S 1639ADD( ICANTTn EB 1 IN wmpmAl WITHIN REO LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO - I4UII,IIING-RLF.CTHICAL
RUILDISNG DIVISION APPLICATION/PERMIT PkUMRUVG. MECnnNICAL
BUILDING PROJECT IDEArrIFICATION
PE ITNO.
1639
oSANITARY
i0 ore o C()`�2 v O C
NO.
AI'i'LICA'I'ION SCENE ITAL DATE
S -e"q/0NER'S
JBUILDINGADDRESS;
NAMI7: PHONE:
CO RACTOR:S NnME: LIC NO/C
fly dotZ4 al
❑
CONTROLX
CHITECDBNGINHER: LIC NO'.
ADDRESS:
aig�j
S 1
CONTACT: PHONE:
=Lg4[O
BUILDING PERMIT INFO
o Gso `-9�
❑ Consultant Fees Paid by Applicant (Initial)BLDG
Z22
ELECT PLUMB MECH
❑ ❑ ❑
LICENSEDC NTRACTOR'S DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
wimsmrion laXOof Division3anhe Business and l'mfessinns Cafe, and mylicensc is
in full force ante 7 -� CfgfLc�CFK
License CI.onti
Dam Comra--l-
ARCfiITECTS DECLARATION
tt
l dd lhll bJ blid
Licensed Procoinnnl
OWNER -BUILDER DECLARATION
1 hereby uRmt but I an exempt from the Cottontail License Law for the
following reason. (Section ]11)1.5, Badness amt Profcxeions Coda, Any city ar county
which requires a Permit m contract, cher, improve, demolish, or repair any structure
prior toms ismamc, also requires theapplicant for such permit to file a signed stmensam
that he is licensed pursuant to the previsions of the Contractor's License Law (Chapter 9
with Sdon 7000)of Division J of the Business and Professions Cale) or
Sec
that he is eummt therefrom and me basis lin the alleged exemption. Any violation of
Section 7031.5M1 licant for a permit subjects the applicant to a civil Ery, of
PP Pena
Y ve hundred
]1.asownermore than ofthundredor yropl
wi Lo the work, nd property,sur isnot moyoedmuffeoges asmeir sole(Sm. com'Businesson.
will P less irk, C d e The cture is not License of
Prnletsiara Coda. The Cnntmdur's License Lnw Jade net apply to an owner of
Lo emd s nut apply 1044. owner
property who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvements are not intended or oOemJ for
.cele If, however, the building or improvement iasnld withinoneycnrof mmpledon.theFLOOR
QTY ELECTRIC PERMIT
JOB DESCRIPTION
RESIDENTIAL,
DWL ❑KITCHENREMODEL
❑ADDITION C1 PLUMBING RE -PIPE
[I MULTI -UNIT � I
MODIFICATION
El ❑CHIMNEY REPAIR
IMPROVEMENT []SWIMMING POOLS
❑ BATH REMODEUREPAM CDEMOLITION
U OTHER
gZ
OF
iV
C a
p y
"Z
Q
�{il
4<
Y U
y¢
n.]
Gf(commencing
❑ O�a
vis,
�y
E<
m
3•.and
PERMIT ISSUANCE
APPLIANCHS-RESIUFNTIAL
PANELS
UPTO2WAMPS
201-1000AMPS
OVER HXIBAMPS
SIGNS ELECTRICAL
SPECIALCIRCUIT/MISC.
TEMP. METER OR POLE ININST.COMMERCIAL:
C3 NEW BLDG/ADDITION U DEMOLITION
❑TENANT ❑FOOD SHNVICE
IMPROVEMENT
U O' HER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCf1E5-PIXTURF.S
NEW RESIDENTIAL ELEC'R SQ F1'.
AREA
fISQ. FT.
owner -builder will have the burden of proving that he did not Guild or approve for pa,
PFEE
pose of stJe.l.
❑ 1. as owner of the property, am exclusively conrmcdng with licensed cants mors to
T AL:
rostrad the project (Sm. Tact. Business and Professions Cl The Commercial a Li-
censeLawdianotapplyrntnawnerofpropenywhobuildsorimproverthereon,read
QTY. PLUMBING PERMIT
who ronoalfor such Projects with a contractions) hearted prommnt ro the Crucia is
PERMIT ISSUANC17
License Law.
I am exempt order Sm. . H & P C for this reason
Date
ALTER- DRAIN & VENT- WATER (EA)
VALUATION
PACK FLOW PROTECT. DEVICE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the fallowing decimations:
STORIES
TYPE CONSTRUCTION
❑Ihavc and will 3sate of Worker's Compen-
abor sode,for
IJRAINS-I'L(IOR, ROOP,AkF.A, GOND.
'
the
Section 7110 of the Labor Cade, for the performance of the
for bynection the
cation, as provided for
mi
work For which this parn;r is Issued.
have and um maintain Waders Compensation Insurance, as required by Section
9](Nlnf theL ulwr Csnle. for the performance of me work far which this permit is i.uved.
?791
FIXTURES -PER TRAP
GAS -EA. SYSTEM-] INC. 401111ET5
OCC. GROUP
APN
My Worker's Cooperation Insurance conics and Pali y
C.ri 44n4 lGf2P PolicyN •` a -fes' rf�
GAS - EA. gYSTEM-OVER4(IiA7
CERTIFICATE OF EXEMPTION FROM WORKERS'
INSURANCE
GREASEIiNDUSTRI, WASTE INTERCEPTORCOMPENSATION
BUILDING DIVISION FEES
(This action need not be completed ifthe Permit is home hundred dollars (SIM)
nr Icsx 7
GREASETRAP
PLANCHECK FEB
Imitifyrhm in me performenceof the wad far which shit permit is issued,]share
not employ uny person in any manner so an m became subject the Workers Compen-
SEWER -SANITARY- SPORM EA. 2(X1 ET.
ENERGY 1tiE
WATER HEATER WNENTMLECTR
GRADING FEF.
1
. O
'
1 ti
z
F
V
Its
to
Z
cation Laws of California. Date
am
NOTEAppli
NOTICE TO APPLICANT: If, after making sati this Cis.... a ofExemption you should
becmtm subject m the Workc/s Compensation provisions of the Labor Crxle, you must
forthwith comply withsuch previsions or permit shall he deemed revoked.
CONSTRUCTION LENDINGAG agency
I herebywhich nn that is suede. construction0 lending agency fnnhe pcnbmence of
thawark for which thispermir is issued (Sca JOY), Civ. G)
Lenders Name
µq'1'ER SYSTEMTREATING
WATER SERVICE
SOILS Bili
PAID RerdrM
p
NEW R[SIUIiNTIgI. PLMB. SO EF.
TOTAL:
TOTAL:
Lender's Addrcxs
BUILDING PE
I really that I have mad mix application and state that he about information is
correct. I agree to comply with all city and county ordinances and state lows relating it,
Wildingcomwaion. and hembyaathaisc reprasentutivesofthixcity In enterupnn the
QTY, MECHANICAL PERMIT FEE
SEISMIC FE
PERMIT ISSUANCE
ELECTRIC FE
'•"
above-mentioned property for inspection purposes.
(We) agree a save, indemnify and keep hornlasx the City of Cupertino agalnar
ALITRORADDTOMECH.
PLUMBING FEE
ban Ire es,jud encs. mosand expenses which may in any way areae against said City
In mnsequenl f the granting of this permit.
AIR HANDLING UNIT(TO IO,(NNICFM)
MECHANICAL fE
APPLICAF/: N" ST Nos AND WILL COMPLY WITH ALI.NON-POINT
SOU "LATIONS.
,
AIR HANDLING UNIT (OVER 10.01X) CFM)
CONSTRUCTION TAX
EXHAUST GOOD fW/DUCT)
HOUSING MITIGATION FEE
Si a re ApplicnnVCantrador Date
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 101,00) BTU)
Will the applicant or future building occupant store or handle Imem es material
as refined by the Coal Municipal Code, Chapter 1), 12. amt the Health and Safety
ale. Section 25572m)?
HEATING UNIT (OVER 100,000 BTU)
❑Yes El No
VIiNTILATION PAN(SINGLE RESIDE
PAID
Dura ReceiprN
or derives which
Will the applicant tat nts a building occupant use ea Air
emit hazardous air cnntmninems as defined by the Bay Area Air Quality Muwgement
BOILER-COMP(7HP OR 100,0001311H
TOf
Dul°d? No E] Yl
❑
BOILER- COME' (OVER 10),001 BTU)
AIR CONDITIONER
requitemen
1 have semi the hada materials rs under Chapter h95 of the Cali-
fomia Ill & Safety Ca •diose 25505.2.550 and 25571. I unJermund rbm if tM
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. ET.
building dtus oma mI; katcnant. dead it is my responsibility m miry the occupant
//J{
aRhe ntswMe ( he met rimmasuance of a Certificate of Occupancy.
Ow rhadzml Dam
�J(]J,//�J /nl
ISSUED BY: t 'r - O
TOTAL:
OFFICE
Received: 3130/96; 9:05AY; 4153890418 1> 1; 03
MIDGLEN FAXAKIO 4 416369-0418
0030!1998 09:41 4082540883 FIM
f$3130198 09:32 AM ❑ 314
PAGE 03
6
60 3DVd
MAY 9 - 1994
DLUU. INSPECTION DEFAn , ..
CITY OF CUPERTINO
ONI Odf B£E9T6999i 00:95 866T/LZ/£B