99090095 (2)APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING. ELECTRICAL
PERMIT NO,
QQ
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
p
F/QTL�%
s
.:'ItUl1.DINGI'ROJFCI'IDENIrIFICATION,,{",, ,�
RUILDINGADDRPS'S:
SANITARY NO.
APPLICATION SUBMI PEAL DATE
. la .3 & Ile, Y0 Pr
q_ T
OW 'IfSNAME', ) // PHONE:
COONNTRApJTOR'S NAMES IAC NO:
N/C
CONROL#
ElOff:/
ARCHI .CT/ENGINEER: LIC NO.
$q,Y
ADDRESS: �C✓LiLF
��
Ivo r� i1
.
CONTACT: PHONE:
Fr'_BIILDING PERMIT INFO,'''
'
❑ Consultant Ftss Paid by Applicant (Initial)
BLDG ELECTPLUMB MECH
1:1Em,❑ ❑
LICENSED CONTRACTOR S DECLARATION
OTY ELECfRIE PERMIT, ,TELE
]OB DESCRIPTION
"Z
1 Hereby an r , tht 1 1 e.aed m d p m of chapter 9 ¢an ne ng
with Seclan]00(RofDivision 3 Ithe Busife. nl Pro@ sslonn Gbe.mmmyl ce t
" _ _-• -. r - - .(
PERMIT ISSUANCE
FF �'n
=U I'-'
full tore and el7ecl
to 16 tll?"? 2
RESIDENTIAL:
❑SFDWL ❑KITCHEN REMODEL
APPLIANCES - RESIDENTIAL
F�w
License Class Lica
Data Canaanor ✓ M o y W sr
❑ADDITION ❑PLUMBING RE -PIPE
❑MULTI -UNIT C1 STRUCTURAL
on 4iARCHI'I
F D m
ECT DECLARATION
PANELS
zc.z
lundcomnednrypl... hall betriadas public records
I
MODIFICATION
pZ 4O
UPT0200AMPS
❑INTE•RIOR - ❑CHIMNEY REPAIR
IMPROVEMENT [I SWIMMING POOLS
W
Q J
Licensed Professional
t 201-1000AMPS
fr
Oat
OVER III) AMPS
El BATH REMODEIAREPAIR 0 DEMOLITION
m the ommelo
I hereby vlElan that I um axempt from the Cmnaactnrk License Law for the
I a. amm,pt
3 c.U
following reams IScctian 1011.5, Business and Professions Cole: Any oily or county
SIGNS ELECTRICAL
❑ OTHER
y
which requires a Permit to construct, alter improve, demolish, or repair any xwaure
��'�I
o!,
pzionoits issuance, vlsn requiresthe applicum for such permino fleasigned aaemeor
SPECIALCIRCUIT/MISC.
�g
that he is licensed pursuant to the provisions of the Contractor's license Luw lChapmr 9
_
�C)
(wmntaneing with Scetimn?0)lol""Division 3ofdm B.,i.esa and Professianx Cnla)mr-
a lL c e
that he is exempt Inerefrom and the basis for Ibe alleged exemption. Any violation of
EW BLDG/ADDITION El DEMOLITION
11111111110y
1,1�� 4•
1+1�m
Section l031.5 byanyapplicanl forupermilsubjcl, theapplicummacivil pcnalry of
S U
TENANT n FOOD SERVICE
FZqnot
more than five hundred dollar ($500).
IMPROVEMENT
01 as owner of the properly, or my employees with wages as their sole compensation,
SWING O
W
will do the work, and the sublime is not intended or offered for aIle (Sec. )044. Btainess
❑ OTHER
' w
and Professions Cole: The Contractors License Law does not apply to an owner of
OUJI- 1 Di5_IlS
55
properly who builds or improves thereon, and who does such work himself nr through
his own employees, provided that such improvcmcnts are not intended or offered for
NEN' RESIDENTIAL ELECIR SQ BE
sale, If. however the building or improvement is sold within one year ofrmalletion,the
SQ. FT. FLOOR AREA $/SQ. FT
Her -builder will have the burden of proving that he did nm build nr improve for Pur-
OsinSsalcnerofthe property, am exclusively contracting with l' d tet to
L:-
constructth p )cl(S 7004 Business'dPr fes' ns Cody)The Can ..... Lo
II I - ll
ceps does nuchplyt rte or property h builds d
QTY ', PLUMBING PERMIT
nt is
who contracts forsuehl jedxwlhownuammHs)Imensed pursuant to lheC mm t n
eC Contractors
Elense ImctmmptundaSec ,Il&PCfmlhi,rurmm
I
PERMII'ISSUANCF. it SEP 1 5 1999 �u
ALTER-DRAIN&VE ( VALUATION✓
BACK PLOW PROf[;C' >B C;
Owner Unto
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of be following - - - -ions:
❑ I havennd will maintain n Cenifeaeof(smoemtoself-insure for Winker.Compcn-
DRAINS -FLOOR. ROUEARLA,
as
cation, provided for by Section 3]) of the Labor Code, for the performance of the
STORIES TYPE CONSTRUCTION
r '
k Por which this permit is issued.
FIXTURES - PER TRAP
have and will niummin Workers Compensation Insurance, as required by Section
JJ91N)nf the Labor Axle, for the perronnance of the work for which thispemtit is issued.
GAS-EA.SYSTEM-I INC.4fsacin F1 OCC.GROUP
CryQnyti_ BlNxn yt nynthsry�0,
'
�.7_�tr
Cam r:rkeY''s PolicyNo.: C
GAS- EA. SYSTEM OVER 4 (EA) 3-
32-4
CERTIFICATE OF'EXEMPTION 17ROM/WORKERS'
`'4
COMPENSATION INSURANCE
OREASUINDUSTRL WASTE INTERCEPTOR I- BUILDING DIVISION FEES
(This section need not m completed ifthe permit is for one hundred dollars (SI))
or Icvs.)
GREASE? TRAP
YLANCHECK FEE
1 certify that in the performance of the work for which this permit is issued. shall
SEWER - SANITARY - STORM BA.2)FT.
nu Compen-
p y any in tory mlmner sn vstobecamesuhject to Workers'
Hattmn
ENERGY PEE
sail Laws of Calilinniu. Data
,2 a
WATER HEATER W/VIiNT/ELECTR
zO APPlicem
GRADING FEE
y NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
WATER SYSTEMGREA'1'LNO
a; become subject to the Worker's Compensation provisions of the Labor Cole, you must
SOILS FEE
Lti forthwith comply with such provisions orthis Nonoil shall be decreed revoked
Q
WATER SEkVICP.
5z CONSTRUCTION LENDING AGENCY
NEW RESIDENTIAL PLMB SQ.Er PAID
rncenf
V 0 l herebyafirm that there iso conntmction lending agency far lheperfarw
Rec eiplM
U. P be work for which this permit is issued (Sec. 3097, Civ. C.)
Lemlcr's Name
0
'TOTAL:
U Lender's Address
TOTAL:
It.. I certify that I have read this application and state that the abase informer, on is
BUILDING FE
fA toren. l agree to comply with all city and county ordinances and state lawsrcluting to
QTY. MECHANICAL PERMIT FEE
U,z building construction, and hereby authorize representatives orthis city to enter upon the
SEISMIC Fit
.-I above aero ned property far inspection purpuras.
PERMIT ISSUANCI?
(We).,me to rove, indemnify and keep hamflessthe Cityaf Cupertino .bbst
ELECTRIC PE
Irmildics,jud,uncri e'srsan expenseswnichmayinanyw ue aguinsisaid City
ALTER OR ADD TO MECH.
in consequence of the gal' of thi-permit
PLUMBING FEE
APPLICANT ER ND. WI Ckm ALL NON -POINT
AIR HANDLING UNIT (TO 10,000 CFM)
SOURCE GO f T S.
MECHANICALFEE
/ �b
AIR HANDLING UNIT 10,000 CFM)
T
CONSTRUCTION TAX
EXHAUST MOOD(W/DUCT)
Sigim ApPlic ors I or Use
MATERIALS DISCLOSURE
HORSING MITIGATION FEE
W111 the apithram or future hod ing mvocTumsmrc mr handle haeantasmatenal
HEATING UNIT (TO 1(10,000 BTB)
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Coils. Sermon 25532(.)?
HEATING UNIT (OVER 100,000 BTU)
El Yes F1 No
VENTILATION FA N IS INGLE RES ID) PAID
Will the app building occupant useequipmentAirQunrdeviceswhich
rnts
Date Receipt If
u
emitict? Bair mmuminants us defnad by the Bay Arca Air Quality Management
contaminants
BOILER- COMP GIIPOR 100,11011 BTU)_
rr
District?
TOTAL:
C] Yes ❑Na
BOILER - COMP (OVER 100,000 B'GD
zmdous nnneriuls reyuire ne undn'Chapterfi95 of the Cali-
AIR CONDITIONER ISSUANCE DATE
forma lWe, r 25$(F.2 1 and 255]4. 1 understand that if be
buildinly I ant than 1
40t
NEW RESIDENTIAL MECH. SQ. FT. �� / �„_, (7
yrexponaibilitymnmifyth
et prior da Ceni
7ofthert
TOTAL: ISSUED BY:
_r authorizedv mDae
OFFICE