99110154 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUH,DING-ELECTRICAL PEH r'
aim
BUILDING DIVISION APPLICATIONAPERMIT PLUMBING-MIECIIANICAI,
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: �1 APPLICAI gLDAATI
IdFa S . S+2.dj1
OWNER'S NAME PHONE. - CONTRACTORS AMC: LIC NO:
T / NIC CON'rHflhp
•ARC]11'TECT/ENGINE.R: LIC NO: ADDRHSS1 "'13 ❑
CONTACT.. PHONE:pl.�'j � - BUILDING PERMITINFO
❑ Consultant Pecs Paid by Applicant(Initial) BLDG ELECT PLUMB MACH
j ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEF,
1 hereby affirm that I am licensed under provisions of Chaptef 9(commencing _ JOB DESCRIPTION
,cc) with Seminal 7000)of Division J of the Rosiness and Professions Code,and my license is RESIDENTIAL
LLpp d PERMIT ISSUANCE
F LL G full force and cObc -29 �'I D ❑SPDWL O PLUM PIN REMODEL
y'U Dole Chos _ Contractor
gppLIANCES RESIDENTIAL Q p ❑AUDITION ❑PLUMIIING RF,-I'II'P:
NQ4 Dom Cin
E,Dy AItCIII'fl!CI"B DECL DECLARATION PANELS OMUM 6lINl'I' OSTURN.
i underhand my pltins xhull be used u.public records MODIFICATIONNEREPAIR UP T021XIAMPS
OZ O ❑IN'PROVIR IIIMMINREPAIR iT
LL Licensed Professional - 201-10011AMPS IMI'ROVP.MEMI' SWIMMING POOLS
;$Yd2m4OWNER-BIMIDERDECI.ARAUON OVERIINLAMPS N It OBATIARENICtiLLLUREPAIR ODEMIGIUTION
C ds Q 1 hereby aRrm that 1 am enempt from the Contractor,license Co.fir the
a'p 6 U Colloidstea.on.(Section 7031.5.Business and Professions Code:An cit count OOI III.R
41 Y Y"r Y SIGNS f:LIiCTRICAL
�+LL which requires a permit m construct,ihaper.improve,demolish,or repair any structure 1
�g that hoslcense pursuant
toires provisions o for such Coop permit no ign,(Cha mens SPF.CIAh CIHCUIT/MISC. Z'
99W9 thnnolscing with
purawnu.the of Division
of the
eBusi toss ni Professions
lChapmr9
P GO (announcing he
ingwitnuareSection
ul mdI the
Division.oftheegod empton.fAny vi Gale)nr TEMP.MITI'IiH OR POLE S'. CGMMBIDGADI
PiGiy5 o y that he ix exempt therefrom and Phi Micr for the ol,Ile exemption.Any violation of - O NI:W IILDG/ADDITION O DHOIU sU Vl
W^0 ECctbn]Ipl.S by any applicant tnru permit subjuts the uppllcannnucivil Canopy of 1'OWEH DEVICE El IENAN1' OIrDDD SI!ItVICI:
=y} anmm than live modreddellarn N51X0. IMPROVEMENT
iiG•60I,ox ownu of the property.army canployeea with wages as theirsnle contpemntin.. SWIMMING IK,I( ,ELECTRIC
�p will do the work,and the.ammum is not intended oroRered 4usule Nae.7(N .Business I!
tij`m and Professions Cob:The Cimmctor's License Law has not apply m an owner of COTIA'1'S-, ITCHES-FIXTURE'
propc ,who builds m improves thereon,and who does Bch work hinmclf aT thnmgh
his own employees,pmvidM that such manorcmems are not imenJeJ ar oRemJ fir NEW R1SI1 BI TIAL ELGCfR SQ Irl'.
sale.IL however the building.,impmvcmert issuld within one year ofcnmpinion.the T.FI.00R ARG $/SQ.FT.
owner-bunder will have the burden of pmvidg that he did not build nr impmve for Cur-
Prsc of sale.).
❑
I.as owner of the property,out exclusively contracting with licensed contractors to TOTAL:
mania the project N..7044,Prosiness and Podhosi.n Cndcq'The Coutmemrs Li- -
mel.awdoesmd on],1. owner al'praPery who buud.nr unloose,tharnm,and QTY PLUMBING PERMIT FEE
who contacts Tmxuch projects with a conwemr(s)licensed pursuant m'W Cirauctora
I.icetso Law. PHRMI'P ISSUANCH
O I nm eaemp"under Sec. ,R&P C for this anon
Owner Dom ALTER-I IN&VENT-WATER(I!A) VA If TION
WORKER'S COMPENSATION DECLARATION BACK FI.OW P ECT.DEVICE �` 3O Q
I herebyaBimt under Certify Certificate
perjuryoneof thefollowing Worker's
n: J
❑ Ihave o voile maintainbyeCion 37tcot the Labor
olf-upsCode.
for boarma Comped- DRAINS-1100R. OOP.AREA,COND' S'PORIF.S TYPE CONST RUCTION
ration, r pmvidM for by is issued.
9](X1.1 the Labor CNet fur the perfmm�ancc of the
work for and
this pennn is issueJ. PIXTUHIiS-PIiH'I'H P '
��..((I have and will ode,o r he pert r Cane III the
w work
ce,ahi m his required by Section$71X1 of the Labor Code,for that perfonnunm of the work for which this Permit is issuul. GAS-CA.SVS'CIIM-II C.4011TLLTS OCC,GROUP
My WntkACI_Lpen ,0o LtmcnJcc cnrriur and Policy ng¢har uA#'
Carrier;tea s -fl/.elLl Policy No.: r5y4 gi- Iciq GAS-EASYSTIIM-OVH 4CA)
CERTIFICATE OIs EXEMPTION FROM WORKERS' ,
COMPIiNSAT[ON INSURANCE GHEASI/INDUSI'RI.WAST1 RCEPfOH
(This section deal not M completed ifthe permit is forme hundred dollars($1000 BUILDING DIVISION I li[S
or less) GHIiASIi TRAP 1'LANCIfIiCK FEE
I cenify,that int he perfameaceofate work far which thispmtit is issued.l shall SEWER-SANI'T'ARY-S RM -A,2W IN.
not anploy any peno.in any meaner so as t.become subjecrai the Workers Campers- ENERGY FEE
O z sation Laws of California.Date WATER HEATER W VNT/ELE k
z Applicant
GRADING I'EE
Q
h N(TFICH TO APPLICANT If,after making this Certificate of Exemption,yon should WATER SYST17M EATING
beco:re xobject tone Workers Compensation ruslsbre of the Lahor Code.roti must Sf LuP.CI:_..�_._�...__,I
(y limhwilh comply with such pmviainns(it this permit shall be dmnied revoked. WA'I BR SHRV ,17.cl, ..
Q CONSTRUCTION hIiNDING AGENCY NEW IiliSll iN'I'IAL PLMR. AID
r�3 z Dale Receipt Or L) 0 I hereby affirm that there is aenngmnion lendirgagemy for the performance of rI I
F' 'he work for which this permit is issued.Seco 3097,Civ.C.) NOV 2 3 1999
T"1
lenders Name
G
I<ndhes Address
- TOTAL: BUT[ FEE
1 cenify that 1 have read this application and one that the move infonnmlon is
Fh correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT EEE
U z building completion,and hereby authinze representatives of this city to enter upon the SEISMIC IBiIi
alswe-mcnrioned employ for inspection purposes. _
(We)agree to save,indudnify and keep Imnmless the City if Cul'cnini again,, PERM1 H'ISSUANCE 2CECI7ITCFB:
Iiahllitics,judgramis,casoand espen,e,which may in any way sceme again"said City AUI11" It AUDIO VIECH.
in mscomence of the granting of this permit PLUMIIING PEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR UANDNZR,UNIT(TO 10,000 CPM)
MECHANICN.FEE
SOURCE REGULATIONS.
AIR IIANDI.IN INIT(OVER 10,0OCFM CONSTRUCTION TAX
Sl..alureofA,ldranUCommuor Dam EXHAUST HOOD\( IDIfCp HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Wiill"Mapplicamorforms tatilding occupant smre or handle haz.Nnusmaubial IIFKn NG ukin(To I t 0noB )
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cede.Section 25532(a)? BEATING UNI'I(OVER 003 BTU)
Yes Nu
O VEN'T'ILATION FA SINGL RESIU) PAID Unto Hcceipt#
Will thice,uhcont.1 Loon buildup occupant use equiuitmt ordevlecs whleh p01L1!R-CO P(3HP(1H IOq 01T'fU)
emit hazardous air commodious us defined by the Bay Area Air Quality Mumgemem TOTAI: ,�
District'! I,� 11011.ER 'OMP(OVP-R 100,(11X) TU)
O Yes �No
I have read the frosnlnm materials rcquiremedv under Chapter 6.95of the Cali- AIR CO DITIONER ISSUANCE DATE
fomia Heald&Safety Code,Section 255115.2553 and 2$534.1 understand that if tM NEW RESIDENTIAL MEC I. tiQ.PT. L�/r n/ A
building does not currently have a tenant,that it is my msp.nsibility to notify the occupan2
�I t —
ifthe r yuireme is which amt Iw met rior m issuance of a Cenificate of( cupancy. W
Owntt nr uu dze agent )arc TOTAL: ISSUED BY:
OFFICE