99080206 (2) APP_ICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY Q
CITY OF CUPERTINO 81111.UING ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONMERMIT PLUMBINtl-MECHANICAL
BUILDING PROJECT IDENTIFICATION
RUILU D S SANITARY NO. APPLICATION SUR AL DATE
o Q� O
NA CEJ / PHO At ONO:
NIC CONTROL is
ICHII'BCI'/IiNGIN[ER: LIC NO:
CONTACT: PHONE: RE �k� rA ❑
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S IIECLARA' ON .' ❑ ❑ ❑
I herchy affnm Thal 1 am Imensed under pmvixions CM1aplcr 9(commencing QTY' ELECTRIC PERMIT FEE
DMZ with Seaimn]fNNpnl amn3 ofthe Businexsand Profe. on'C�xk.and my lice JOB DESCRIPTION
,WC in full force and cf rvt PERMIT ISSUANCE RESTDENTIAL-
U Lice C ❑SFDWL
I,-< D m.p El KITCHEN REMODEL
CLon
ARCHTECTS DEC APPLIANCF_S-RESIDENTIAL
❑ADDITION
❑PLUMBING PIPE
ZOZ Iundemm�dmyplainzhallbeusedapbit PANELS ❑MULTI-UNIT ❑STRUCTRAL0Z y
UPT020dAMPS MODIFICATION
<,%L'L Licensed Nolbsninnal 1:1 INTERIOR ❑CHIMNEY REPAIR
281-]UN)AMPS El SWIMMING POOLS
y YE;a OWNEk-BUIL' RDECLARATION IMPROVEMENT
hereby affirm thin 1 am eve ne frons the Connal CI License Law for the OVER 1 WOAMPS [I BATH REMODEVREPAIR Il S DEMOLITION
P
3 F lollnwmg rwvon.($¢tion 7031.5.Business and Profasionv Cock Any city or coumy Ir
F 0 yd which requires a pernm to CUnmNet,alma lmprovc,demolish,or repay any structure SIGNS ELF.CIRICAI. ❑OTHER
�y m..1 pfionall,i.•suanre,uNaortmhea the appliannt for Inch permit m Elcusigncd,mumanc SPECIALCIRCUU/MISC.
zly¢S thothc fi : Ip ....I thep n•nfth C I t .1 1 (Chpter),
W O (conn ny 'tl S lint];NNB fD -.'on3 ftl B : II : Cdc)or TEMP.ME'TEIt(IR PDLB]NST COMM R IA
L L o C thus he pt th (n d;h ba,i,for the alleged vxanpl on.Any v'ol.uam of
W;m Section]031.5 by any applicantsix a permit subjects the upplicammn civil penalty of POWER DEVICES El NEW BLDG/ADDITION El DEMOLITION
yZI not more shun live hundred outfits(55001. []TENANT ❑FOODSERVICE
BYO ❑ I.as owner of the progeny,or my employees with wages as their vole compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
p. will Jo the work,and thearucture is not intended oroRcml for sale(See 774.Business ❑OTHER
W 3 m and Professions Cede:The Contractor's License law deals not apply to an Owner of OUTLETS-SWITCHES-PIXY
Progeny who builds or improves Bronson.and who does such work himself or through
his own anployees,provided 11.1 so,,improvement,,are not intended or oRculd for NEN'RESIDENTIAL ELECTR SQ
side,If,however,the building or impmvemenl is sold within one year of completion,the
owner builder will have the burden of proving that he did nos build or improve for par- SQ.IT.FLOOR AREA &SQ.FT.
poseof sale.).
Los t—net of the progeny,am exclusively contracting with licensed contro to TOTAL:
conmruet the pmjecl ISec.]LW,'allows and Profeslom,C de:)The Convectors Li- 1� I
c selaw woes nut aPply to an ownerofpmpeny who build•,,,improve•mesion.ata TY. PLUMBING PERMIT I 1
whoemnlracahn,,och pmjeets wuhacommcnn(s)liwnsd Q FEE
Licen.•e Law. a parwamw he C.......im, i l
❑ not cxen;pl mWcrScc ,B Ok P C 1'nr his reams PBRMITISSUANCE AUG 3 0 1999 I),
r Dole ALIUR-DRAIN&V17NT-WATER EAI
n W(IRKEHS COMPENS.... IE' 'IDN VALUATION
I hereby uffrm under penahy of pejurya Ibc•follu ing declarations: BACK FLOW PR(TTGCI'.DEVICE
Ihavemadwillmuinwina Cenifcate ofCo m I elf-insPm for Workcr's Cnmpcn- NO
ROOF.AREA.COND. Y
scion,as hick hi for by Section l]IXl of a lobo Gde.Ynr the performance of the STORIES TYPE CONSTRUCTION
work for which till,,pcnnn is Worker
FIXTURES-PER TRAP
❑I have and will maimain Worker ompensatinn 1 ranee,as required by Section
3700oflhelabnr Corle.fortha Pe rman<eefthe k for whichthia .it,,issued. GAS-EA.SYSTEM-I INC.4 OUTLETS
My Workers Compenvation Ins sncecamerin Olicynumhram: OCC GROUP .fit q�
Carrier: P ey No: GAS-EA.S YSTENI OVER 4 BDU /U
CERTIRC OF EXEN ON FROM WORKERS'
0MPENS ON INSURANCE GRGASE/INDUSTRL WASTE INTERCEPTOR
(Thixscctionn na he co -ed ifthe permit is foron,h
nr les") GREASE.TRAP BUILDING DIVISION PCE$
Ioyany lbw n r1'nr one rk r hiccc'to
isissual,lvhap PLANCHECK FEE
nntanplo1of int ny v eeun the Workurn'Cnmpen- SBWF,R-$ANIT'ARY-ST()NM BA.2;NV FT.
Z 0 ,,Minn Lawa of.nlib ; .[ ENERGY FEE
Z Q Applicant WATER]IEA"f1ER WOVEN'1'/F.LI?CTR
(� N(TI'ICE'f AV .If, per making thin Ccrtilicule of Exemption,you should GRADING FEE
aF become. WAT ER SYS'TEM/IREATING
• ,iect In c Worker' Cmnpens do, pm I'I al of the meed Code,you muse
r-+
1'nnhwi amply iib.inch or this it shall he deemed rcvoketl. SOUS FEE
a-Q tions WATER SERVICE
5z CONSTRUT 'LE' ING AGENCY
U0 ]hereby atram mut there i manumu anlendin NEWRESIDENTIALPLMH, SQ,FT. PAID
ry F s arkforwhichthispermtl' sutl $agency(nr th<perfurmance of
e ( .309].Civ.C.) Dan, Rem emits,
N
U 1 der'a Name
1 I ndcr' Address
Ems„ L3. cenify the I It reatl mio
I ',applicn and,rate that the alwve information is TOTALTOTAL:
I orect.l ague u,en Y-11 I city and count ordinances and mm laws relain to
U z buildin ) 3i 6 Ty. BUILDING FEE
I conmmnio ,and by amhoriee representatives t,s I mcnmru Q MECHANICAL PERMIT
ebOle-nn ornate d opc fminspccuumpirpous. y poo the FEE SEISMIC FEE
( ')ugr e,indemnify and he models the City of Cupertino against PERMIT ISSUANCE
lialthincI. aVl,,andexpcasc ich may many way accrucnguinsl said City ELECTRIC FEE
allonn.wyuen t 'ng ors permit. ALTER OR AILD T(I MECH.
APPLICA ra AN AND WILL COMPLY III AL1.NON-POINT PLUMBING FEE
SOI]NCii E l A S AIR HANDLINGUNII('101(finto CPM)
/ MECHANICAL-FEE
AIR HANDLING UNI'C(OVER III,OW CEM)
Sign urea Applin UGm acmr ' rr ]Jam CONSTRUCTION TAX
ITA DOUS F.RIALSDISCLOSURE EXHAUST H000(W/DUCT)
Will the' plica rtfmure ]ding occuPmi sumem ImAchamrdoux mammal NGTING UNIT(TQ IRB,OOB BTU) HOUSING MITIGATION PFR.
s def ncd by t e Cu no Mule,Chapmr 9.12,and the Health and Safety
Cale,Section (a) HEATING UNIT(OVER 100,(X10 BTU)
❑Yes
Will the appllc l nr future buil - _ V TILATION FAN(SINGLE RFSIU) PAID
ng occupant use egmpm ilcvim which Date Receipt p
nit District?
un air c mminanm as men by the Buy r Quality which
BOILER-COMPOHPOR 100.000 BTU)
Dismal
El Yell, T BOILER-COM P(OVER I01IXI(1 BTU) TOTAL:
I h-c •ads .,do ataVals requlremema under Chapmr 0 95o the Coli- AIR CONDITIONER
forma Hcuhb/&. 'onium'25505,25533 and 25534.1 undcatund shat dthc ISSUANCE DATE
building Jvnu , muu'lunl,mal it ism,rnpnmib" mora" Ibe occu I NEW kI?SIIII?NI'IAL MECH. SQ_FT, /m
III;llhac kiln, I um Mmes prior m iesuvncet �;�le y Pun -y{ 7 I/yl
i ' upancy.
own o rr d� en' Dam
TOTAL: ISSUED BY: �-
- OFFICE