99080115 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF,RTINO BUILDING-ELECTRICAL #LIPERMITNO. 4
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDEJI'IF'ICATION
HUILDING AIIIIRIi`01 / ` I .aa �� SANITARY NO. A A'1'ION SUBMITTAL DATE
OW NF TN/-/A/M�`I' w/ N.yj�„F/I�l]OONE: /v,77y/�•+ CONTRACIORS NAME: LIC NO: �^
/G tfo6 NIC CONTROL#
:HI ' (E['GIryEE kir LI � ADDRESS: ❑
CONTACT: II/rY1v4L/. /CSL-rI�_! PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(initial) BLDG' ELECT PLUr MECI
LICENSED COMTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby warm that 1 am licensed under previsions of chapter 9(commencing JOB DESCRIPTION
W=Z with Section Division 3ofthe Bmlrreand P..ovQ.....Co1cmdmylicumeis FNIDR�ENTIAL, _
WOO I'IiRMIT ISSUANCE
FW.. infolfarcnaadelldct. ❑NIgm. KITCHEN REMODEL
aUU hiccnse Chis Lica APPLIANCES-RCS IDENTIAL C1 ADDITION
❑PLUMBING HG-PIPC
NZ6 Dete Cmuractor
(_Dh ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT OSTRUCTURAL
Z e m Z I understand my plans shall be used as public records �' MODIFICATION
O Z�G UP TO 210 AMPS &4FERIOR [I CHIMNEY RF.PAIR
F
co i- LicensW Pmfessioa.l 201-1((0AMP5 IMPROVEMENT C]SWIMMING POOLS
���-? OWNER-BUB-DCN DECLARATION OVER IUlN1AMP5 [I BATH RI?MODBIJREPAIR ❑DEMGLI9'IDN
1 hereby aanu dea 1 nn%encntpt form the ContmeLicense nse Law for the
X 3 a U following reason,INection 7031.5,Business and Pmfesuinns Coca.Any city or countySIGNS ELECfRLCAI. [-1 OTHER
W W N which requires a permit m comtrua,eller,improve,demolish,or report any strach re
�j prior m its issuance.also requires the applicant Gorsuch permit to file a signed statement SPECI AL CIRCUIT/MISC. �AflrlAl;
} that he is licensed punuantto the provisions of Ne CnmmetioS License law(Chapter 9
�yrQQ (commencing with Senium 71YJO)nil)ivisionJof the Business and Professions Code)(it 'THNI'.METERORPOLEINST COMMERCIAL' ,L �j,S
L q o eG That he Is exempt therefrom and the hasis for the alleged exemption.Any violation of ❑NEW BE ❑DEMOLITION
m 5cdion]11315 by tiny applicant fur a p:rmil subjcns the nPFlicunt m a evil penalty of 1'OW IiR UEVICFS ClTENANT ❑FOOD SERVICE?
I more than rise hundred dollars(Mar)
F Z} IMPROVEMENT
5 _Q D 1.as owner nr lho propenY.or my emNoyees with wages vs their sole compensation, SWIMMING POOL ELECfR �r yANreN�-
FE will do the work.and the strvcwrtisna imcndcJ proffered for sale(Sec.]ON4,Rosiness ❑OTHER / —
aa= and probe,ins,Cods:The Contractor's License Law Jove not apply m an Iwner11� OU LfTN-NWITCHE9-FIXTURES �0
progeny h builds imp to J h J :: E work ti If through
.
h:own employees,provided Int sucti improvements are not i lended fl I for NEW RESIDENTIAL HL1EC1'R SQ FT
,d,Ifhooseca,the huilding or itapioveneent IJ within one yearofcomplenion,theLj4(1�\SS 'E FLOORAREA SISQPI.
er b II h theN b I proving that h J'J I build p f Fur W
ry lis of sale.) T'�
Cl 1,a +f the pmpeny m ntelua vely communing Ibis 1 sed tre cenbars In TOTAL: I ,
mswct the project(Sec.70W.Business and Professions Crde:)The Contractor's Li-
a
nseLaw does not apply tosoownet ofptopY enywhobuildsorimprovesthereon,and QTPLUMBING PERMIT E
who aamams far soars proiecn won.commnor(a)GcemW pursuant mine cnmmcmrs SEP 2 2 1999
Liron%e Law. PERMIT ISSUANCE
E]1 son exempt unde,Sm. .11&P C I'onhix,canon
ALE-DRAIN&VENT-WATER IEA) VALUATE IN
Owner Dom
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT'.DEVICE Ate O
1 hereby affirm under penalty of Perjury one of the following decimations V
❑ I have and will maintain a CeniBcme nr Comenuosdl-innum for Worker's Comport DRAINS-FLOOR ROOF.AREA,COND. STORIES TYPECONSTR ION
xaiion,as provided for by Section 9700 of the Labor Cale.for the perforreancc of the
work for which This penno is issued. FIXTURES-PER TRAP v
Q 1 have and will nminmin Worker's Compensation litarmove.as rcquircd by Section
370Bofthe Lal.%Qdl forthe performance ofthe work llawhich this Ferrol,is issued. GAS-FA.SYSTEM-I INC.A OUTLETS otc.GROUP
My Worker's Compensation Imumnm carrier and Policy number mre: l
Cmtiee Policy No.: GAS-ESA.SYSTEM-OVER 4 DEA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSAI ION INSURANCE GREASFANDUSTRI.WASTE INTERCEPTOR
HUILDING DIVISION FEES
(TM1ix section need nm bcamq+lctad if thcpetmit i%Inr one hundred dollars f$1(0) Olel?ASH TRnP
or
less.) PLANCIIECK ErEB
E sonify that in the performance ofth,work for which this permit is issued,I%hall SEWER-SANITARY-STORM EA.200 FT
not employ,any Fersoa in any,tanner so as Io become subject m the Worker,'Comped- ENERGY FEE
Z cation Laws of California.Date WATER HEATER WNFIFEMLECTR
Z 2 Applicant GRADING FEC
p7 NOTICE TO APPLICANT:If,alto,nuking this Ccnifiore of Exemption,you should WAT I?R SYSTEMRREATING SOILS FEIi
I^ ; become xablecl to the Worker'.Cmnpencanon p..ixinn%of the lahar Code,you natal
tonhwith comply with such pmvi%Floor lM1ia permit mall no devoted revoked. WALL 1iR SERVICE. �x
Q V
7Z CONSTRUCTION LENDINGAGIiNCY NEW RLSIDEMIALPLMB. SQ.W. PAID (late RecciplN
V O L hereby affirm that there is a construction lending agency for the perfonatace of
I" rthe work for which this permit 1%issued(Sec.3097.Civ.C.)
- Lenders Name TOI'A
V Lender's Address TOTAL:
BUILDING PER
1 certify tbm I have rcuJ Ihix uPplkaunn unJ%luso that the nhnve inlianwtinn Ix
E" h vamccf L agree to csnoply with a0 city and county ordinances and.state laws relmingm QTY, MECHANICAL PERMIT FEF
V Z building cnnurrov.n.and hereby amhmizc tepresenati%es of leis city to enter upon the SEISMIC FEE:
'- above-maMoned Propony for impeco purposes. A PHRMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
Iiablinies.judgments,costs and expenses which may in any way acerve agaiml stillCity ALT ER OR ADD TO M ECH.
PLUMBING PEE
in consequence of the granting of tank permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNII'('1010,OW CFM)
MECHANICAL THE
SOURCIi RF.GUhAI'IONN.
AIR HANDLING UNIT LOVER 10.000 CPM) CONSTRUCTION]'A%
Signature dnpplicauVOrmrmtor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION HE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle ha.atdous motorial HEATING UNIT ITO 110,00(7 BTU)
as dcF.,d by the C'npertina Murae,al Code,Chaplur 9.12 and the Health and Safety
Cade,Section 25532(.)] HIM UNIT(OVER I00,171(1 BTU)
❑Yes E]No PAID
V17M'RATION FAN(SINGLE BESIDE Date love
WilI
emit
applicant or antra huilding occupant yA equipment or devices whichCan
mit nazardzmdws air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(}HP OR 103.000 BTU) Taft
Dlari"I BOILER-COMP(OVER 100,000 BTU)
E]Yea El No
I havcrudthe ha.b.smmarials is under Charer,6.95of the Cnli- AIR UINUI'TIONL'R ISSUANCE,DATE
rcyuiremcn F
forms Health&Sala,Code.Sections 25505.25533 and 25534.1 understand that if the NEW RESIDENTIAL.MECIL SQ,FT.
building docs no,currently have a tenant,that it is are resrymsibiliy m notify the occupant
of the tequitetnanu which must Inc atm pilar m i,nance of.Conlficzte of Occupaoey.
Owneror andoved.,car Date TOTAL ISSUED BY:
OFFICE