30998 APPLICANTTO FILL IN INFORMATION WITHIN'RED LINES-USE'SALL POINT PEN,ONLY ` -'
CITY OF CUPERTINO 11 1 1 1 BUILDING-ELECTRICAI, n0^PERMIT NO. "
BUILDING DIVISION APPLICATION/PERMIT 'PLUMBING.MECHANICAL 3 y
98
BUILDING PROJECT IDENTD'ICATIDN
UILDING ADDRESS: '- ' . 'SANITARY NO. APPLICATION SUBMITTAL DATE
/a ai
JAVNEIVS NAME: Z PHONE: '. C ACTOR' NAME: LIC NO:
CONTROL#;
AW ARCHITECUlsNUNEER LIC NO ADDRESS' L Q'ri
CONTACT: PHONEY BUILDING PJATOIT INFO
Consultant Fees Paid by Applicant(Initial)' " _ - BLDG .- ELe pLU ME
LICENSED CONTRACTORS DECLARATION s
.1 hereby dfirm that I am licensed nde mv'" f Charter 9 i QTY ELECTRIC PERMIT PEE
r p P < memm�g OBDESCRIPT[ON
'000 Ih04 Z Sae(on9IXA1)of DMilan 3 of the Buunessand Profess ons Coicandmyiaereots
F O intfull forcas act. PERMII'1SSUANCE E
,�U rbj License Class Lic# '❑SF L El KITCHEN REMODEL
4F/IQS Dale Coinmemr - APPLIANCES-RESIDENTIAL 'IT
❑PLUMBING REPIPE
F.Dm>
ARCHITECT.9 DECLARATION �pp����� pANELS' MULTI-UNIT ❑STRUCTURAL
ZO G I understand my plans shall be used as puhlic records I- "' / MODIFICATION'
vv'� UP TO 100 AMPS
02:4❑ ' - r'- AIJ / [I INTERIOR , " ❑CHIMNEY REPAIR'
� 1"' Licensed Professional 201-1000AMPS ' ' IMPROVEMENT _
J OWNER-BUILDER DECLARATION OVER IOOOAMPS ElBATH REMODW
EREPAIR EIDEMOLITION:'
1 hereby affirm that I no,exam,,from the Contractor's Liceuse Law fnr the _
ap5�O d U fallowing reason.(Section 9031.5,Busineus find Professions Cade:Any city or rally ❑'SIGNS ELECTRICAL
OTHER
W 3 LL F' which requires a permit to construct,:titer,improve,diameter,or repair any sknomme _ .,
prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
C� that he is licensed prrsuaul to the provisions of the Contractors License Law(Chapter 9
_QO (commencing wild Section 9000)of Division 3 oflhe Business and Professions Code)or TEMR METER OR POLE COMMERCIAL:
4 4 o n Ila,he is exempt therefrom.and the basis for the alleged exemptiwlAny d oluders of (]NEW BLDG/ADDITION ❑DEMOLITION
mi tL Section 0031.5 by any applicant fnr a permit subjects the applicant m a civil penally of„ POWER DEVICES
t more than five hundred dollars($500), ❑ ❑
TENANT FOODSERVICE
_C O ❑ I.as owner of,he Beverly,or my employees with wages as their sole compensation, 'SWIMMING POB
IVC IMPROVEMENT
C2L' will ado Na work and the swewre is not intended orofi«od for sale(See.'lM4,Business 0OTHER
Sm and Professions Code:The Contractor's License Law dues not apply to an owner of OUTLETS- WS-FI RES
l property who builds or improves thereon,and who does such work himself or through - 1 -
his own employees,provided that such Improvements are not intended or offered for NEW!EAfWLELF6R- SQ FT.
sale If,however,the building or improvement is sold within one year of completion,the SQ.FP.FLOOR AREA $ISQ,FT.
owner-milder will have the burden of proving that he did not build or improve far pur-. i11 q I'��
posem,od'.). - - ,
❑I,as owner of the properly,am exclusively contracting with licensed contactors to TOTAL:,
construct the project(S 7044 Beimoss'and Professions Coda:)The Courtrooms Li � ..
tens L does n tapplyt a fproperty h buildsonmprovesthereon and UMBINGPERMIT FEE RECD
who tracts for suchprojects with a canlmesads)licensed pursuant to the Contractors b
License Law - ERSSUANCF. (rel! Ur -
❑ Irnexempt under Sec. ',n&PC forthisre M
.. LUI'EH'I` .
A '
rl
Owner k-DRAIN&VENT-WATER di - VALUATION
Dale '
WORKER'S COMPENSATION DECLARATION C
I h by ffinn de penalty of pe j ry f the following dial at - 1
❑Ih and will mains Cnficate ofC a elf-insure for We s en- DRAINS-FLOOR,ROOEAREA,COND.
small,a provided for by Section 3900 of Ih Lab Cade,for Ne`pe c, of the STORMS TYPE CONSTRUCTION
work forwhichthis Permit -ed SprmrR pan check completion
- '
I have and will maintain Worker§Compensation Insurance as a e Sectio �[��.,� '
•.( 3900 of the Labor Code,for the performance of the work for which thisdis fest Elan .00FO Ier ac a t completeOCC GROUP g APN
MWork F s s
y p anio l umncecurtier and Polic nnbera:-
Cions,espos Or4correctin dd,
I XE ONI NFRO PRO ORKER ' ,fin FM�we�err�mn
4{/ ATION INSURANCE �afl�r wr'NI'OIYp{nl k 3 = A BUILDINODIVISIONFEBS;
(T�/� fie no,be complelW'fth Pe is[o2 h d dl '($I W) -
firle' ) �TE2 ,u o lased Blue Prints, PLANCHECK FEE
1 uhfy lh in the pert rtnance of lh Af h pe tl ts, a Is p�1�r♦♦ '
not employ my
person y o as 1 become subject t the ,kers Compen- CSP
thft ENERGY FEE
O ,Z cation"issof California Date e WATEk HGATER WNF,NT/ELE11
CTft
O Applicant - GRADING FEE
Tai Vi NOTICE TO APPLICANT.If,after making this Certificate a'
a.'frm,you should
a �^, become subject ld Ne Worker's Compensation provisions of ll abet Code,you must SOUSFHE'
W G fnnhwith comply with such provisionsmthis permit shnllb led rcvaked, WgTF.k SERVICE
a
U z: CONSTRUCTION LENDING AC CY ,
PAID
U O -• thereby affirm that there isvconstnction lend_i agenty for the performance of Dine Receipt#
-� the work for which this Permit is issued(Sec,3099, .C) a _
O U Lender's Name TOTAL:
L7) Lenders Addreex ' eAF '
f can fy that I have mad this application d state Thal the ahwe mfotmmtrn is BUILDING FEE
F !q
correct.1 agree to comply with all city and wt y ordinances and state laws telling to QTy MECFIANICAL PERMIT FEE
U build gcn.truction,adhereby authorize sentafves of this city to enter upon the SEISMIC FEE'
above-mainioned rim
property for p n its -
We)a e m save.Indemnif PERMIT ISSUANCE
( gra yen ;cep harmless the City,afm agaid void City ELECTRIC FEE '
liabilax,juive ofte granting expense high inayinany wny uccme againa saidCity ALTER ORADDTOMECH.
in camequcnce of the graining of this ,min. PLUMBING FEE '
APPLICANT.UNDERSTANDS A WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURC REGU ATIONS. - 'MECHANICALFEE -
� AIR HANDLING UNIT IB,000CPM)
i(j ' �2 CONSTRUCTION TAX -
Si re ofA ¢anVContra r - D e EXHAUST HOOD(W/DUCT) HOUSING MITIGATION TEF..
° U
HAZA1{ OUS MATERIALS DISCLOSURP. _
Will the applicanno/taro building occupant sloreorhandla hazallous material HEATING UNIT 90 100,000 BTU) p
as defined by�lda Coprrtl I Municipal Coda,Chapter 9.12,and the Health and Safety
' Cade,Section 25532(x)' HEATING UNIT(OVER IOO,OINI BTUj
❑Yes'' FIN. ,.
' VENTILATION FAN(SINGLE RESID) PAID '
Dale Receipt#
W'111h ep wt fire building occupant rte equipment or devices which BOILER-IX)MP(3HP OR IOO,OIXI BTU)
L7
le Id ratite ants as defined by the Bay Area Air Quality Mmwgemem
Olsm t - BOILER-COMP(OVER 100,000 BTU)- TOTAL'.
_ ❑Yes ❑No - -
I have read the hazardous materials m4meemems under Chapter 6.95 of the Cali- AIR CONDITIONER
' folia Health&Safety Code,Sections 25505,25533 and 25534,1 understood that If the - - ' ISSUANCE DATE
bu din doe at tl haveamnanl,that it is NEW RESIDENTIAL MECH. - SQ.ET.
`^ 6 n y y rcspanslbilty to notify the occupant f, -
Ih ����rel be net pro,I ce of a CerEfte-m of Orcnpaney,
` Ownerorauthorizedageat •.33'' Dale A TOTAL:
ez �`' 'ISSUED BY: '
OFFICE