99100099 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY ��Iwoqq
CITY OF CUPERTINO RUu.DING-ELECTRICAL FERMI
BUILT NG DIVISION APPLICATION/PF,RM IT PLIIbIB1;VC.-MECHANICAL �000,
BUILDING I'R(IJ I:CT IUN:N'1'IF'ICATION
IiU1LDING ADDRESS: SANITARY NO. APPLICATION SIJ13MI'IT At,LAI
�" �C S� d -/ • 4
NAMH: PHONE: CONTR NAME?: LIC NO;
\ NIC CONTROLp
7CO�ACPZ LII I'IiCTIIiNGINEER: LIC NO ADDRESS ^ `s^I ^
PHONE: CHUILDING PGRMIT INFO
Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MIiCH
❑ 5 � ❑ ❑
LICI:NSIi1)CUNTRACI'uR'S DECLARATION QTY ELECTRIC PERMIT FEG1 henchy uRrm Ihnr 1am Iicioledunder provisions of Chapter 9(commencing JOB DESCRIPTION
h Si ]rXU)of Oivision3ol the Business and Rofessions Carr.madmylicensels RESIDENTIALPERMIT ISSUANCE?fullhncemnd eRcrC_ — � ❑SFDWL ❑KITCHEN REMODEL
cense.ClassLicAPPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RIIHIE
me Crnvucror
ARCIII'IIiCT'SDECLARATION ❑MUCI'I-UNIT ❑S'IRUCTUItAI.
~n Z I sanders and sur Pl....all he used as public ncmrds IS\N[I ti MODIFICATIONOZN� Oil DO 200 AMPS []INTERIOR ❑CHLMNEYREPAlk
1=4E-al Licensed professional 201-10DJAMPS IMPROVEMENT [-]SWIMMINGPOOIS
6C1'4 5_1 OWNER-BUILDER DECLARATION
y.Y OVER IINNI AM1I CS ❑HATH RT:MOOfiIIkEPA1R DEMOLITIONe' 6 M1creby off rte IM1m 1 nm exempt Irnm the Cnmr°clar'e License.Law fur the
4O y V following ot,on.(Scclioa]1131 5.Business im l Profcssin I,Code.Any city at county SIGNS 17LECE RICA], ❑OTHER
YI�+t y which requires.pennil to construct,alter,improve.demolish,(it repair any strunarc
�.Q.1 prior m its issuance.W.nexpireslhcapplicanl for such permit,,Ble.'ared shremeat SPECIAL CIRCUIT/MISC.
} the he is licensed armorial to the provisions of the Contractors License Law(Chapter 9
u� COMMERCIAL
Wa00 (commencing wit,,Section Division Joflhc Puniness and Professions Gxlc)nr 'I'IiMP.M6TER OR IK)LT:INST.
0.a m C tbar he is cxcmpl thereunto and the basis for Inc alleged exemplu—Any Omminn,,r ❑NEW BLDC/ADDITION ❑DEMOLITION
X Isco, Suwon 7I31.5 by any°pplicnnl rnr a pennil suhrei,the applicant Ina dvil pumahY or POWER DEVICES ❑l ENANT ❑pOOD SERVICIi
Y] notmare than live hundreddullars($5001 04PROVEMENir
SO ❑1,a%owner of the pmomy or my employees with wages as their sole compensation. SWIMMINGI'OOLIiLEC'I'RIC OOTHER
F will do the work.and thenmcmte isominrandedmofeed for stile(See IDli.Business / �I
6 3 m and Professions Core:The Commctor's License Law does not apply to an owner of OUTLETS-SWITCHES-FMURE.S ' !
property who builds or:mpnrves thereon,and who does such work himself ar through
his awn cn,pinycca,provided Ihm such inlpruvarears arc non initialled or offered tar NHW NESIDENTIAI.I!LECTR S FT _
talc ll;tuwever.tnc building orin)pmvemmn ix sold wilM1in one Yrandcmnalcrinsthe lI11SQ.PI'.il(()OR,ARI?A 6Q.pl'.
owncr.huilder will have the burden of proving Ina,he did no build or improve for par-
Five I sale.). L'r
0 L as owner of the pmpeny,am exclusively contracting with licenud contractors 1n T°TAL OCT 1 9 1999
construct the project(Sec-]044.Business and Professions C(vle:)Ihe Conam a I.,
,TT,cLioldoe,nor apply it)an owner of property who bulldxor Improves therein,and QTY. PLUMBING PERMIT FE PI
whoc°ntracwforsu°hprjcctswithaconlraclur(v)lic wdpursnanl lathe Commajan's
License law. 1117RMIT ISSUANCE
❑I tode
n exempt under Sec. .H&P C for this reason ^V
ACfER-DRAIN MVIiNT-WATTR(UA) '--.net [)are
Dale n
WORK 17R'S COMPENSATION DF.CLARA'I ION 1 P > 1? /
I hereby affirm under penalty of perjury an,of the following declarations: PRIES
v
0 I have and will maintain°Cerilicotc°I Cmncal m tall-insure for Worker'e ConTen- 1) F h I S'TORIE'S 'rYPH CONS'IRUC'ITO
sato.,as provided far by Seaton 3700of the Lher Cude,for rhe perfurmanm°f the
work for which This permit is issued. FIX'IT P
Fl I have and will maintain Worli Compensation Insurance,as required by Section
3700 ufthc Labor Code.for the pcfrormanw al'the work 6r which his pennil is issued. GA. YS : I OCC.GROUT'
My Wnker ' tdPnlymmthe
Comer: Policy No.: •7 GAS-]:A.,,,,
CERTILICA'Ii OFE) vM11 ION FROM WORKERS' A '1 E )R
COMPENSATION INSURANCE BUILDING DIVISION 1165
(pa,section need not be completed ifthe permit is future hundred blimx(51
in lass.)
oy
ilyfuOun ann:meeofthw
uarkfor whichthis per irlisuual,Lehu1l SI?WHR-$ANI'I'AItY I'LANCHECK ITE
nOR -fXl
' nal nalny any lcrsoanyman
n in any ner so as In b:�:�n� .uric L 'Wnrkcrs'Cnn:pcn- ❑NBkGV Plili
Z station lawn of California. Jn WATER ABATER W/lI NT/ELECI'R GRADING ITH!
Z O Applicant 1 Ji
NOTICE TO APPLICANT,If,ufc. m ring this Certificate of Exemption,you should WATER SYSTEMTREATING SOU-S FEE
F �) eae rotten m ton workers cm aa
xmminn nm.min.x of Labor code,you rotor
1'artbwallcoloplywiOnmdlpmvkiomor Ills P,on,shall nedcroudr°vokod WKIHR SERVICp
O Q
CONSTRUCTION LENDING AGENCY NEW BESIDES'1'IAL I'LMB. SQ.FI'. PAID Date Beretta p
V 0 thereby of en that here is.consltunion lending agenerformance of
cy for the p
the work for which this Permit is issued(Sec.3097.Civ.C.)
TOTAL
QI'-' Lcrdcr's Name TOTAL:
LU I<ndcrs Addr... BUILDING FEE
1'entry Ihis 1 haw rend Ibis appliaalim:n,d aline dwt nm an,,ve I.IOfIr)mi°n it
L.i V1 rotten,l ugrtem wmply with all city and rouayo connect and stare laws relating to QTY. MECHANICAL PERMIT FEE SEISMIC FEE
V Z building conntmclion.and hereby auNnnec mpmmnmrives of city to enter mann the
these-mentioned property fill inspection purposes. 11I7RMIT ISSUANCE ELECTRIC FEE
(We.)agree to save,indemnify and kccp harmless the City of Cupertino against
Ilabilines,judgments.coals anti expenses which may in any wayaceruc against said Ory N:ITR OR ADDIO MECH. PLUMBING FEE
in unning cl ills permit.
APP[]CAN UNDP STANDS AND WILL COMPLY WI'I'It AL1,NON-110IN'I' AIR HANDLING UNI'I'(TO 10Jm0 C11M) MECIIANICAI,FEE
SOURCE!R.!ULA NS
Signl ore nl Appllr INI %uAHo1oq Q
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
mm MDme EXHAUSTHOODOVIUUC) HOUSINGNIHIGNOO
NE1
DIr
Will the appildant or form building:a.upmt more orhandle hazardous nuncrial III7AIIN6UNIT('TOIIX).0k0B'1'U)
as defined by the C°penion Municipal Code Citapar 9.12,and the Health and Safety HEATING UNII(OVER 1 W.(M,0 B'1'UI
Core,Section 255321a):'
❑Yes ON. PAID
VENTILATION CAN(SINGLE R6SID) 1}te Rrr ' t
Will the applicant or linure building occupant ate equipnent nr devices which BUILBk-COMPUHPOR 1 MAX)B'I'U)
main hwnralnrx air cnmmuinunrs ata de0nnl by the Bay Arra Air Quality Mimagemenl
DistrictA! BOILER-COMP(OVER IWAX)
❑Yes Fl No
I have read rbc hvardous materials requhcmems under Chapter , of the Cali- AIR CONDITIONER ISSUANC17 DATE
h:mie llcahh k Safety O:xle,Sections 25505,25533 and 25534.1 undnannd That i1'the NEW BESIDE MECH. SQ.FI'. /D�/ r-
////11
building does nor eumady have u Tram.Ihm it is my resivol6biliny m notily tho,x<upam
ofnhe q'r ants cI)mud met Pi l"amorcol acerlllµu of Ossupacy.
Owner ora ions a at I V Umc TOTAL: ISSUED BY:
OFFICE