99090108 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY O /
CITY OF CUPERTINO BUILDING-ELECTRICAL .RMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
NUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
4 '� lib; D� -i 7-<-4
NC11({S NAME: aled PIIONE: CONTRACTOR'S IT P LIC NO:
Ad 1_•n /pn � / tl. fix 22 NIC CONTROLp
IITECT GINEER: /�1��f LIC NO: ADDRESSal e4 : • /1CIP ❑
CONTACT: l/ N PHo9NF;:ilgv l BUILDING PERMIT[NFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm ata I am ucemed ander Provtdons of chapter 9(commencing JOB DESCRIPTION
WON who season nNlO)mfuh;xion3oftne Easiness and lM,Ibadcns Code,and mr hrenu is
WOO PERMIT ISSUANCE RESIDENTIAL:
i-,= in Lalli!furcen� sS 2Z ❑SFDWI. C1 KITCHEN REMODEL
QUuj Licznsc Lica APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
tF Q i bale rS DECLARATION
FOy ARCHITECTS DECLARATION •Of PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z O n� 1 undemmad my plans shall he used a public rccards MODIFICATION
OZ—� UP T02W AMPS ❑INTERIOR [I CHIMNEY REPAIR
F r?f'Ili Licensed Professionalj 201-If11N1AMPS IMPROVEMENT C]SWIMMING POOLS
Sa y E❑� OWNER-BUILDER DECLARATION pyER IIXx1AMP5 [I BATH REMODE REPAIR 0 DEMOLITION
yIY C i hereby affirm that 1 am exempt Tram the Contractees License Law for the
xOLV Tolhw g .(Sect 70315E 'ne IPrf ns Cod Any orounty -Nti IiLECTRICAL [I OTHER
W 3 W to which y Permitt construct, ❑er p lis! ,di c ct /
ear t1: ane 1. re4 're.the I"caml uhp ruin fl INC
} ibmh licensed on a The pro
10 fth C 1 me L 'CC e k
QO (commencing with Section 7(Io0)of Division 3 m the Business and Probes - -Is, COMMERCIAL:
C, o C Thal he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
t� Section 7031.5 by any applicant for a Ferrell subjects the applicant to a civil ty of E
^y ❑TENANT [I FOOD SERVICE
not more than five hundred dollars($500).
^�zz IMPROVEMENT
=6 I,as owner of The properly,or my employees wit wages as their sole cont . don. S R 1
will do the work.and the stmmuts,is not intended snolTcred formic(Sce.7014.
[]OTHER
L3 ao and Professions Code:The Contractors License Law does not apply to an owner of It y 'TNT-oES
pro,my who builds or improves thereon,and who does such work hi
his own employees,Provided that such improvements art not Imende r o e &WWElJ1lE
saleb
.IL however.the building or improvement is sold within ane year of m SQ FT.FLOOR AREA _ $/SQ.Fr.
ownt,mildr,will have the burden of proving that he did nm build.,, ro
pose n(sale.l / TOTAL: r^
❑1,as owner of the property,am exclusively contracting with licensed contractors to i('
comment me pmiacr(sea.70LL Business and 11 fies,ion,Coec:)The Commerce,Ll-
croxvLawdocsnot...lytcan ownuaf pmptny who hails or impmvcatherem,and Y. PI.UMBIN PERMIT FEE Ij �'
who contracts for such pmphni with a comfumm(s)licensed pu....at to rhe Conuaemr's i 1:
License law. PERMIT ISSUANCE i; gEp 16 1999
❑lam excmr Sm a,PC for this reas
7a ncr Da¢ AI-TER-DRAIN&VF ER(EA) I-: VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PR V 1,
1 hereby oQirm under penalty of perjury one of the following delle ons: _
l have and will maintain a Certificate of Consent to self-insure for Wor es Cmd,n- DRAINS-FLOOR.R STORETYPE CONSTRUCTION
6nion,as previded for by Section 370 of the Inbor Cale,for the pc nuance of the
work for which this permit is iaaal. FIXTURES-PER TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section
7-
370d of the Labor Cade,for The performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4oTLETS OCC GROUP2 APN
My Workers Campenm ler Insurance'amen and Policy number am: b O,�
Carrier: Policy Nn.: GAS-EA.SYSTEM-OVER 4(EA)
CERI'IFICAT60FEXEMPTION FROM WORKERS' GRIiASEINDUSTRf.WASTE INTERCEPT OR 3
COMPENSATION INSURANCE BUILDING DIVISION FEES
CUtissecrion need not be completed flhe ennit i,Lorene hundred dollars($100) GREASETRAP
ar
less) PLANCHECK FEE
I certify that in the peffmcnaccof the .,,it far which this permit is issued,I shall SEWER-SANITARY-STORM EA.200 FT.
• not employ tiny person many manner so as to hecome m1 jea to the Workers'Compen- ENERGY FEE
QZ mhos Laws of Califomia.Date WATER HEATER WNENT/ELECTR GRADINGFEE
Z O Applicant
•Na NOTICE TO APPLICANT:If,after making this CeniOcate of Exemption,you should WATER SYSTEM?REATING
F , become subject to the Wurkces Compensation previsions of the Labor Ctsde,you must SOBS FEE
forthwith comply with such provisions.,this .it shall he deemed revoked. WATER SERVICE
C6
DZ CONSTRUCTION LENDING AGENCY' NEW RESIDENTIAL PLMB. SQ.Cr. PAID Date FIT I eceipra
V 0 l hemhyaffimnhavhere iso construction lerningageacy for the performance of I - f
F the work for which this permit is issued(Sec.3097,Civ.C.) /a[Q Of Q
W Lsndds No
TOTAL:
U Lender',Address nhoLe TOTAl-. BUILDING FEE
cenlfy that 1 have read this application and stunt thio the above infarmotiou is
«F.1 IA correct,l agree to comply with all city and wanly ordinances millions lows rah ting to QTg MECHANICAL.PERMIT FEE
V Z building cunsoucrimn.and hereby aphorize representatives of rho city to enter upon the SEISMIC MEW
aMveancntinacd pupody for im,welion purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep moults,The City of Cupertino,Finn ELECTRIC FEE
liabilities,judgments,costs andexpenses which may many way seeme almost said CityALTER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBINGE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. MECHAN Al_FEF.
'f,,x // �C•C AIR HANDLING UV10,000 IO,WD CFM) CONS CTION TAX
Sign res ppl'cara Contractor !O Date EXHAUST HOOD(W)DUCT) HOUSING GATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Willtheapplicant or future latilding heripuntsmreaz
or handle hazardous material HEATING UNIT(TO I0g000 BTU)
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety
Cale,Section 255321,)" HEATING UNIT(OVER 100,0130 BTU)
❑Yc, ❑Nn PAID -
VI?N'I'ILATION PAN(SINGLE RESID) Date Receipra
Will the applicant of future building occupant est r,mpmem or devices which 1301LI?R-COMP(3HP OR IIX1,000 BTU)
snit notorious air contaminants as defined 1,the Ila,Arca Air Quality Management TOTAL: b `
DisRin l
[2 Yes BOILER-COMP(OVER I00,000 BTU)
❑No
I have mad the hafardous materials requirements under Chapter 6.95 of the Cali. AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Code.Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT. n � ��� Q
building does not currently have a tenant.That it is my responsibility to notify the aeupam 7 /
I
the iremenuw ich must be met prmamixmmccofa i0xftof c ry.
Owner r alonzed agent ' Date TOTAL^ ISSUED BY: el_-
OFFICE