S 2831 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RUILDING-ELECTRICAL PERMYT NO.
BUILDING DIVISION APPLICATIONA'ERMIT PLuhIRIIS MECHANICAL S 2831
II1111,DING 1'ROJI?Cf IDI:N'1'IFI(:AL'IUN
IIUILDING ADDRESS: SANITARY NO. APPLICATION SUBMI'1'I'AI.DAH!
99 � G/cb� cin F� o y-- 7—y9
OWNS 'S NA`. < ONE:: 1N'I JtxNAM11 ����� LIC NO.Al '
C. k A124 401 '//J/( Q' V Al
NEC CONTROL#
AI "fJCI/EN/OI�NHP 2i� C /yCICNOADDRESS: JJI�WS N' ` ❑
C NTA/CT::: 7/UYA` PHONE: BUILDING PCRMI'f INFO
of F To00 3 s-`�-94 Consultant Fees Paid by Applicant(initial) BLDG GLL�CI' r1.UMit ME❑CH
CI
III ICPSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE )LrnK/
I hereby affirm that I ant limireed under provisions(If Q
f chapter 9 mnmencing JOB DESCRIPTION
OMZ with Section 700(bol Davison oftim Business and Professions Gude Radio,llcensels RESIDENTIAL:
W O p FERMI'I'ISSUANCE
b-W.. .n full forcep and offer,. R 99'Z / OSFDWI. 0 KI'TCI IEN REMODEL
aUU Lactic A l'ic'# nl'I'LIANCIiS-RESIDLNTIAI. []ADDITION [I PLUMPING RF.-PIPE
NQa D.IIe. Cnalmchat
F.Drn RCHITECI"S DECLARATION PANELS OMUI.T1-UNIT [I SO RUCTURAL
zonz I understand my plans shell R poet as p.hire reopens MODIFICATION
OZ1=0 UP*10200 AMPS 0INTERIOR OCHIMNEY REPAIR
W Licensed Professional 201.1000Ab1ES IMPROVEMENT ]SWIMMING POOLS
Q
OWNER-❑UILDT:R DECLARATION OVER Hold AMPS ❑HATH REh10DF.URCPAIR 0 DEMOLITION
I hereby affirm that l am exempt from the Comraclar's Liefox Lim,for the
K3 a V following reason.(Section PU1.5,Rosiness and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHI.
W W W N which requires a permit to amaor a.aller,imp..se.demolish,or repair any omplam
0, pai I SPIiCIALCHOCUlT/MISC.
t�ps thw he is licensed Pmvoamm a ha provisions of the Couraror'a Llcensa Law fchapmr9
(wmntcncin h Seat 7001nof Dwkiol,3 al the Buoinvssnd Pnl'a,slpm Code)or COMMERCIAL:
g wi. 'I'RMI'.MII'TI?R OR POLE INS'I'.
dp.ey� Shatec io Ix exempt therefrom am the basis for the alleged exemption Any vipenalln of ❑NEW BLDG/ADDITION ❑DEMOLITION
XmW Senion"10115hY anY applicnm lirznpennil subjats the applicant neivll pemmy of POWER DEVICES
W^w of marc than five hundred dollars(551Mp. ❑IMPROVKANT ❑FOODSERVICE
FZY OTHER IMPROVEMENT
❑I,aaowner kf and the
or my employees wimwages male Spesole cital,bsiioq SWIM MING POOL ELECTRIC
F=-,O
will do tire work,and mcae Companms License fferad'won for o,aplyto ' Business [I OTHER
3 m end Professions ild,or'Me Com thermal.
License Law Jas not apply m an,caper of fIVRIi I'S-SWITCHF_S-FI%TURF'_S
hpropertyis own who huilds or improves therch i and who Jces such wvrk deed or or through
his own mwcm,a,provide)that such improvement arc urn intended or offered for NEW kESID1?NTIAI.ELECIR SQ FT.
sule.l[bowever,the Freidman,orpon,enum,is sold within one year of cpnmlctinn,the SQ.FT.FLOOR ARBA SISQ.Fn
pucoY sale.).
c.huilder will have the had,u of proving(bar hedid not laid or In.pnrve far pur-
I,as owner pf the properly,.an oxumslvely contracting with liencsed cournic am to 'I'0'IAL.
conga net the project(Sec.9114,Business and Profession+Come)The Cnmmemr'a Li-
cense Low does not apply u,;in owner of property who huilds or improves lhemor,and QTY. PLUMBING PERMIT FEE
who commmx for such projects with a cnnamctnr(x)licensed purouani m Ibe Conlmct.es
License Law. PERMIT ISSUANCE
0 1 am exempl under Sa. .B&1'C for this reason r
Owner DueAIA 11R-DRAIN&VENT-WATER(HA) VALUATION
Wander pi
COMPENSATION DECLA RAI ION RACK FLOW PROTECT.DEVICIi 7
I hereby affirm under lwnulry of perjury one of the following Aechtrnlinm: / d •0
] Ibuve tine will mainminuCcnlhcum nfCnnsenup vdl-insure li,r Workcr'x Campeo- DRAINS-FLOOR,ROOF.AREA,COND. ,TORIP.S 'I'YPECONSTRUCTION
wnima, Pmv,dhi for Seaton 310n of the Labor Cndc,for the rfurnwnec of the
ods bar which This pcmm 1'i"pons Z ILX'I'llllllS-PBR'I'RAP 2
] I have d will mnitvutn WnrkeGo Cmnpenmlinn Imumove,ns ma, red by Section
17 a,
oil
tire lbfnnnnnca"fnJePnlirckQflarwhicrh/�t�hi/qs pennil is issue/r. MS-IiA.SYS'f I?M-I INC.40U'1'LIi1:5 r —� APN�
CvrzieF! s ipgsp gm laflGiance catricrVolicY N' L� "( ����• GAS-IiA.5Y5TEM-OVERJ(fiAl V O3742
CERTIFICATE OIs EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE IINDUSTRL WASTE IMI'IRCHVI'OR
RUI )1 DIVISION PIKS
(This section nod not kcmupletW iftbe pentyl is forme hundred units.($101)) Ac1 � e
) GREASETRAP APR
or less.)
I canify that in the perfpnnanm oflhe work for which lhispeuniliduued,lshall SEWER-SANITARY-STORM HA.21N)FI'.
not antploy any person i nanyou cit sousm become subject In t he W..Aars'Compen. HNERGV PEE LJ
'rein..Lnwsof Calif penia.Uwe WA I FR I IIiNI 17R WIVEN'I'/F1.CC'I'It
A,Rfanmt GRADING FEF.
N NOfICE'fO APPLICANT:II',uficr making Ili.Cenillcalo pf Ilxamplion,you should WAFER SYSTEM/CREATING SOILS FEE
a ; become subject Io the Wake's Cnmpensatalt provisions of the Labor Com,,stip must
fntimilh comply with such provisions orrhis permit shall hadscmatirevoked WA1'I7R SERVICE
0
7z Cattle is.a ONmica.LENDING AGENCY NEW kESIDFNf1A1.PCMB. SQ.FT. PAID
V QIherchy affirm that is ucnnslruction lending agency fm the perfnrmence of U keceapdp
the work for which this permit is issued(Sec.3151,Civ,C.)
W E" Lender's Name DOTAL
G henJar's AJrress I'O'fA1O O
aI ready that have read Ihis application and stale fl al the above allainunon is 11UILD 0 ?I?
corrcn.l tierce t"comply wllh en oily and amnty onllnvnca+and smm lows nlwing m QTY. MECHANICAL PHRIOUT FEE
lomidingcnnstmction.and hereby awhoriverepremnmivesol Inki,irymcam.upon the SHISMIC TE
above-mentioned property li,r inspection purposes. PERMITISSUANCE
(We)agree to save,indemnify and keep harmless he City ol'Cuperpon,agalnn ELECT IC FEE
liabilities,judgments,costs and expenses which may in any way aceme against aid CitygUl'Iik OR ADD TO MECfi. r
in asequence of me groming of this pemtit. PLUMBI FEE Or
APPLICANT UNDER STANDS NDWILL COMPLY WITH ALL NON-POINT AER HANDLING UNIT(TO 10,01x)CFM)
SOURCERF ,UL ONS. CONSTNICTIONT
` AIR IIANDLING UNIT(OVER IB,INNI CPM) CONSTRUCTIONTAX
S,fig fApplicv mhae, Data I?XI IAUST HOOD(WMUCT) DOUSING MITIGATION FEET
HAZARDOUS MA'I'HIfIA1S DISCLOSURE?
Will the applicant or funm holding tecnpant won or handle nuardnns mncrial 1117AI'INC,[INET(110 1(It's),1,111D
as defined by the Caper inn Manic' al Code,Chapter 9.12,all the Imaddl and Safety
Cale.Section 25532(.)'! HHA'I'ING UNIT(OVER 10ando It'I Or
❑Yee No VENN I IATION FAN(SINGLE RFSID) PAID
Dae Receipt Or
Will the air contaminants
inants as
by the Pay A equipment Quality
of Mara which BOILER-COMP(3HPOR 100,000 FI TU)
emit lasmJous air conmminant as Jefincd by the Pay Area Air Quality Managemcm TOTAL:
Dram"? �
]Yes ❑No POIL1?N-COMP(OVER 100,IXI0 ItT1J)
AIR CON DI'1]ONE R
have rcwlmefansad ns m:neri.lsrcquircmemn under Chapmr h,95 of Cali- ISSUANCI3 DA
Contin Ifauhh ek Sofcty C Semipro 25505,25533 and 25534.1 u idae nn l thatIf the NEW RESIDIiN'UAL MSCIL SQ.17
huildingdwsa an • yhovcalem Inlay male ihibry u,nndfythmactmont 1
of the Ie lob mos ono issuance of.Cenill.eof Occurymey.
O me aumorimda Dam TOTAL: ISSUED BY: Q
OFFICE