99080177 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY Q q 02 Q
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
'HUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL
l,'t), - BUILDING PROJECT IDENI'IFICAT10N.,' I',i,n 6 B•
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMIITTAL.DATE
1101 RL4;15 G Z7
ao
OWNER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
�'L� NN/G �j A f' �. a NIC coNTR///OI���.a
Pact I1TEENGINELR: LIC NO: ADD S5: nye. ' ❑ ��
(V: ! 1
CONTACT: P�ONN,E.:., '' 'i; 'BUILDI GPERMIT INFO '
'
El Consultant Fees Paid by Applicant(Initial),. BI ELECT_ PLUMB
l A17 14MECII�
M. Lt717 g z- I
LICENSEDDECLARATION QTy .,d ELCCTRICPERMIT FPE
I hereby aRirnd tI la f n of Ch.pmt9 woman ing t% - x(•. q ,.., .,. ?,I`- JOB DESCRIPTION
WOO with Scxdon70XjofD 3 fth Bus dProfessions Code,and my scene is RESIDENTIAL:
WOO in fail fnrceird eflext PERMIT ISSUANCE
U License Class I c.# ❑SFDWL '�ICITCHEN REMODEL
6 U ♦�.. nOI(� ' APPLIANCES-RESIDENTIAL ❑ADDITION PLUMBING RE-PIPE
f+Q,6 Ddle--2=-�F "-/-e—Conlmclor
r� AR6BTECFS DECLAR ION ❑MULTI-UNIT ❑STRUCTURAL
F 7'� I'ANF.I,S b
ZOZ=K IunJvxtand my plons.choll be used as public records I 1 !V' MODIFICATION
m F-n UPT02W AMPS INTERIOR C1 CHIMNEY REPAIR
F.. J Licensed Professional 201-1000AMPS IMPROVEMENT SWIMMING POOLS
�ad OWNER-BUILDER DECLARATION OVER I"AMPS ❑BATH REMODEIIREPAIR El DEMOLITION
IY :4 I herchy affirm that 1 am exempt from the Contractor'%License Law for the
xL 0.U following reason.(Section]031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OrHF.R
ly a W[- which require,a permit to construct,alter,improve,demolish,nr repair any structure ,'W I /V
F40trJ
prior it,its examine,also requires the applicant for such Permit o rite a signed statement SPECIAL CIRCUIT/MISC. is, IN4 em Li
' } that he i s licensed pursue to the provisions of the Contractors License Law(Chapter 9
IYO� (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL'
11 a c that he is exempt therefrom and the hasis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
iC^'
Section 70315 by any applicant for a permit subjects the applicant to a civil pc..ahy of POWER DEVICES
W^'m ❑TENANT ❑FOOD SERVICE
FSDnot marc than five hundred dollars(850). IMPROVEMENT
❑La%..wcook, ndilicpeny,or myemplended or owagesaz(hei...lef..menadin. SWIMMING POOL ELE IC
f.. and Jn Newark,Ceade, he Coreisnnls Livens nrawdosnooffered for tapply to an Businecs ❑OTHER
W"� and Professions Code:The oyes thereon.
License do does not apply ht if owner of OUTLETS-SWITCHE.-FIXTUR S
his opropeny who builds or improves(hereon,and who does such work himself or through
hisewnowever,be provided ohmsuch mentIvemmnware im intended orputin,for NEW RESIDENTIALELI?LTR SQIT
mle.ILhoweveethevethbuilding burden improvement itsold didOone yearof improve
rhe -_._SQ.ET.PIAOp AREA- ""'.VSQ.FT.
porn of s deer will have the burden of Proving that he did not build or improve for pm- ru\ I
e of sole.), )(• Z '
❑ 1 as owner ej the Sec.70y ,B exclusively a contracting e h licensed contract t TOT L: �,
cowmn the protect(Sec ]044 Business dPr f Code)The Commemr Li-
.......arove,
.... .prove,Iherem d QTY, i PLUMBING PERMITsu ,��',,I AUG 2 4 1999 P
who contracts for ch projectswpursuant ,IJ
with a contractors)licensed pursuan
o the Contractors - --- -I"
License Law.
I no exempl under Site ,R&P C for this reason PIiRMIT ISSUANCH
Dale
ALE ❑ALDER VALUATION
y
WORKER'SundePCOM PIpsrjurION DE Ce folio ing HACK FLOW PROTF.C'1'.DEVICE -
1 hereby uf0rm under penalty of Perjury one of the following d¢Iemliom:
❑Ihave and will mainminaCcrifcacof C"nscmmself-ensure for Wrnkcrs Conspen- DRAINS-FLOOILROOF,ARHA.COND STORIE TYPE CONST UM[ON
action,us provided for by Section 3700 of the Luton Cove,far the performance of the
work for which this pemtil is issued. FIXTURES-PER TRAP
I have and will muinluin Workers Cred,co atiot Insurance as required by Scclion
37M of the Labor Code,for the fecrf"rma ce of the work for which this permit is issued. (iA5-EA.SYSTEM-I INC.40UTLETS OCC.GROUP AP
My Work e ,tli:�Ouruccs er and Policy number are: Z�
Camcr: L�.`.�J-11-Policy No.: GAS-EA.Sys'rl?M-OVER4EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFJINDUSTRL WASTE INTERCEPTOR ' BGIIiDINO DIVISION IT. Is
(Thisxcction need not be completed film permit is Sir can hundred dollars SIM) s
3 s���tS tri
or less.) GREASE TRAP PLANCHECK FEE
I cenify that in the Performance of the a ork for which this permit is issued,I shall SEWER-SANITARY-STORM V.A.2RB f4.
not employ any pc,.n in any manner su nc to become subject nt the Workers'Comsat ENERGY FEE
Z mfimi Laws of California.Darn WATER HEATER WNENT/ELECTR
7�0 Applicant GRADING FEE
q ti NOTICE TO APPLICANT.If,after staking this Certificate of Exemption,you should WATER SYSTEMIrREATING
a > become subject to the Workers Compensation provisions of the Labor Code,you must SOILS FEE
Da forthwith comply with such pmvidmor this permit shall he deemed revoked. WATER SERVICE
Q
DZ CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLACE. SQ.1.7. PAID
U O s Ihcreby nflirm lhvubem isec..ngmctinn lending agency fortheperfarminccof Dam 1pt#
the work for which Nis pc.mif is issued(Sec.YND,Civ.C.)
U lenders Name TOTAL:
Lenders Addmss TOTAL:
1 cenify that I have read this applic.Ilon mrd state that the above information is - , BUILDING FE
Z
correct.l agree to comply with all city and county ordinances and state laws miming to QTY. s , MECHANICAL;PERMI'P• FEE,'
U Z buildinioq
g c...urr .,,it herchy amhnrimocps—cntulivosofthis city l.enlerups"the t ' SEISMIC PEE
above mentioned properly for inspection purposes. PERMIT ISSUANCE
(We)agree to rove,indemnify and keep harmless the Cil,of Cupcninc ag.inst ELECTRIC FEE
1.bilifio.judgmcma.coe,andcxperews whichmay many way accme against said Cif, ACI ER OR ADD'TO MIiCH.
in onsequence of The grunting t/Ibis permit. � PLUMBING FEE
APPLICANT UNO TAt IS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT To 10.001 CFM)
SOURC 1" U I S MECHANICAL PEE
�. .a�' Bey AIR HANDLING UNIT(OVER 10.(100 CFM) CONSTRUCTION TAX
Sig "fA Dvm if EXHAUSTHOOD(W/DUCT)
H a U 1A'1'F.RIAfS DISCLOSURE HOUSING MITIGATION FEE
�'(( Willtheupplican mor iidi.goecnp.nt store or handle heracim.material HEATING UNIT(TO 100.0[hI BTU)
npdeEnW by the Cupet unicipal Gds,Chapter 9,12,and the Health and Salety
Code.Section 25532(.. HEATING UNIT(OVER 100.000 BTU)
[3 Yea
+� VI?N'CILA'I'ION FAN(SINGLE RESID) PAID
Date Receipt If
Will the applicant or .1,a defiling occupant use equipment or devices which Q
mit District?
uus air conmminams as defined by the Hay A.Air Quality Management BOILER-COMP(3HP OR 100,0110 BTU) - J Lai Uistrimp TOTAL:
❑Yes �JIY-y�r'.�' BOILER-COMP(OVER IIp,IXq BTU)
I have re ad the hnmr3o.1 mime- c rcmennunder ter6.95 ofthe Cali- Alit CONDIT10NER
qui vp ISSUANCE DATE
4tmia Health A,Safety Sectio.2 O5,25533 an 4.1 understand for if the NEW RESIDENTIAL.MECH. SQ.PIT O, (}
building does not, all 1, ed nn thafit L, speed ilifytonadfytheocupant L1%l 7`
of The recall m me pr' issuance info Cerifwm of Occupancy. -
9.
Owner" a,W Dude TOTAL: a ISSUED BY:�Q
OFFICE