B 0378 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BDILDING-RLE(7RICAL PERMIT 0 .%O
NT
BUILDING DIVISION APPLICATION/PF.RMIT378
PLUMBING.AIECHANICAL SOOOI IYYY�f� 40
BUILDING PROJECT IDEIFICATION
BUILDINGADGRESS: SANITARY Nf1. AVI'I.ICATION SUBM1'MAL DAT
'A -2,9 — YTP( L ._ L �
OWNER'S AME: THUM CUMITACIORS TME: �� ((// LICNO: / NIC CON I ROI,
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`ARCIIITE /IiNGINIiER, LIC NO: AGGRESS:-7V3wGVR �gm"K, OvL.` s.�1 E]
CONI'ACf: PHONE: BUILDING PIiRNAIT INFO
/1 L L-IA/ U �l ^� ❑ Consultant laces Paid by Applicant(Initial) BLDG ELECT PLUMB ❑l
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LICENSED CONTRACIOR'S DECLARATION C� y QTY ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
"Z with Sadan7(XXuu1 D1VIX1Op3of the llminesanJ Profcaxioro'Cude.and mylicemeis RESIDENTIAL,
W 0,
! �•�I PERMIT ISSl1ANCE
�ty0 in lull force an'ef(cd. h / (� ORI'DWL El KITCHEN REMODEL
QUV Liccnu Clas: Connector
APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE PIPE
FF..Z W Date Contactor A- • -M F% f�•U
NQ1 ARCHITECTS DECLARATION El MULTI-UNIT OSTRUCTURAI.
~HZ [undcanmdm hll bemcdus blicrccords PANIiIS h10DIPICATION
YP:mxsa Pu UI11090AMPl
❑INTERIOR OCHIMNIiY 121!I'AIR
[=aint Ed Licensed Professional 2111-1WBAMPS IMPROVEMENT OSWIMMING POO1,3
Cy dOWNER-BUILDER DECLARATION OVER loop AMPS PATH RENIODEI/REPAIR El DEMOLITION
C Q I hereby if ire the I ten exempt from the Commctor'v Liccme Law for the O OTHER
XO 6 U fallowing reastm.(Section]1131.5.B mines and Professions Cale:Any city or county SIGNS ELECTRICAL
W LL H which requires a permit in construct.alter,improve,demolish.or repair any stucmrc
Fsa:fnng prior to its issuance.also requires the applicant forsuch Permit o file a signed statement SPECIAL Cl RC!j1r _NC.
�p. the he is llcensW pursuumwthe pmvixinnx of the Cnntramor'e Lieensr low lChuptu9 COMMERCIAL
Cep (commencing with Section](%Xb of Division 3 of the Business and Professions Code)or 'I'1?MI'.MET11120R POLE
d E e 5 that he is exempt thcmfmm and the basis for the allege)exanpion.Any violation of ❑NEW BLDGIADUI'1'ION ❑DIiMOLITI(lN
ad Section]831.5 by any applicant far a permit subjects the applicant to a civil Penalty of POWER DF.V ICES OTISNANT' El FOOD SERVICE
e more than five hundred dollars(5500). IMPROVEMENT
Z� Q has awnvndthe propeny.or my enployeus with wvgcs us their u+lc cantprmntiam, SWIMMINGPOOLEL T
F- will Ju the work,trod theswcwreis nm inmmdcd mndl'crcd prop salt lSec.9N4,Business OGTHER
W3 m and Professions Code:The Canurxaaa s License Law does not apply to an owner of OUT LETS-SWI'I CH '
0. property who builds or icap ntvcs thereon,and who does such ,,,it himself or though
his own employees,provided that such Impmvemenu are not intended or offered for NEN'RESIDENTIAL ELECT RAR. $/$Q.IT.
,sale.If,however,the building or improvement is sold within One year of eonmpledan,the
cr-builder will have the burden of proving ppu
ing that he did not Wild or imrove far r-
E, of ale.) TOTAL: MAT 1 7 1999
O m I, owner of the property,am exclusively contracting with licensed omtrauos
construct the pmicm(See.7844,Business and Pndessims Codv:)'Ihe Contractor'.Li
cen¢Irw does nm apply m or mmer of Property who build.is,improve,thereon.and QTY. PLUMBING PERMIT FEIi
who contracts for such projcctswith a contramotfs)licensed pursuant to the contactors �J �/
License Law. PERMIT ISSUANCE s J
O l am cmmpt under Sac, ,I1&P C fill this mason
ALTER-GRAIN&VENT'-WATER(EA) VALIIA'IfQN
Owner Do1C 3ovo W,
• WORKER'S COMPENSATION DECLARATION BACK FLOW PRCIECI.DEVICE
1 nearby affirm under Penalty of perjury one of the following dcelumtion.s:
Q l have and will muimuln a Cerifieae'If Consent it,self-insure for Worker's Comber. DRAINS-IROGR,ROOF.AREA,COND. STORIES '1'Y 113 CONS'IRUCTTO
saeion,as provided for by Section 3701 of the Labor Code,for the Performance of the 30
work erm
far which this pit is issued. FIXTURES-PER TRAP
I have and will maintain Worker's Compensanum Immune as required by Section
3 Ib of the Labor Code,or the perouraicc Of the work for whichthls permit in issued. GAS-EA.SYS'1'IiM-I INC40UTLl!'I'S OCC.CROUP ANN
My Workers Compps� Minn lncur99nc, mer and Policy another amD Vw I-
CurfeeCTA--/Ks Fs,N l4sca Policy No.:��q- /p �1 GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE Oit EXEMPTION FROM WORKERS' GREASF/INGUSTRL WASTE INTF:RCEITOR
COMPENSATION INSURANCE HUILDING DIVISION FEES
letflfiisscninn medialb,comPlated,fdo,cnnl is former lmadreddollun($BX) GREASETRAP
i'LANCHECK FEE.m
lit,an,theinmanyreturnttof,tobestock for x.bjv,Itopc W i ass,Cocal, shall SEWeR-SANITARY-STORM EA.200 b.
rot mmpiny any tors unym nu sossmhernnm sunjaun the Wnrkrd'Comlem ENERGY FEE
Z nsuinn Laws mf California,[)air an WATER HEATER WNHNT HLECTR GRADING FEE,
Z O Applicant t
NOTICE*10 APPLICANT.IL after making this Cerificate of Exemption.you should WATER SYSTEMITREATING SOILS FEE
a; NNecmne subject to the Workers Compereadon provisions of the labor Cods,you must
s„s limhwida rmnply with such provisiom a this permit shall he dccmed revoked. WATER S17RVICF
yQ PAID
oz CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.PT Dme Receipt
U O I hercby aRimuhat there is a construction lending agency for the performance of
Leader.,Is rk for which this pemnit is issued(See.ANl7,Civ.C.1
w f✓ amp 'I(('IAL:
O L) Lenders Address T(YfAi.: o e
W 1 ratify that 1 have read this application and state that the above information is BUILDING PEIi
�..t a' b TY. MECHANICAL PERMIT IER
Uh buddir lagrecmcunply herchyeityaad uumynmovel exam.arum lvwsrrlmin is Q SEISMIC FEE
U 2 bnilJingn nUmetion.and hrrebY mnhnri'ic nTrexmmives of this city wen¢r upon the
above-memimeal progeny for insl'ectinn p wolves. PERMIT ISSUANCE ELECTRIC FEE
(We)agree m save,indemnify and keep harmless the City of Cupertino againt
liabilities,judgments,cases and exl'enses which may in any way areme against said City AEfER OR ADD TO MECII. PLUMBING IBE y3
in canat rvearr of the guning OI'this Permit.
APPLICANT TNDERS"ANUS AND WILL COMPLY WITH .L NO -POINTAIR HANDLING UNITGO Ib,dbp CFM) MECHANICALFEI3
Sir L l IULADO S.
S AIN HANDLING UNIT(OVER IO.(I(%1 CFM) CONSTRUCTION TAX
/f
Sign ureo.ppll n ommcmr Ume P.XHAUST I BK)D OVIDUCT) HOUSING MITIGATION 113E
HA9.ARI>nUS MATF.RIAIS DISCLOSURE.
Willdre pliant or future building occupant store Or handle hmaNaus material I(EATING UNIT(TO U0.000 BTU)
;is dclined by the Cupertino leuniclpul Code,Chapter 9.12,and Ne Heahh sad Safety Ilin'TINC UNIT(OVER 100.000 BTI(]
Code,Section 255.32(a)?
O Ycs ONnVENTILATIONFAN(SINGLERESIDI PAID
Dor Receipt a
Will the applicant or future building occupant use equipment or devices which BAILER-COMP Ofilo OR 100.000BTU)
mit hvurdous air contaminants ax defined by the Bay Arca Air Quality Management T(IIAL:
qW L
BOILER-CQMP(OVI?R il%LBfI()BTU)
es ON.
AIR CONDITIONER ISSUANCE DATE
vu rwd the bamrduas nwterials ralnlranrnts under Chapter 6.Y5 nhM Cali
th&safety Code,Sections"No,25573 and 255)4.1 understand Wm it pre NI?W RESIDENTIAL ME:CH. SQ.PI'.ts norcurrently have a tenant,that It is my responsibility to nonny the excul atrements which must he net poor m issuance of a Certificate of Occupancy.mnorfred agent
Date
TOTAL ISSUIiD Ii Y:
OFFICE