❑DEMOI.IT'ION
C 6 I M1eby aRthI
nn at um Irnnnthexempt e ContrU
omor's ccw Lw f
nnor the
3 LL e
F following reason.(Section 7031.5,Business and Professions Cale Any city or county SIGNS ELECTRICAL ❑OTHER
W y whish ne,u'nes n pcnnil ,,uae mcl. he,improve,demolish,or repair uny xhuc ure C
prion)it,i...mce,ahn reyuircolheapplicareu—neh pemit I,Glc asigncd,mmnant SPECIAL CIRCUIT9MISC. 2 q
that he is licensed purmanno the provisions of the Commemr a License Law(Chapter 9
yaoo (commencing wah Section7000,of Division 3oftic Bmineceand Pmlc..mn,Ca1C)or TEMP:METER OR POLE INST. COMMFRCIAI.
a.E o�, mm he is ucmPt thereGon+metes,hosts fur the alleged c.cmpdon.Any set.Gm+of ❑NEW BLDG/ADDITION ❑DEMOLITION
x,_N Section 903 L5 by any applicant for a Permit.subjects the applicant to a civil penalty of POWI!R DEVICES ❑'PENAN'I' ❑FOODSERVICE,
nut rucre that,live hundred dollar,(3500). IMPROVEMENT
ASO¢ I,ao nwnendthe pmpeny or my enpinyces wish wn,ec as(heir sole Crmry enation. SWIMMING POOL ELECTRIC
F- will do the work,and the structure is not intended or offered for sale(Sec.T11M.Business ❑QTlllik
L3 m end 11 lr,ninn.C:dc The C)rneacon,License Law does nod apply n+an —.I,of OUTLET'S-SWI'I CHES-FIXTURES '_'--
,re,rty who build,),impmvcs thccceH and who dose,such work himself or Ihmugh
his own employee,,provided that such improvements are not intended or oBBmJ for NEW RESIDENTIAL ELECTR SQ FT
sale.It,howt,se,debuilding or'unpmvemem ix cold svlNinom yemofcompletion,the SQ.IT.ItYlORAR: $/sQ.17.
+ nectuilder will have ihC Cunfcn of proving that hC did nut Fuld ur improve fur ,pur-
r7 1 if
ow°ne�r of[he properly,amoxclusively contracting with licenses(contractor,to TOTAL: APR 2 6 1999
mamd the Pn,j,,r(see 21114.Badno's and Prof c,slnnr Came Me C...nmclor,psi- 1
[I
wse lawdms not apply h+an)wnerof proNny who builds or mpmvcs thereon.and QT}•, PLUMBING PERMIT FEE
ho contracts liar such projects whh a contractor(s)licensed pursuant)the Contractors f5
License Law. Pchtmi r ISSUANCE of
I]1 an c, mpt under Sec. .B%P C for this mason
Owner DueATTER-DRAIN A VIr,NI'-WATER(EA) VALUATION
WORKERS COMPENSATION DECLARATION (SACK FLOW PROTECL DEVICE J m
I hereby affirm under penally of perjury one of Ne following duelmutions:
❑Iln;rvnmd will maintnina Ccnilicwenf Cunnam need(-insure❑r W..kut',Cumpcn- DRAINS-FLOOR.RODEAREA.COND.
onion,as provided for by Section 3]01)of the Luton Cost,for the pmf enence of the SIORIES "1'YPIE CONS"I RUC'I[L
work for which this permit is issued. FIXTURES-PERI'RAI'
[]I Fav)and will rnvinein W..La,Co nfe eatine Insurance,as turned by Section
3700ofnc,Labor Code,forthc performance.f1he wink for which this Karen is issued GAS-IEA.SYSTIiM-I INC.401`11.1715 OCC.GROUT' AQw`y
My Worker'sC'omrymalion Insurance carrier and Policy numMrurc: ��
Carrier. IIONY R : GAS-EA.SYS'fhiM"OVER Ylily '^
CERTIFICATE OF SSI IO INN FROM WORKERS' V
COhll'F.NSA'110N INSURANCE GRIEASI%INDl15TR1.N'AS'1'E INTERCEPTOR
(This nenion nreA nut he eonq+IcnDfOhC lis ler nuc M1undmddullnr,l$Hq) BUILDING DIVISION PEES
porno GREASETRAP
or Iers.) 1'LANCIIIECK FEE
I certify thin hill port mann a vurk for h 'h this permit is isweJ.l shall SEWER-SANITARY-STORM EA.2W T.
not ennpl)y any pn:rn in any un r , cum so jc t to We Workers'Compen- ENERGYPEF,
zz sit In Wwsof Calilrmio.
A licmn WATER HEATERW/VENT/ELEMIr
PP GRADING FIEF
.y y ...... ET(1 APPLICANT;If,aper r akin,ibis Ccnr tc)I Exumplinn,y)u should WATER SYSTEM?1tEATING
> bveome,ubjxt ,,the W),kers Compensation provisions of the Whir Cape,you must SOILS ITE
forthwith comply with such provision,or this pcnnil shall he deemed revoked WATER SERVICE
UJ
0. Q
CONSTRUCT ION LENDING AGENCY NEW RIESIUEN'I(Al.PLMB. SQ,FI. PAID
L)O I hereby vlfirm that there is a construction lending agency for the Pmfermance of UX Is. k
D. (~" the work for which this permit is i,s.CJ(See.3097,Civ.CJ
0 WnJero Name V T(TI'AI:
} Lender',AJdre„ ITUAL:
(✓ L\r I CCnify that I have read this application and¢nm Wnt the ahnvu inhmrmcom is BUII.D1N0 i 7
tq cornea.l agree to mm�ply wdlh all city and antnry oMin:mces and sr:ne I:nws rclnting to QTY. MECHANICAI,PERMIT FEE
V z building constructions and hereby anhorire represenative%of this city to enter uno'he SEISMIC PF. O
vbnvo-muntion,d propertY h'r ifspocnon pugnnes' PERMIT'ISSUANCE;
(WO agreemnave,inJenNfy unJ keep hurmlese the City of Ca,meoagalnsl ELFCI'R .FEE
lebilitic,,judgmenu.costs and expenses which may in any way accrue against said City ALTER OR ADDTO MUCH.
. Ance ofWe ailing of rats permil. PLUN ApltD^t STq[JUS ND N'ILI.C(lhl i'LY WITH ALh NON-POINT AIR I IANDLING UNI'f('1010.(NXI CPM)
C,, /lfF4f�� //Y MECHANIC .FEE
/ / F AIR((LADLING UNIT OVER 1O,IXIB CIM) CONS'1'RUCION'[AX
Signature of Apple V1 ._tmAur S Date ` EXHAUST 11001) W/DUCPI f10USING MITIGATION FEE
IA%ARDOUS MATERIALS DISCLOSURE
Will the applicant or future building ocarpant.nocor hmellc hwammu,mellidal H EATING UNIT TO 100.000 BTU)
as deineal by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cndc,Section 255320p'1 ((EATING UNIT(OVER IIIQ(NID BTU)
❑Yes El Na
V12NI[CATION I-AN(SINGLE RESID) PAID
•
Will thea,
e plicaDate Receipt k
nt ur dowse builJing mcupmn uu cyuipmenl nr device,which
mit harardous air conlannnams as dcllned by the Bay Arca Air Quality Man,tinem MOILER-COMP(3111V OR 100,(00)B'i'U)
D61.II I I U'
EJ yes _1 No BOILER-COMP(OVER IW,IIfI(1 it'ru)
1 ,krc:ul �aud)u, rials rtquiremenm under Chapter 6.95 of the Cali AIH CONDRIONER J¢._ql tp NCIi DA]7i�
fond: ceder, Q Se 25505,25533 and 25534.1 undnstard that If the NEW RESIDENTIAL MECH. L\l0 !- `--(
hni mgA cs red JYM1avc cnnntJhut itixmy pc{{nn bililY tofserol}y'thccxvvpnnl
: the I, it I v nlch mu met prior to i,aaanl'Csnl,.f rSiBc:]e 0lf_fk'
Ow ,riimulror cd agmn `l/ Datc TOTAL: ISSUED BY O
OFFICE