99080120 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY Q O
CITY DI CUPVISION BUELB NG-ELECTRICAL YEYE 1
BUILDING DIVISION APPLICATION/1'F,RMIT PLfIMRING-MF,CHANICAL
BUILDING PR(IJRCT IDRN'1'IF'ICATION
BUILDING ADDRESS SANITARY NO, APPLICATION SUBMITTAL GATT
048 I s+c k� i�, e
OWNER'SNAME: 'I{ANE: CONTRACTOR'S NAME: LIC NO:
G_ _ _ _ �i S 50 3 N/C C NTAd& ROLx
IW AHQIII'fF:C'I'IIiNGINEL'R: LIC NO: ADDRESS: ❑ �•Q
C(INTACI': PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MF.C}iy
Q` �2-
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby mfinn seal 1 am licensed andel powilnec of Chamer 9 Bmmmeacimg JOB DESCRIPTION
WON with Semi.n]Ixp)of Division Sof.he Rosiness and Professions Codc.and my licen¢is RESIDENTIAL:
WOO PERMIT ISSUANCE
ed-= in full force and cRal. ❑SFDWh El KITCHEN REMODEL
6VU LirotG«Class Licx APPLIANCES-RESIDENTIA ❑ADDITION [I PLUMBING RF,-PIPE
CI Ilam Conn.,
FDy ARCHITI?CI-S DECLARATION PANELS
OMUI.TI-UNIT ❑STRUCTURAL
Z O m Z I undcmand my plans shall be used as public records MODIFICATION
O
UPTO2W AMPS Z ❑INTERIOR ❑SWIMMING
REPAIR
Ia1 LicensedI'ndcsnional 01dtAM1AMPS t�t��M/P,.R��OVEMENT �SWIMMINGPOOLS
C tY C Q I hereby union that N am enema,in,LDER.the Con rCLARNI eam's License Law Entire OVER I(po AMPS l(Ie^"'REMODEL/REPAIR Q DEMOLITION
Cipyyyy O a U fallowing reason.(Section 7031.5.Business and III rafc,kms Code:Any city or ttmn.Y SIGNS IiLECTHICAL ❑OTHER
w'3 LL N whleh sequin's a Pennit h c..nslr.cl,.Iles,imprvve,demolish,ur repair any ntrvclure - /
¢issuanre, ''''
Fu'OQ ......ialm rcgnires me.pplicam m
formch pennil lofile.u,nedsmme^t SPECIAL CIRCUIOMISC. i 'iiiil
that he is licensed pursuant o the provision%.fthc Curnowtors License Law(Chapmr9
p0 (c"mmeneingwith Section Di...am3 ofebe Hoslnesn and Pr.m,,o.ms Cde)or TEMP.METER Ok POLP,INST COMMERCIAL:
'.L c ea that he is exempt.henilam and the basis lin the alleged exemption.Any viola........ 0 NEW BIAG/ADDITION ❑DEMOLITION
�-m Secti.n]fIJ LS by any vpplicam Bnepermil subjects slit epplicannoecivil pcwlly of POWER DEVICES (]TENANT ❑FOOD SERVICE
F Z>' not mom than five hundred dollars(SSW), IMPROVEMENT
Q' 0 L as owner ofthe property,or my employees with wages as heir sole compensation, SWIMMINGPOOI.E,LECTRIC
EFC will Jothework.anJlbestf..am isnot imendedorurrered lin sale(Se,7044,
Business ❑OTHER
d 3 m a^d Professions Cude:The Contactors License law does no.apply m as owner of OUI'LEfS-SWITCHES-hIXT'UHE. ..
property who builds or improves thereon,and who does such work himself or through ' �'P
his own employees,provided that such improvements un-not intended or offered for NEW RESIDENTIAL ELECTS S f
san.If,however,the building orimprovcmem it sold within one yeurml cmmplcuou,lhe SU s PI. .A IIT
caner-builder will have.he burden of Proving the.he did not builds improve far per- S Itp
Powe of sale.).
0 I❑IILIII
1.a,.wner of the ppeny,ant exclusively c^ntmaing wih emanon I.eaoI. I AUG 17 19S9
cursors,the projec (Sri. Busness and 'ndchCode:)Tho Canvanm's Li-
vers,Law does resupply .arc ofpropeny whoWillimproves , rJ QTY PLUMBING PERMIT OPEG
who contracts forsuch projects with aconaannrty licensed pursuant mthe ConnemoR
--�License Law. PERMIT ISSUANCE 18y-
0
1 am exempt under Sec. .B It P C for this rota.n
Owner Dae ALTER-DRAIN&VENT-WATER(EA) VALUAi'ION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICEe^1
I hereby affirm under penalty of perjury one al the following dmlaralimrc v p rM1.J
Ile-
Fl I have and rill maintain a Cenificam of Cname self-immm fur Workers Corrigan- DRAINS-FLOOR.ROORAREA,GOND. STORIESe 'rYPECONSTRUCfION
moon,as provided for by Section 3700 of the Lahr Code,for the performance of the
work for wbi.h Ibis ppt its i...al. FIXTURES-PER TRAP
0 1 have and will maintain Worker's Compensation Insurance as rtyuire l by Section
3700of,he Labor Code,for the performance ofhe work for which his Permit is issued. GAS—LA.SYSTIIM-I INC.4 OUTLETS OCC.GROUP 7 / APN��
lilyW kne,Compemium.To mare:ra.ea carrier and Policy number !lT�
Carrier: Pahey No.: I GAS—EA.SYSTEM-OV ER 4(EA)
CERTI FICATE OF EXEM PT TON FROM WORKERS' GRLASI%INUUSTRL WASTE INTERCEPTORCOMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not b•completed dhPermit e Peit is lin one hundred dollars(SIW) GREASETRAP
or Icss) PLANCHECK FEE
I reality that in the performance ofthe work for which this permit is issued,I shall SEWER—SANITARY—STORM HA.203 PT.
nut employ any Person in any manner%a as to become mbjec.m he Workers Compcn- ENERGY FEE
Z Ovan Laws of Caldoode.hale WATER HEATER WNENTIELEC R
ZtioO ATIa,au GRADING FEE
.N. NOTICE TO APPLICANT:If,after making this Cenilicum of Exemption,you should WA'I'lik SYSlEM11/rREAI LNG SOILS FEE-".
a > become.objet,m he Worker's Compensation provisions'If the Labor Code,you must
W fonhwih comply with.such provisions or this Permit shall be deemed mocked. WATER SERVICE
Z) z CONSTRUCTION LENDING AGENCY NEW RESIDCNI'IAh PLMB. SQ.FI'. LAID Ua.c Rccciplq
V Q Iherehy affirm thnuhcre iso conarvaion lending agency for he Performance of
sr he workfor which his pennil is issued(few.3057,Civ.C.)
11 U Lender's Nn to TOTAL:
QUJ Lender's Address TOTAL:
y 1 certify the.1 have read Ihis applicu.ion and slam don above information is BUILDING FEE
.Fay sneo.],agree to comply with all city and county ordinances and.state laws relating to QTY MECHANICAL PERMIT FEE
UIZ lai Wing nnst mesio. annu'
, d hcrchy tril i,. Tm SEISMIC FEE
pro,o,for impce.ion puHarses. flvvs ofm,,,ay memo upon'be
PERMIT ISSUANCE
Wed agree to save,indemnify and keep h tr^lea he City of Cupertino against ELECTRIC FE
liabirtus,judgmems.costs and expenses which may in any way active against said City ALT ER OR ADD TO SfOCH.
in nncauence of the it; ing.l'this pennil. PLUMBING FEE
APPLICANTUNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,(x%)CI'M)
MECHANICAE,IEE
S RCF.REGULA IrC
VO - t `gyp \ AIR HANDLING UNIT(OVF.R 10,000 CFM) CONSTRUCTION TAX
Signature of ApplicarmCommc.or D11am` EXHAUST HOLD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will he applicant or lumen building occupant store or handle hacrdeus material HEATING ONE r(TO 100.00)BTU)
ax defined by We Cupenim,Municipal Code,Chapter 9.12,and he Health and Safety
Cal,Section 25532nd? HEAPING UNIT(OVER 10(.000 HTU)
❑Yes Fl No VENTILATION PAN(SINGLE RESID) PAID 1
Data Receipt x
Will the applkanl or faire building oceupam use equipmm,tt or device,which BOILER-COMP(3HP OR IdLod BIG)
emit hacuNou.air contaminants as defined by the Bay Area Air Quality Managemem TOT L:
1 DixWm'10 Yes r7 No
BOILER-COMP(OVER 100,00 BTU)
I have real he hanswous mamriah"remarks under Chapter 6.95 of he Cali- AIR CONDI I IONER ISSUANCE DATE
forms Health&Safety Cole.Sections 25505,25533 and 25534.1 mrboatnd that if he NEW RESIDENTIAL MECH, SQ FT.
building docs not curtcnfy hawse mnunt,mr,n is my rewplmsilediry¢t unity hcuscupre
of he re nl w of�a.�Ceenlfic�5I�•j ufeO�eovuPuncy.
CIA-A ■1
Owner mamhanecd.gem Date TOTAL ISSUED HV:
OFFICE