S 4351 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL S 4351
BUILDING PRWl3CT IDEN'TIF'ICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
-7(a - - �-
OWN k'S NAME: I'H(ING: C 'rRACTOR:S NAME: LIC NO
E E� b S6 NIC CONTROLq
�ARCHITECf/13N EEA: LI'N )U !.S r, ❑
l!' L
CONTACT: PHONE: S'LO BUILDING PERMIT INTO
o
7.30f
30' ❑ Consultant Fces Paid By Applicant(Initial) BLDG 13LF.CI' PLUMB MECH
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT:71 FEE
I hereby affirm that 1 am licensed ander provision.of Chapter 9(commencing JOB DESCRIPTION
"Z with Section 700(dof Division 3elthe Businessund Prim,00n,Cide.and Iny license es RESIDENTIAL
won . PERMIT ISSUANCE. D
Fs,,= mfullfomeand ffeck ❑SFDWI. ❑KITCHEN REMODEL
aUU Liccn.c Class _�- Leap gpPL1ANCES-RESIUEN'I'IAL ❑ADOI'rION El PLUMBING RF:-PIPE
H G L Dare Cummaor
ARCIflrLCIS DI!CLARAION ❑MULThUNIT ❑bTRUCNRAL
F.7 m PANELS MODIFICATION
h Z I understand my plan.shall be used as Public cannot,
OZ�� UP TO 200AMPS ❑INTERIOR El CHIMNEY REPAIR
W licensed Professional 201-1000AMPS IMPROVEMENT OSWIMMING POOLS
El OWNER-BUILDER DECLARATION OVER IOMAMPS BATH REMODEUREPAIR [I DEMOLITION
x x C G I hereby affirm that I am exempt from the Condi mre Licomc Law for the
k d U following reason.(Section 7031.5,Business and Professions Code:Any city m cuunty SIGNS ELECTRICAL ❑OTHER
W 3 LL vFi which requires a permit to construct,alma.myrove.demolish,or repair any structure
F]�'Oat prior to its issuance,also requires the applicant for such Leari,to file a sighed statement SPECIAL CIRCUIT/MISC. 2
.E y-I Ihat hCu lice ed Pursuant to be pmvoionsof the Cummcmr',License Law(Chaml,9
0p (commencing with Section 9W0)at Division 3 ofthe Business and Pmlessions Code)or TFIARMISrHKORPOLEINST COMMERCIAL'
L L ethat he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITIONE Section 7031.5 by any applicant for a permit subject.the applicant m a civil penalty of POWER DEVICES El TENANT ❑FOOD S17RVICE
not mart than five hundred dollars(55001. IMPROVEMENT
01.anmwncrofthe pm,p,,ontyempmyee,with winos as thcirude coodnomn, SWIMMING POOL ELECI RIC
1.. will du the work,and the structu ,is not intended mongered for sale(SeeT(WLliusiness ❑OTHER
13 m and Pralrssinns Cuda The Cmranann Liveme Law does not apply or an nevner mf OUTLIifS-SWITCHES-FIXTURES
progeny who builds or improves Comfort,and who does.such work himself or through
his own employees,provided that.such improvements arc not intended or offered for NEW RESIDENTIAL ELEC 1Z SO FT.
sale.If.however,the building m improvement iasuld within one Ymmmf completion..he SO.FT FLOOR AREA $ISO.FT.
wnenbuilder will have the burden of proving that he did not build or improve for put.
'se o1 sale).
❑I,an owner of the property ma exclusively comment,with formed contm[mrs to i
AL:
mens, lot project(Sol.I Was Im,ine,s an I Profession,Codeq'me Cona—'s,Li.
sense Law does not apply to on owner of property who builds or improves thereon,and Q'T'Y. PLUMBING PERMIT FEE
who contracts for such projects with a commeno(s)licensed pursuant to the Cammemr's
License lave. PERMIT ISSUANCE /a
❑ l ant cxanpt under Sec. .B&P C for this rtamn
O.Ire, Date ALTER-DNAIN&VENWA iAl VALUATION 1 I
WORK17R'S COMPENSATION PECLARATION BACK FLOW PROTECT.DE IC: JUN 2 5 1999
I hemby affirm under pemlty of pepury one of the followmg dcelamtimvs
(have and will.nuinminuCenificam of Consent msclf-insure for Workers Compcm DRAINS-[LOOR.HOOF U. STORIES TYPE:BONS RUCTION
cation,as provided for by Section 37W of Ne IaMm Cale,for Ne performance of the
work Ibr which this permit is karat, FIXTURES-PER TRAP
1 have end will nininmin Workers Compensation Insurance,as required by Section
3700of the labor Cole,forthe Kirfumance of he work for which this Permit i,Iz..ed. GAS-EA.SYSTEM-I INC.6 OIITLEr. -,AA
My Worker's Comlenwtion Insurance sumer and Pot icy number arc:
Cartier: Policy No.: GAS-EA.SYSTEM-OVER 0(13A)
CHRI IIICAT1i OP EXEMPT ION FROM WORKERS' GREASI➢INUIJSTRI.WASTE IN'TEHCEI'TOR
COMPENSATION INSURANCE BUILDING DIVISION FEEL
(This,cetion need a...he[o.nplemd3(hepemthh froom hundred dollan(SIM) GREASE TRAP
m less.) PLANCHBCK FTE
I cenify that in the performance afthe work for which this permit is issueJ,lshall SEWF,R-SANITARY-STORM EA,2W FIF
not employ any pe in y man nm bens no
a sob,ca Workeri Cnmlen. ENERGY FEE- an
Z wtirn Lawn o .Dt, WATER HEATER WNENT/ELECFR I
z2 Applicant a a� rrte tGRADING FEE
ti NOTICE TO APPLICANT:IL for,dj o nmficate of bmealli n.you should WATER SYSTEFI/rREATIFG
becoe nrhj,c,mnnge
.he W..Ima's Cnwtion mokinm of the Lor abCode,you ma,t SOII S FEE
m
{tl forthwith emmply with such pmvismonsmlhis penmt scall M1e defined revoked. WATER SERVICE
Q
p" CUNSTRUCT'lON LENDING AGENCY NEW HI3SIDI3NTIAh PLMB. SOFT. PAID
V Q thereby affirm that there is a construction lending agency fnnhe performance of atc Rmeipte
W E-' me work for which this ptnnit is I,sucd(Sec.3097,Civ.C.)
Lender',Name 1(YI'Ah.
'
Lender's ALL., TOTAL:
0. 1 cenify that 1 have fad this application and pate that the above inf.statim is BUILDING FEF
F+ h carr....I agme m amply with all city and roomy ordinances and ,are Laws minting to QTY. MECHANICAL PERMIT FEE
C.) Z building conscondom.anal mrsbyamhoriamprtfnlativen of this city to emcr upon the SEISMIC FEE
abovemvminned property,for inspection purposes. PERMIT ISSUANCE �O
(We)agree.n,ave.indeoolfy and keep hamlets the Chy of Cupertino aga.n.t ELECTRIC FEE
Ii00
abilities,judgmart,copsand cxprow,which may in any wry accme against said City ALTER OR ADD TO MECH. PLUMBING FEE
in nssequem[e ol'the mart e,of this pc....a.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINTPRESIDEN1
NDLING UNIT LID 10,000 Cl.-M) M[CHANICAL I'EE
EOUI TIONS. is
NOLINGUNIT(OVERIBIM CPM) CONSTRUCTION TAX
Signature of APPlicaMContmctry Oaf S'1'1100D OVIDUCT) HOUSING MITIGATION TLE
HAyARDO d _ )ISCLOSURE
Will the applicant...future huilJingarupum.umre nr handle ht..N.....mm[ridG UNIT(TO IOgIgO BTU)
as dcrined by the Cupertino Municipal Calc.Chapter 9.11,and the Health and Safety
Cuda,Sianma 25532fa)1 G UNIT(OVER 10,M0 BTU)
Y" Nu
� � ATION PAN(SINGLE RESID) PAIL pate Receipt N
' �' Will the applicant or future building occupant use equipment or devices which
cult harardou,air conmmhmnts as definedh the Ba Arca Air Quality Management -COMP DHP OR]BOMB BTU)
Y Y Q Y� 8 TOTAL:
Diana? BOILER-COMPFOVFR q),IMX)BTU)
Oyes ON.
I have mad the hoeznlous materiak requifiners under Chapter 6.95 o1 the Can-
ft
ali- NUI'1'IONIiR ISSUANCE IJATP
fono..IIrshh&Safcty fide,Swom,255115.25533:cad 25534,I understand that if theESIDEN9l AL MHCH.
building does not coredly have a¢nnnl.that it is my mspinsibility to notify the reentrant �� e
man whicM1m st be mc.porno issu�nceufa
6 upanc.
Cmlficucnf Qc
0,amoliuthoircdagcn -
t " Dam TOTA ISSUED BY:
OFFICE