S 2943 ---APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PHRMITNO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL.
.BUILDING PROJECT IDENTIFICATION S 2943
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DA'I'H
c5e
sill
OWNIER'$NA- PHONii: IY1R'S AME: LIC NO'.
NIC CONTROL#
•n ARCHITECrILNGINVER: LIC NO: ADDRESS: *_ ❑
Cm i
CONTACC PHONE: a BUILDING PE2MIT INFO
❑ Consultant Fees Paid by Applicant(Initial) HLDG, ELECf/ PLUMB ME.CH
f4rQl/ ��CIJ ❑ ❑
LICENSED CON'TRACTOR'S DECLARATION QTY. ELECTRIC PERMIT PEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing _ JOB DESCRIPTION
qaZ BSxe1aal7d0)of1u,NIo.3anhe Huxine—nd Pows nasCade,and any license is RESIDENTIAL:
a00 WI PIiRMI'f ISSUANCE
{��+ nNll limes unJ cu' ❑tiI:DWI. [_1 KITCHEN REMODEL.
6�U Jce... s1 — 1.10.#
mCW I Cammcror � �• APPLIANCES-RCSIUENTIAL ❑ADDITION L1 PLUMBING RE-PIPE
m
AI{CHHECI"S DECLARATION 0101-UH-UNH ❑STRUC'FURAI.
PANELS
Z O to ZI z I lia'mml anans y plof ell he a ad as public mcnrls MODIFICATION
to UPI'0200 AMT'S ❑IN]ERIOR ❑CHIMNEY REPAIR
W Licensed Pufle"a n I 201-I MAMPS IMPROVIiMENTSWIMMING POOLS'
OWNER-RUILDF.R DECLARATION
C I herby albou That 1 an exempt font the Convect.,,[,,cause Law for the
X foil—in OVER l01#1AMPS C1 BAFII RIiM(1DBVRHPAl12 DEMOLITION
3 W F n.Self 9031.5,Hm,iness sad Profassians Code:An ❑O'1'iliV _
g rea,e rairor�mntr s[crvs l!LeGFR1cn1.
y which reports u permit to condoner,alley,improve.Jeri or repair any svuenn,
st prier to its issuance.also rounw,lheapplicanl fnrsuch permit to fileasigned statement SPECIAL CIRCUFDMISC.
MMn�-a hat he is licensed pursuant the provisions ofthe Conlmclor,License Law fChapmr9
no
icommmrcingwith Section l01(nufDivision 3ofda Busine,xod Pofeaina,Codc)or TEMP.METER OR POLE INS'E. COMMERCIA:
0.d p C That he is exentpl therefrom mW the bmis far the alleged exemplinn.Any vinlmioa of ❑NI!W BLDG/ADDITION ❑DEMOLITION
X m a Section 7031.5 by troy applicant for a peon subjects the applicant to a civil penalty of POWER DEVICES
Lal^y ❑TENANT ❑FOOD SERVICE
not mare than five hundred dollar 155118). IMPROVEMENT
El 1,as oxner of he property,or employees with wages as theirsele compenxgion, SWIM M INC,11001.RLEJ IC
cs willdothc vork.turo esllncmre isnul imendedorol(a¢dforsale(See 1000,Business OTHER
6 3 eo and Proleo,ions Fall Me Contractors Licenu Law does not apply to an owner of OUI'LEFS-SWIT FIXTURES
.. propeny who huilJs or innprnvcs thereon,ani who does such work himsaHf m Ihnmgh 1 1
his own etnpleVecs,provided but such impovements are not intended or offered for NEW HEMDEN'I' .ELE SQ FF. t
sole.IL howcvernhc huilJing ur imprnvemem is soldwithin one year ofrompletion,rhe 1 7 Q.INIPLOOR EA s/SQ,1T.
ecbuilder will have the huNen of proving that he did net build or inf rou for he
I APR 1 5
,,a Ite led. 1999
1,m owner of the prapery,our exclusively contracting with licensed o nfruna,to i 7.y
maom the project(Sec.1144,Bvsinv„and Profa,sires Cadv., -Comuehr'e I..- t -
,a Law does nal apply munownerof prtpeny who builds or improves thereon,and QTY. PLUMBING PERMI T FEE
who,.... uss etr,neb prcticefs with anow, r(s)licensed purvuoet.othe Convenor's
License LawEl , Pf;Ii MIT ISSUANCEI ant excngnnnl,r Sea .B&P C Fr lhlx zcexnn
Owner Data ALIER-DRAIN&VBN'1'-WATER HIM VALUATION
WORKER'S COMPENSATION DF,CLARA'I'ION AC 1, PROTIECT,DEVICE S;Voo
1 herchy affirm under penally of perjuryane of the following declarations:
❑ I have and will nnainmion Certificate of Consent to self-insure for Workers Cannen- Olt gAOR,NOOEAREA,COND. Sr FORMS TYPE CONSTItUCI'ION
,than,vs provided for by Seen nn OW of the Labor Code,for the performance of the
work for whicM1 this permit is i,sucJ. FIX'I't1Rl.,' Elt'I'ItgP
❑I have and will maboup Worker's Compensation Insurance,as repaired by Section
72(10 of sec Labor Collor fnnhe performance of the work for whish this(,pannit i�s/ix�sucd.
GAS-b 'YS -I INC.4OUTLE'FS OCC.CROUP MIN
Carrier c' nn sntion rvntt co is PoliiicPolicy in
cy Nu:I L4 a--'"s?)( GAS-P.A.SYSTEM OVER 4(EA)
CI!R'1'll'ICA'IP.OI'DX PFION FROM WORKERS'
COMPENSATION INSURANCE GREASE IINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
('Htls.sntien need not b,eempleadRae permit is fsrnne hundrcddellars(SIgB GREASETRAP
or less.) PLANCHICK ME
l certify IM1ID in the parfannocc ofihe work fora hich this Permit is issued,I shall 51!N'13R-SANITARY-STORM EA.200 FT.
not employ any ancon in any manners)as u,secure subject m Ne Workers'Compem ENERGY LEE
zz union lrwsof Califomia.Date WATER IIEAI'ER W/VENT/F,I.ECI'R
0 Applicant GRADING FEE
fA NO[[CI!'10 APPLICANT:If,alter making this Certificate of Exemption,you should WATER SYS'I EMIT BEATING
a ; hu:omc subject the Workers Compensation pm omen,of the Labor Code,yotnmv SOILS PER(kI forthwith comply withxuah pmv:brsatni,pernitoull be deemedocwuwd. WA117R SERVICE:
6 A
CONS faire UCFIONLBNDING AGENCY NEW RHSIUI3N'1'IAL PLMIi. SQ.FT. PAID
UO Iherw1h,ch 0r, unit
isacomw,.30 lending agencyfnnhe podnnnunco of Ione Roecipt#
fLH 'he work forwhich Otl.v permit isissued(Sec.31191,Co.Cd
I'n lm
r,Ndn
e '101'AL'.
WIcnd6 Andre„ TOTAL O
I,sorry that I ltnve read Ins nnp0cuden ma,sum mat mo above mfornnnniont is BUILDING m;r
v'i correct.I agree m comply with all city and county ordimmce,and sum laws 111—fol to QTY. MECHANICAL PERMIT PEE
U z huilJing conslotion,and hereby authorize representatives of this city In enlnnTnn the SEISMIC T)i13
cNor-mantioned property lin inspm0on purposes PERMIT ISSUANCE
(We)agree to save,indemnify and keep hurma,s me City of Cupenina against 131.17CI'RIC FEE
Iionlities,judgmens,ensu and expenses which may in any way accrue against said City ALT AR OR ADD TO MECH.
n,csryenae of the gmnling of This permit. PLUMBING IyiE
APPLICANTUNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,00)CFM
IRCR REGULATIU '. jAe7leLMM, MI!CI{ANICALIHiE
�I5 AIR HANDLING UNIT(OVER10.000CFM) CONSIRUCTION TAX
6 urea Ap tr,,hCnn1g,lo Dae BXIIAUS'FHOOD(W/DUCT) HOUSING MITIGATION FF:F.
I{AZARDOUS MATERIALS DISCLOSURE
Willth Iicanl or Room building occupant store or handle huardl material BEATING UNIT(TO I00.DXJ BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(,)'1 I I[EATING LRB I'(OVER 100,000 BTU)
0 Yc'sPAID
o VENTILAI'I ON FAN ISI NCLE RF.SID) Dare Receipt#
Will the applicam or future building occupant use equipmetn or devices which
emit h,anlru,air conmatimans av defined by the Bay Area Air Qualify Mmugentant BOILER-COMP(3HP OR 100.000 BTU) O
TOTAL:
Disuierf Vas BOILER-COMP(OVER 100,000 B'I'U)
I have rand the hantrdons nmtcHals raluircmenrs under Chapter 0.95afthe Enli- A I R C'OND I'I'IONER ISSUANCE DATE
Rana Health&9u cl,Cede.Scotian,25505,25533 and 25534.1 undersmnd that it the NEW IRE l LrI IAL MECH. SQ,ET..
nniltfing d,vs tel enneony nava a imam,Ilan it f,my re,rym,mil4y m rnpfy the o,,,a nl
tea nem,sublet . bonnet rias fie i,suamaarnemaljePoer oecupyln.
r umhorir 11col _G ]))are TOTAL: ISSUED HY:
OFFICE