99090155 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF C,DIVISION BUILDING-ELECTRICAL PERMITI'ERMITN�
BUII,UING DIVISION APPLICATION/PERMIT PING BING PROJECT IDENTICAL
FICATION BUILDING PROJECT IURN'1'IFICATION '
BUII.DINGADD�ESS SANITARY NO. APPLICATION SUBMITTAL DATE.
4 8 C6r b re_ 1k.
V ;S NAME: 1'1{ONE: C RACTOR'S NAME: I,IC No
S C ^ _ lav / U N/C CON'IROLO
C 11"FEC/ENGINFER: PLIC NO: ;DDRB S:f ala Li 15 �Jl f
Q I / ❑
[
CONTACT: PHONE: _ BUILDING PERMIT INFO
��—�' ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ E3 ❑
LICENSED CONTRACTOR'S DECLARATION QTY. (ELECTRIC PERMIT FEE
hereby Avon than I not licensed ander provisions of Chapter 9 monmtenaios JOB DESCRIPTION
O3Z with Section 7000)of Division 3 of the Business and Proresiom Code,and my lieerove ns
O O PERMIT ISSUANCE RESIDENTIAL:
5 u:F- in full force and effect. ❑Sll]N'L [I KITCHEN REMODEL
aUU Date—
Class CoLicntractor
APPLIANC12S-RESIDENTIA1, El ADDITION E4614MYING RFiPIPE
y<� Dmc G-SDECr
F,7m As shall Ea use DECLARATION 1'ANF,L.g ❑MUI:TI-UNIT �MOSTRUCTURAL
O
Z O H K 1 understand Any plana shell be used as public records MODIFICATION
OZ_, UP TO 200 AMPS F)INTERIOR OCHIMNEY REPAIR
QEF; Licmt¢J professional101-1O10AMPS EMPROVEMENT E)SWIMMING POOLS
C < M1meby ullirm OWNER-BUILDER
u I R-BUIILDEGom c C DECLARATION
License I,uw far the OVER IBB AMPS ❑BATA REMODEI/ItEPA1R 0 DEMOLITION
X01 O following reason.(Section 70315,Ruumss ad 11..sons Code:Amy city or county SIGNS ELECTRICAL ❑OTHER
3
c which colones a Permit to mareno et,alter.improve,demepair a
demolish,or rny Rmamu
f-'4Q prion,is,issuaince..Loo requite,the applicant for such Peron,w Bk au'rted monnom SPECIAL CIRCUIT/MISC.
fly— that he is licensed pursuant to the provisions a fine Comranm's License Law(Chaum!)
W 00 (commmncingwmh Section700O),c Division 3nfthe Busimesand Professions Galc)Or TEMP.METER OR POLE INST COMMERCIAL,
a a o m that he in exempt therefrom and the basis for the alleged exemption.Any violation of Ll NEW BLDG/ADDITION El DE OLITION
Mw PeD
Xu- Section by any applicant far a permit subjects the applicant u civil Penalty of POWER EVICES ❑
u:—tom TENANT ❑IOOD SERVICE
not mart than five hundred ty.or y cripl
F Z Y IMPROVEMENT
Q 0 1,as nwnaaf m]I atipeny.m is employees with wages astheir Nce7lompemvtion. SWIMMING IYNJL EhF.CFRI
0 willAu the wnrk.nndlMnlmcwrcin nm intcnJd nrnRrnl far nvlclSro.]IH4,I{usiness El OTHER
W�'m and Professions Code. The Contractors License haw does not apply alt an owner of OUTI,EL;S-$WITCHIiS-FI%TU Ov
!�- _
propcny who builds or improses thermal,and who elms such work himself m through (n / \ ^ '
his awn employees,provided that such impmvcms caart not intended or offered for NEN'RI_SIDIiNT1AL ELECTR SQ
sale.IL however.the building or improvement is sold within one year of completion,'he SQ.FTI BOOR AREAL, Lis/SQ.I{la
owner-btu Wer will hnsc l u,bmdmt of oa, ,that ha did not build or improve lor,um- I Ul U
pace m a
E] 1.as owner
ted: SEP 2 7 1999
wner of propcny,am uduaivdy contruning with licensed contractors m
aaTOTAL:
construct the project(Sm.7044.Business and Professions Code.)The Contrasmrs Li-
anselaw does not apply toanowner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who conmmks for such projectswith it unt..w osa)licemed,moua n m the Commcmr..
License Law. PERMIT ISSUANCE ?y
L am caempl unser Sac ,B&PC for(his.,on L-
�wncrIymc ALTER-DRAIN&VENT-WATER BEA) VALUATION
WORKER'S COMPENSA'I PIN I 11iCLARNION BACK FLOW PROTIECI DEVICE
I hereby vllirm under penalty of perjury one at the fallowing dedumtion%
C] I have and will maintain a Ceni{icmc of Consem to self-insure,for Worker's Comport- DRAINS-FLOOR,ROOF,AREA,COND. STORKS TYPE CONS"IPUCION
station.us Provided far by Section 37A of the Lather Code,for the perfom
rance of the
work for which this permit is:sawed. FIXTURES-PER TRAP
❑I It,,,and will n intom Worker's CoraDc lion Insomnce,its required by Section
39110nfthe LnhorC'nJ.tonic pedinaaw,ollhe w,rk for which this pumita issued GAS-EA.SYSTEM-I INC.4OUTLE'rS DEC.GROUP / AW2 s
My Workers Componsmiou Immune.carrier and Policy number am: V G-f— Ll
Center: Policy No.: GAS-E,\.SYSTEM-OVER 4(EA)
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE, GR ASIVINDUSTRI.WASTE INTERCEPTOR
BUILDING DIVISION PEPS
('I hianccti,nnced ern bccontpleled it the tomtit is for one LundmJ dollars(SIOD) GREASB"TRAP
or less.) PLANCI{ECK FEE
Irarlfy that inlhe perf0rmswad!the work for which this Pmdt i,owed,lshall SEWER-SANITARY-STORM F.A.200 HE
not employ any Penn in any manner s,m w be nese utbject w the WbHeti Compen- ENERGY MEOZ at 0 laws of Calitorniu.Date WATER IIEAFER W/VENI'MLECTR
z O Appl'm:ml GRADING PEE
t= NOTICE I O APPLICANT:If,after making this Cenificao at Exemption,you should WATER SYSTEAUTRENTING
become subjcm to the Workers Cooperstown provisions of the Labor Cde,you mus SOILS WE
forthwith comply winsuch provisions or this permit shall be,deemed!conked. WATER SERVICE
z
7 z CONS]RUC iso c ON LENDING AGENCY NEW k1351UHN'f1AL YhMH. SQ,PT PAID
UQ IM1crcby u(fimt that them isattmstnctian lending agency for the performance of Dam RtteiptM
L� P the work for which this permit is issued(See 3091.civ.C.)
0 U lender's Name TOTA1.:
y, lenders Address TOTAL:
r d I ttnily lint l have cud lhie TTIicmion and su¢that the ahove inlonnminn is BUILDING FEE
t� Z) correct.1 agree to comply with all city and count'ordinances and sae law,timing to QTY. MECHANICAL PERMIT FEE
U Z building construction.and hcmbyuuthmrae tepresomaive,o(this city winter urym the SEISMIC FEE
above-mentioned property for inspection puBoses. PERMIT ISSUANCE.
(We)agree m save,indemnify and keep ss harmlethe City of Copenino against PERMIT FEE
lnhilitic.s.judgmnus,costs and expenses which nay in any way accrue against-aid City ALTER OR ADD TO MI?CH,
in asequence of the graining of B" aur. PLUMBING FEE
APPLICANT UNDER. ND U WILL COMPLY WITH AL1,NON-POINT AIR HANDLING UEPI'(10 I0.000CPA)
SOURCE REGI MECHANICAL FEE
A S.
"f 7- AIR HANDLING UNI T(OVER I0.000 CFM) CONSTRUCTION TAX
Si,modle,t Ap icardC,mrsi 'C Dole EXHAUST HOOD BW/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will she applkam or future buildingom.pammom or handle hazardous material HEATING UNIT(TO 100.000 BTU)
us delved by the Cupertino Municipal Code.Chapter 9.12,and the Hmhh and Safety
Cn 1,,Section 2553200p HEATING UNIT(OVER I W,OW BTU)
❑Ye, ❑No PAID
VE[sT11.A'FION PAN(SINGLERESID) Dam Be ptN
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants an defined by the Buy Area Air Quality Manage nom BOILER-COMP CHP OR 100.000 BTU)
DisnlcB T( L'
C3 Y- ❑No HOILER-COME(OVER 101.00)B'1 U)
l have real the heziNws nate'ak uundea,C'biter695ofthe Cali- AIR CONDTDONER
mquimmen p , ISSUANCE DATE
forma 121th&Salcty Coda.Sect 25505.25533 and 25534.1 malconaud thin Brhe NEW RESIDENTIAL MECH. SQ.HE g
bnllding Aoefnotoomtn have auk tial it lr my revpansihi litymnmifylhetcalpum /
mfthe ressIhm ono issuance of a Certificate of Occupancy.
7-9 J
Owner uth,ri al agent Date TOTAL: ISSUED BY:
OFFICE