S 4140 99080085 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY O
CITY I_PF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDINGDIVISION APPLICATIONA'ERMIT PLUMBING-MECHANICAL S 4140
BUILDING PROJECI'IDENTIFICATION
B'I IOSUURSESS�.� G""-Ia/E et P45;1 I�.�� CA
�II^^ SANITARY NO. AVPLICAI'l(IN SIJBMI'1'1'AL DA'1'I
V/
W RS NAME w (�.. /PHONE: COIyTRACfOR" AMI': LICNO:
IZ1 Q&pRodI,(A'/k1 Goq"7 vP- NIC CONTROL
CHITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
El ��
C� ❑
LICENSED CONTRACTORS DECLARATION QLY. ELECTRIC PERMIT FEE
1 hereby afr m that I am licensed under prevision,of chapter 9(commenting JOB DESCRIPTION
OaZ with Section]l10)ofDiskion 3m the Bdamr,.,and Profession,CrWc,and my license is RESIDENTIAL:
0.00 PERMIT ISSUANCE
Q1-y)� L ene Class effect. ❑SFUWh [I KITCHEN RIiMODiih
UV License Class Lic.p APPLIANCES-RESIDENTIAL. ❑ADETION [I PLUMBING RE-PIPE
F 7d- Da¢ Contractor
In ARCHI'TECT'S DECLARATION ❑MULTI-UNIT [I STRUCTURAL
Z C m Z 1 undcrsrand my plana shall be used a,Public records PANELS MODHICATION
O
OF'TO AMPS Z.. ❑INTERIOR ❑CHIMNEY REPAIR
t:we Licensed Prufcssionvl OWNER-BUILDER DECLARATION OVER
IMPROVEMENT [IDEMOLSWIMMING POOLS
C W Q 1 hureby alllun that I um emmpl Irr.a me Cocurm o ,Livense Law for the OVT;R IIl(XI AMPS E:1 BATH RF.MODEf/REPAIR DEMOLITION
1ky 3 tz1,F rollnwing re-mm(Section 703 1.5,Bu,itim and Promotion,Cade:Any city or county SIGNS ELECTRICAL72'❑dl'HERC 2u/�J�e
rq which requires a permit m construct,alter,improve,demolish,or repair any structure /
I"'n•O�'
prior it,i,mance,alsomquiras docapplicanl for.weh pman itto dead statement SPECIAL CIRC UI"f/MISC,
that he is licensed pursuant o the provisions of the Conmacmrs License Law(Chapter 9
12Qp (cnmtnuming with Sectio 90fNpof Division 3 ofthe Husinea,and Profession,Cmdq nr TEMP.METER OR POLE(NST. COMMERCIAL'
=U e C rat he is exempt therefrom and the basis for the alleged emmplam.Any violation of ❑NEW BLDG/ADDITION ❑DEM0IJ NON
^vi Section 7031.5 by any applicantfor a permit subjects the applicant to a civil Penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
mol more then live hundred doll.S500).
F Z YIMPROVEMENT
=Q ❑Lothe owner k,the pmpeny,of myemntendedwith wage fosalei(aelecempcnsiness Sw1hiMING POUT.ELT:CTRIC
will Jntbework.Code
TheCureisnoaimcndedor.medJ for sale 0.1See11, 91114.owner
❑OTHER
1 m andpro Professions Cole: The Cunwereo License Law docs nal..ply m un nwmcr of OUTLETS-SWfCCf{BS_FIXTURES
property who holds or improves lemon,and who efts,men tinte deed o r or"o...,for
hi,own employees,provided that such improvements is old w arc not intended or a ed a.for NEW RESIDENT ELECTS SQ FT
salc.IL Mmever.aM1e buildineorimpmvemme is sold within nneYt'^ndeontplctiom the SQ.14.PhODR AREA SISQ.FT.
low nerbuilder will have the burden of proving Nal he did not Wild or improve for put-
Tole
/1hp ny,vm cadusively convunin6 with licensed commemrs to TOTALonnmtha 14, hlitoate Law dot on vt of properly who Wilds or improves thereon,and QTY, PLUMBING PERMIT PEP,Winntractsct ommeorts)licensed Pursuant eco the Cuntmclors
Licence' PERMIT ISSUANCEmc ,B&PCIo'aM1i%m xIV r t
ALITER-DRAIN&VENT-WATER(EA) VALUATION
sner Date ^ 00
Rm RKER'S COMPENSAi'ION DECLARATION BACK ROW PROTECT'.DEVICE - ^�
1 hereby arunder penalty of perjury one of the following declaration,: V
lbnvmud willmtimain oCenilicam of Co-mon m,clf-'msure frWorkcr's Geopen- DRAINS-FLOOR,BOOR AREA.COND. STORIES TYPH CONSTRUCTION
,.tint,as provided for by Sectien 3700 of me Labor CWe,battle performance or the
work for which this permit is issued FIXTURES-PER TRAP
M I hove and w111 mainmin Workers Compemaliun lmmance,tux required by Sectio
370)of the Labor Code,for the performance of the work for which this permit is ismed. GAS-IiA.SYSTEM-I INC,4 OUTLE'T'S OCCLGROUP APN
My Workers Compen,stion Insomnce carrier and Policy months,am: �•
Carrier: polity No GAS-IiA.SYSTEM-OVER J(EA)
CERTIFICATE OE EXEmp DON FROM WORKERS' GREASFJINDUSfRL WASTE..INTERCEPTOR 44
COMPENSATION INSURANCE BUILDING DIVISION FF,F_S
0his.seclinn neednm W completed it bepemnil is facer,hundred doll...($100) GREASETRAP
or le-l PLANCHECK FEE
I curtly than in the vilirmance oldie work[or which this permit is i,wed.Iahld1 $1iWER-SANITARY-STORM EA.21X1 FT.
nor employ any person in any manner so aco
s In become subjecuo the Workers'Cnpe
mn- ENERGY FEE
Q z saint Law,of Cldlrnrnia.Date WATER HEATER WNEhT/ELECTR GRADING IEE
z 0 Applicant
NOTICE 11)APPLICANT:If.after making(his Cenificam of Eaemptitm,you should WATER SYSTEMICREATING
a ; SOILS FEE
become subject np
subjeco the Worker's Cmensaunn provision%of the Labor Code,you must
fenhwilh comply with such prom oma or lis permit shall be Jeenmd revoked WAFER SERVICE
0
Z)z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL('LMB. SQ. L PAID Date Receipt#
U O (hereby affirm that mere is a consimednn lending agency for they Hismancc of
LI. H she work f..which his permit is issued(Sec.3041,Cie.C.)
O U Lenders Nance
Lentlors Address TOTAL'
r 6Wi 1 certify that I have read this application and one that the above information is UILD.' FE
F" tO coned.I agree to comply will,all city and ammy ordinances and scale laws relating to Qry. MECHANICAL PERMIT FEE /
U z building construction.and hereby stabilize representatives of this city un enter upon the r SEI'MIC FEILg I
alvrvameadoned pmpeny fm inspection pori PERMIT ISSUANCE. uuUu
(We)ngrt•wdiva,indenmify and keep hornlessthe Cnyof Cupediim...ins11 ELECTRIC IEB �JJton I so
imbilities,judgn ms,cmppa,vnd eapenus which may in any way acerve againxl sail City AFTER OR ADD TO MECH. PLUMBING PEE
inda
APP t[CAN c UN(DFg 5TA gDS AND rW ILL COMPLY WITH ALL NON-POINT
AIR HANDLING UNI'1'(TO 10.000CFM) rre q.{j
SOL CE .GUL N.
Cq AIR HANDLING UNIT LOVER IO.INNICFM) CONSTRUCTION 1—
am EXHAUST HOOD IW/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MAA 17RIALS DISCLOSURE
Will tbcapplicanlor future buildingoccupantamcnr handle hazardous material HEATING UND(TO 100.01111 BTU)
a,defined by the Capernnn Municipal Cole,Chapter 9.12,and the Health and Safety
CtNc.Section 255321.)'! HEATING UNI((OVER I(X),IIIXI BI'UI
❑Ye s 13:•toPAID
VENTIhATLON PAN(SINGLE RE51D1 -Date Receipt a
Will the applicant or future building occupant use reciprocal or devices which
emit hazardous air contaminants as defined by the Bay Area Air QualityManagement BOILER-COMPLEHPOR100,1X10 BTU) TOTA O
Dixtricl^ BOILER-COMP(OVER 11X1.100 BIL)
Ye
s �
I balerials requiomm�l,Older Cbnpler E950 the Cali AIR CONDITIONER ISSUANCE DATE q
Omnia Reduns 25505.25533 and 8531.1 ural candidal ifle NEW RESIDENTIAL NIECE. SQ.FE /.as
buildingdt content ..m,that if iu my rcapun,ihilll�iqty}�t t lythe "cruor �/ v
of the regaelpim, mismoseval.Ceml Me tRnY eJ� TOTAL: ISSUEDBY:�OC
OFFICE