S0001C0427 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USS BALL POINT PEN ONLY
CITY OF CUPERTINO BUIL)ING n?LEc
PLUMBINGrRICAI. 1 u7A I rv( n 2 n 7
BUILDING DIVISION APPLICATION/PERMIT .MECHANICAL SOOOI p0427
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS SAM L\RY NO. APPLI 11'IONSUBM11TALDATL
103 1Ll fttI3 A
O]VN BR'S NAME p110NE: CONTRACTOR'S NAM r'
\/C1J NIC CONN Kid.p
ARCIII'ItCT/LNG EER: LIC NO: 1ADDRE.}S: �� _ ❑
CONTACT. PHONE: //YY__1111YYff DUIhDING PIiRhtl'1'INPO
❑ C0 rpdjR tet Fecs Paid by Applicant(Initial) BLDG CLIEM, PLUMPI MECH
LICENSED CONi'RACfOR'S DECLARATION QTY ELf:CI'RIC PERMIT FEE JOB DESCRIPTION
I berehy olfrm thm 1 am licensed under provisions of Chapter 9(commencing
WWZ win Se<6an nXXp on)mir;an3onbe Baainerx Baa Prmfeaxior CWe,andmyficenseia RESIDENTIAI;
W p PERMIT ISSUANCIE
FW2 infull Looe and ❑SFDWL ❑KITCHEN REMODEL
QUU I,irensc Cl ars Lica APPLIANCILS-RESIDGNI'IAL ❑ADDITION ❑11I.11NMING RE-1'11'1:
F-Z W I Contract,
mQy ❑MULTI-UNIT ❑S'I'R1JC1'URAI,
AIICHITi[CPS DIECLAR TION
~y Z I rad,rstmd m plans shall be u,ed vx public recmNs PANELS MODIFICATION
OZ�M y OP 1021XIAMI',S ❑IN'IPRIOR ❑CHIMNEY REPAIR
W L,mhwJ Prof honul 201.1001AMPS IMI'ROVHMEN'r 0SWIMMING POOPS
n
OWNER-BUILDER DCCLARA'1'ION
OVER 1000AMPS ❑BATH RIEMODI]IIRFl-AIR 0DEM01.1I ON
^y
Cz� Ihrch,all that fault ruI theCommerce,L '1far the
W U O'1'HIER
p( 6 following : (Section]Ilii S Banc J I 1.:' nxC J A y tY Co..',rttmntY SIGNS I:LfCI RICAN
W�O y wh h 4 p u I alt p demolish, p' y stmdure `C,A
Fey; prior i I. requiresthapplicantl hpernit 11 signed statement WhCIALCIRCUI I/MI}C. I fir,
'hat he p . n the p :of the C t t r L La (Chapter9 COMM—E�I CIAI;
(commencing with Section 7000)of Division 3 afthe Businesshad Professions Cale)or TEMP METER OR POLE INS'
d e mbar he is amania thomfmm and the basis for the alleged exemption.Any violation of ❑NEEW BLDG/ADDITION ❑DIEMOLI'TION
ac Straiten 7031.5byany applicant linape,.if subjects the vpplicanuo a civil penalty of POWER DEVICES []TENANT 01'001)SERVICE
m more than five hundred dollars(5500). IMPROVEMENT
OTHER
=Q D Las owner or the properly,ter my cnmloYas with wages us their sole compensation. SWIMMING IDOL 171.170 RIC
F. will Jo the work.and dalliance.i.not inacraNdorolfcad for ml Nec.70a4.Business ❑
a :m and Pndccsions Cade:The Contractors Licence Law does not apply to an Owner of OUTLETS-SWITCI IES-FIXTURES
property who builds or improves thereon,and who dues web work himself or through
his own employees,provided that such impmvemcna,are not intended or offered for NEW RESIDEM'IAL LiAll 'R SQ FT
.cele.IL howinom the building or impmvemem is sold within one year of completion.the S Fp FL )RA RIEA 95Q.FY.
masim,builder will have the hmden of proving that he did not build or impmse for put-
polof,deJ. TOTAL D a
pnl1,a,owner of the properly,am exclusively contracting with licensed conaacmr,to
construct the projcet(See.701 .Business and Professions Cade:)The Contractors Li-
cerise
i- D
Law docs pill apply to an owner of properly who builds or lmpmves thereon.and QTY. PLUMBING PERMIT FEE
whocommersarmchprojectswith acentrenmis)licensed p000min otheContractor's JUL - 1 1999
Liam,Law. PERMIT ISSUANCE
1 am exempt under Sec. .B A,P C for this reason
A1.11iH-DRAIN.h VT:NT-WA'111R(EA) B VALUATION
Owner Date Y
Wu maker:S ned,of NSATION DfCLARATON BACK FLOW 1'R(YI'IECT.DEVICE
Hardy mfr,under Carroty ter perjury ane of me ihlum for docWorker
s Co
�Ihuvc and will nminlvin nCurlifieum of Consent self invurc for Worker's Compete- DRAINS-I�LUON,ROOF,AREA,GOND, STORIIES 'TYPE CONSTRUCTION
vminn,as provided lira by Scdinn 5]1X1 o1'the Libor Code,for he performenec of the
work for whichmi,pe, it.,momd. FIX'IGRES-PERT RAI'
in I have met sell nuonwin Worker's Conpansalion insurance,ns required by Section
3]IXlof if,Loh...Cade,forms lnr6anence or the work for which this permit is issued GAN-EA.SYSTEM-1 INC.0 OU'I'LE I:S Occ.GROUP AVN
and Pchc
Com r� X I MyWxu Pat,, Nuy IC GAS-IEA.SYSTIEMAVHR 3 THA)
CIIFIC,E UPIEXEMITION FROM WORKERSGREASIDINOUSTRL WASTE IN]IiRCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION ITEES
(This section need had he lithe permit is forme,hundred dollars($100) GRIEASE'I'RAI'
err Icss.l YLANCHECK 19E1i
I cenify that in the performance of me work for which this Permit is issucd.I shall SEWER-SANITARY-STORM EA.2W FT.
nut employ Any Person any man -u �y t m the Workers'Compen- ENERGY PEE
Z Smion La fCalilnrniu.Data �','`�('n-e}yam- �J Tec WATER HEATER W/VIENT/11ECfR Q D
ZApplicatr 1�� u +lt CRAVING PEE
N NOTICE TO APPLICANT:If,after making this Cemficam of Esempnon,you should WATER SYS1 ISIORENI'[NO SOILS PEG
? f a hre subject to the Workers Cmmpcnaation pmvisions of the Labor Cade.you must
fothwithcomply withsuch prvisions m,,hi%permit shall Be deemed revoked. WATER SERVICIE
6 PAID
CONST RUCTION LENDING AGENCY NIEW R[.SIDIENTIAL PLMB. SQ.FT. Data Rcccipta
L) O I hereby affnn that hem is a construction leading agency for the performance of
H. f-' the work far which this permit is issued(Site3097,Civ.C.) 'T(.,.
O U Lenders Name
} W Lender's Address BUILDING IZ
ll 1 certify mm 1 have mail this application and stem thus the above information is
F. rte am,a.1,gra Io.amply wilh all city and county ordinances and state laws relating to QTY. MECHANIC,
PERMIT FEE SEISMIC P'i
U Z building conamelam.and hereby authorize representatives of this city la enter upon the
abovcumntioned property for inspection purposes. PERMIT ISSUANCE BLECrRIC 17
(We)agree I,save,indenmry and keep harmlexs the City of Cupertino against
labilltics,judgn¢K`
„cnsr<anJcspcnmswhich Amy in any way recmeagormst said City AITER OR fidAUD'I'O MECH. PLUMBING P.Ii
'mscqucncc tbcgru 'mg tel ifixWWHI,
i
APPhICAN' JNDI' .'G DS MpLYWITHALLNON-POINT AIR HANDLING UNI'T(10 IIkWOCi'MI MIiCI1ANIC. IBEIi
SOU .Gill ONS
✓ AIR HANDLING UNIT(OVlpR 10,MXICFM) CONSgRUC'I'ION'IA%
Iglecomol'AIndieal COntmelor Date EXHAUSTHOOD(W/DUCT) HOUSING MI'I'IGAI']ON Ilia
HAZARDOUS MAIPRIALS DISCLOSURE
WIII Ihcnpplicaut ter room building occupant otavorharele hazardous material i ING UNITTO InUtdi1 B'RJ)
as defined by the Cupenina Municipal CWC,Chapter 9.12,and the Health and Safely
Code.Section 25532(u)] +, HEAIINC.UNIT(OVER 100,000 131 U)
❑Yea IMNn PAID
3xNn PAN SINGLE RfSID) Dae Receipt#
Will the applicant aro future building oceupant use equipment or devices which BOILER-COMP'T3HP ORIIXkIXXI BTU)
emit h:ruNous air contaminants as defined by the Bay Area Air Quality Management
District'.10 Ya%
❑Yea BOILER-COMP(OVER 100.0TX)BTU)
�Nm
I Use rand 11,5,40.•vurdho,mvmnaL requionomnu under Chapter 6.95 of Ne Cali- AIR CONDITIONER ISSUANCE DATE
fomis Health&Ser ly .Sectio 5505.2.5533 wJ 25533.I makrstaW mhd if the NIiW RESIDENTIAL MECH. SQ.FT.
buildingdmsn Yh: sear mum that iY Y msprenability to nmify rhe occupant / y
of the tee tech arm of it C�fmcate of Osrr�"
12 O ror authan agent �L CiDatc TOTAL: ISSUED BY:
OFFICE