S 3977 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. P17RMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL S 3977
BUILDING PROJECT WENT'IFICATION'
BUILDING ADIRtES$' r SANITARY NO. APPLICATION SUHMI"ITAf.DAD
WNEI SSrN & �klf N}rJ //J CON `A TOR:ti AM' ter— - LIC O
( IP/ tM 5—/l4JC /G K/FG/J(" NIC CONI'ROLp
AItCHI FECI'IENGINEER, LIC NO: ADDRESS: ❑
CONTACT. THOSE: Iy^` BUILDING PERMIT INFO
T�I J X333 ❑ Consultant Pecs Paid by Applicant(Initial) BLDG ELECT' PLUMB MECH
❑ C� ❑ ❑
.ICENSED CONTRACTORS DECLARAI'ION QTY ELECTRIC PERMIT FEE
I hereby affirm that I am fcenacJ ander provisions of chapter 9(conmtenang JOB DESCRIPTION
OaCZ with Sen inn 9(NXpoflnvision 3ofmc fd,inass and Profexsione Calc,and my liecoae is �0 RESIDENTIAL_
FOO in full force and cB'W rf/ t� 1.. I'ERMII'ISSUANCIi
,)CWF m ��._ O L✓ ❑SPDWL ❑KI'ICHIiN REMODEL
QUU License Class Lica APPLIANCES—RISIDEN'I'IAL ❑ADDI'TION O PLUMBING RE-PIPH
NQ6 Dale ConlRtlnr ��
Oh ARCHITECT'S DECf, PANELS ❑MULTI-UNIT ❑STRUCNRAL
Z O y Z 1 undccannd my pl:ms shall be used asp tic record. MODIFICATION
OZ-0 UP'f O 2q1 AMPS 1_1 INTERIOR ❑CHIMNEY REPAIR
1=L�F'W LiccmcJ Profcssianal 201.1000AMPS IMPROVEMENT (3SWIMMING PODS
OWNER BUILDER DECLARATION OVER 1000 AMPS 0 BATH RHMODEL/REPAIR 0 DEMOLITION
1 Nachy affront In.,1 On.eennpt from the Comraclor's Licence[.aw fn IM1e
EX:Otr:U "/^� ❑OTHIiR
W 3 a following mason,(Section]on 5,Bualwos and sae,de iat li Code:Any airy or county SIGNS ELECTRICAL Z —
la: C)� which.as omopentyln con.wel.,hersimprove,Inpcmnikoor repair any structure F�'O� that be slicenedpursuant to the lhovisiosofthe suchlbetar s averfiks,Lawinod(Chapter
SPECIAL CIRCUIT/MISC.
Syy that menden witpursuanuomep D,,i,isofine Conlracmr'x license Law(Chapmr9
W�00 (commencing with Scnlon TNXO nl Uivi,ian3ofthe Bu.cincss and Professions CnJc)or TEMP METER OR POLE(NST. COMMERCIAL:
C,qx e c that he is exempt therefrom and the basis for the alleged exemption.Any p91J,O�, ❑NIiW BLDG/ADDITION 0 Up ORATION
W�H
Section 7031.5 by any applicant for a permit subjaa the applicant to a civ Fmltyahl POWER DEVICES DTENANT 0FOOD SERVICE,
F.ZYno,more than five hundred dollar,($500) IMPROVEMENT
< ❑Lux owner of the pmpcnY,or mY emPlnyces wilM1 wages as lhcirsolec �matiion, 1 $WlMpvf - 00 LF:CI'RIC
Sy+=O will do the work,and the structure is not intended of offemd for sale(See] mss [1 OTHER
{a13m and Professions Cale:The Conuacloex Licence Low does not apply 1 n owner of }Y; OU'I CE'r5—SWI HF E.
pnmperty why huilds or..prove,thereon,and who docs such work min f or through ---
hi.s own employees,provided that such improvements are not intende furl i 1 N��''RPSIDIN'IAL ECTR jf
SQ
sale.It.however.the building or impruvemcnt is sold within ons)-art of comp My FT.FLOOR AREA $ISQ.Fr.
erbuilder will have the burden of proving that he did not[wild or improve for par-
❑h as owner of me prnperY,nm exclusively contracting with licensed nmlmamhra m SO
(�
c instruct the project(Sec.]UW.Business and Professions Code:)The Contractor's Li- D D
carve law does not apply to an owner of propmly who huild,a improves thereon and QTY, PLUMBING PF,RMI FEE
what contracts for such projects with a conlmcams)licensed puteuanuo the Contractor's JUN 17 1999
License Law. PERMIT'ISSIIAN
0 I am exempt under Sec. ,B&P C for oris rtazon
Dale ACI IiR—DR IN —WATER(EAJ ; VALl1AT10N
her WORKER'S COMPENSATION DECLARATION BACKFLOW t 'F.OF
I be,,by alliin under penalty of perjury one of IM1e fmarxing&clamtionr,
I haveond will maintain aCenifcatc ofConunuo solf-insure fo,Wmkcr'a Compete DRAINS—FIA PA. S'1'QRIIiS TYPE CONSTRUCTION
.anion,as provWed I'or by Section 3700 of the labor Caddo,Wrthc pcdbnnancc of the
wink for which Ihf.v permit is i.ouui. FIKTURP_S—PER TRAP
0 1 have and will maintain worker'%Compensation hnumne'e,as required by Section
3]Wofine Lubar Coode,Gmhu perfnnnunct,W he work for whichtbispenni,,c issued. GAS—EA.SYSTEM.I INC.J L' OCC.GROUP APN
My Worke{s Cgmpe sanio rns�uru�nce carver and Policy a yiyg'- 9h GAS—EA.SYSTEM OVER 4 EO
Cericc ^M'{_,t�c ,an,,d Nn.: ( R E
CER IPI AIM Ob EKEMPTIINN FROM WORKERS' GREASEfINDUSTRL WASTE INTERCEPTOR
CUMPIiNSA'1'ION INSURANCEBUILUING DIVISION FEES
('Ihisscedon need nal Mcompleted iflhepenbi,is forma,hundred dollars($100) GREASE TRAP
or IcssJ PLANCHECK FEE
Iccnify mat nthepcAnninonofine wink for whwhthispermit is issued,[,hall SEWER—SANITARY—STORM EA.2W FT.
not employ any person in any manner so as u)become subject to the WorkersCamper- ENERGY FF:E
O Z .tylion laws of Cold(,roia.Dale WAT12R HEA'PER WNENTMLECIR GRADING FEE
z 0 Applicant
NO['ICE'PO APPLICAN'1:H..afmr making hEi.Cenlficam of Exemption,you should WATER SYSrEMO R17ATING Tr
Ft become subject to the Worker's Cuohpens anion provisions of the Labor Cafe.you must SOILS PEE ' $F
fonhwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
a �
7Z CONSTRUCTION LENDING AGf:NCY NEW RESIDENI'IALPLMB. SQ PP. PAID Date enipta
U 0 1 hereby alliin that there Lencnnxwetionlendingagencyfiamelerformanecnf
44 P" Ihcwork for which this permit is issued(See 3W].Civ.C.) TUTAL
U Len&r's Name
�.
Lcndcr's Address TIYTAi,.W� BUILDING IEE
1 ttnily that have read This application and state that the aMwc information's
F' fn correct.]agree to comply with all city and county ordinances and state laws rdming to QTY. MECHANICAL PERMIT FEE
U building construction.and hemby authorne representatives ofthi.aciny menleruPon the SEISMIC FEE
aMwe-ntentioned properly lar inspection purposes. PERMIT ISSUANCEELECTRIC FEE
O
(We)agree to save,indemnify and keep taintless the City of Cupertino against
Iiabilui s.j.dgments.ensu and expenses bi,hon y in any way u,com against said City ALI17R OR A DO TO MECH.
PLUMBING FEI It
nuquence of the granting of this permit.
APPLICANT UNDERS/IANDS AND WILL COMPLY WITH ALL NON-POINT AIR IIANULING UNIT(1010.000 CFM) MECHANICAL PE
SOURCIiR U�I TI NS / 'T a
�`' " V 6 121 AIR HANDLING UNIT(OVER 101100()CPM) CONSI'RUCI'ION TA
Swt c of Applicant/Contruanr Da¢ EKIIAUST HOOD(W)DUCT) HOUSING MITIGATION FEE
HAZARDOUS MAI ERIAIS DISCLOSURE
Willthnvppllcamnrl'umn,building occu Pant,mrc atr handle hmrdou,nothnal HEATING UNIT(TO I01W)B'M)
as defncd by the Cupertino Municipal Code,Chapter 9.12,wad the Health and Safer
Cuda.Section 25532(:,)'! HEATING UNIT(OVER 100.00D BTU)
0 Yes ❑No PAID
VENTILATION FAN(SINGLE RF.SID) Dmc Receipta
Will the applicant nr future huilJing occupant use equipment or devices which yO1LER—COMP(3NP OR IW,OW BTU)
emit harmdous air conlamimnts as ddined by the[toy Area Air Quality Munugemmat T
Uictria 7 EOI1.F,R—COMP(OVER 100,0(0)BTU)
❑Ycz ❑No
I have mad me tacticians materials requirements under Chapter 6.95 of me Calc AIR CONDITIONER ISSUANCE DATE
lihmia ileal.&galuty Code.Sections 25505,2.5533 and 2553J,1 undtaomJ mm if the NEW RESIDENTIAL.MECH. SQ.FI'.
Is rd*ng rotes ria vmrtnlI haves tewnt,that it is my tespon4bility no notify the oeennion
of the rtquirt Ns w me ,)nor to i„uunm of a Cenifcmcr-(kcupan v
Ow r rived oganlDec. '1(YTAI„I I ISSUED BY,
OFFICE
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