S 0985 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPFRTINO BUI LI)ING-ELF.CTR ILIAL PERMIT IB
BUILDING DIVISION APPI,ICATION/PF,RMIT 1'IAMBINc.MECHANICAL S 0985
ItUI1.UING PROJECT IDEN'1'IF'ICAI'ION
SANITARY NO. APPLICA'DONSUBMITfALDAll
BUILDING ADDRESS:
OIJ77 141—P %Ise ��/3� `�
OW�ja;S NAME. / PHON17 CONTRACTOR'S NAME: LIC NO: NIC CONart.9
z• ( nJh hz�-F d 53 3/76
�ARCIIU /ENGINEER: LIC NO: ADDRISl:
3 BUILDING PERMITRMIPERMITINFO
CONTACT: PHONE:
J2� Or !e5 Lown,34t», 3Y7b � CBnsultant Fees Paid by Applicant(initial) BLDG e1.E(TI' _ PLUMBMe❑CII
J I.ICENSIi)CONTRACTORS DECLARATION QTY ELECTRIC PERMIT IzEE JOBDDrSSCRIPTION
I hereby affirm that;mer licensed under provisions of Chapter 9(commencing
DaZwith Scainn9B0pdDivision3olue Hasinessard Pmtaxliors Code undnry Starer is PERMIT ISSUANCERF�ID TI
1-1- in full force and effort. 1. ❑KITCIIIiN REMODEL
License Class Licx APPLIANCES-RE.SIDENrIAL ❑ADDITION ❑PLUMBING RE-PIPE
I-ZM Dam Contmen'r ❑MULTI-UNIT ❑STRUCTURAL
read ARCH I[CTS DECLARATION PANIi1S
I.D. I understand my plum shall h used as public records MODIIlCA1TON
ZOy� unemanOil TO 200 AMPS ❑INIE.RIOR ❑CHIMNEY REPAIR
OZ—p
F-h WOOL)AMPS
IMPROVEMENTCUE Od1NGPOOLS
Fly Licemed l'rofeoloral 2p
<'l E; OWNER-BUILDER DECLARATION OVER lUOAMPl C]HAITI REMODF.UREPAIR ❑DIiMLIrIUN
C W a 1 hereby affirm that I am exempt from the Contractor's License Law for the [-)OTHER
yyXX 1 U lullowing mamr.(Section 71111.5.Bu,iness and Probes orro Cmle:Any city or county SIGNS ELECTRICAL
Ii13 LL N which rc9vires a permit m umomcr,ohne improve,demolish.nr«pair uny I'mor rc
F-u'O J poo , its issuance.al Hare.the applicantfor such Rican t rite avigradvatervem SPECIAL CIRCUI'DMISC.
that he is 1 ccusedp tt the n ' o. f he Contractor s Livence La (Chapter9 COMMERCIAL:
� 0�0 (eummcargw'll,Section 71)00)of D'v':om Sof ths Budar—mod to ls,iornCde)or TEMP MITER OR POLE(NST
[D to BLOGIADpI'IION [D DEMOLITION
a a ed exemption.Any violation nl
Xnfa.
Section 703IS by any applicant for a Permit objects the applicant to a civil Penalty of POWER DEVICES ❑[MPRNT ❑FOODSERVICE
Wim rrc mon Eve hnmdred dollars(SSS)t IMPROVEMENT
fS0 nn 1.
as owner of the pnrpertpor my cnnployer,with wages as their vJeamopenxeion, SWIMMING POOL IiLECT'HIC '1'HER
willd tit A and the Strutt tintendedofferedfo 1 Sc IBYI,Husme,s
yFo dune DIIIL6fS-Soot LCHES FIXTURE -/
a3o0 aneP 1 Cook:The Contractor's LicenseLa d r applyr ref
,,.,city who A 'Id orve,lit J Is or dor,snth Work hift,61 or than gh NEW RLSIULN'I'LAI.CLI:CTR lQ 17L �•
his own employees,Provided that such imPru e notintended 'Hared for .IcL FLOOR Ak iA
.sale,If,however,the building or improvement is sold within one year of romple ion.thetoxc /
crhuilder will hove the burden of proving that he did not build or improve impar'
pose ofsuleJ.
Fl 1,a,owner of the property,am exclusively contracting with licensed commotion ur x
construct the project(Sec.]BYE Business and Professions Cade:)The Contmnor's Li-
sense law docs not apply(11 an nwrcr of property who buildsor hnpoces,thenar,evil QTY. PLUMBING PERMIT
Who contracts for such pmjeas with a commissions)licensed pursuant it,the Contractor's F2ECEIVE
vLiicem
License Law. B&PCfnrhis PERMIT ISSUANCE
roicxet under Se' . lsreann
ALTER—DRAIN&VENT—WATER IIiAI VN.UATIfIN
Owner Dole J' NOV 131997
• s WOR S COMPENSATION DECLARATION BACK FLAN'PROTECT.DEVICE
ulfln rnearby ol'purjc,ynna ofmc milowmg dedmuoos',
(] Ihavc will mon 1mnvCeri!mord Con¢nt,cm,nmre for Worker's Conlan- DRAINS-FLOOR.HOOF,AREA,COND, I'`)�t S OWES 'I'YPEC'O STRU(THO
motion,as provided for by Section 3400 of the Lothar Code.for the performance of the It1%TUHILS-PEH'fRAP D 1
work lir which this permit is Issued.
El I have and will maintain Worker's Compensation Insurance,as rcyuited ny Seelnn
370orlhe hdan Cods,fmtheperfonnance nfthc work forwhillOn,permit is issued GAS-EA.SYSTEht-I INC.40U'1'Llill (KC GROUT' AYN
hfy Worker's Compensation lnsumncc artier and Policy nomhr are GAS-1?A.SYSTEM-OVER 4(CA)
Cerin: I'Ohey Nn.:
Gf.RTB'IGATE OP Ii%EMI'TION FROM WORKIiR9' GREASIVINDUSTRLWASI'EINTERCEPTOR BUILDING DIVISION FEES
COMPENSATION INSURANCE
(HasseNan neulnot heumnplcted if One pemit Ix for one hundred Jollun(S 10 ) GREASETRAY PLANCHECK FEE
ar Icss.l
Toy any the in the any manner so asI sun tom which this the W isiro'Compnll SEWER-SANITARY-l'lY)RM En.200 IT, ENERGY Ffili
not employ any Person in any manner so as m hwme subjcn m the Workerr'Compeer
O Z muen laws cf Caldron,Date WN'IiR IIEER WIVEN'1'IIiI.EC1'R GRADING FI'.I!
Applicant
z' y NOTICE TO APPLICANT:If.after making this Certificates of Eomprinn,you should WATER SYSTeM/IREATING SOI(S FEE
,�•I becnnne subject In the Worker's Corgscn,ation Provisions of the Labor Code,you must
forthwith comply with such Pmvininns or this permit slmll he decried revoked. WATER S17RVICE
0. Q PAID
CONSTRUCT ION LENDING AGENCY NEW RESIDENTIAL PLMB, SQ.FT. pair eiptp
U O thereby vffinnmat there iso com.dmcdnr lending agency too'he Perfannanee of
I.L. the work for which this permit is issued(See 307.Civ.C.) 'IOTAI
p Lcndcls Name TOTAL:
r Lender's Address HUH.DING ITEE
O. 1 certify that 1 have read this.,bruJon and stole that the aloe iolbmmnrm is r
F•' V) career,l a green'comply aiN all city and county ordinances and slate laws mining ern QTY. MECHANICAL PERMIT FF.L SEISMIC IEE J t
U Z bei lding conehvetion, ad hereby car—rift,repremmeives of this city in roar upon the
abnvommiti....d no,eft,fin inspcclion Purposes PERMH ISSUANCE ELECTRIC FCL?
(We)agree 1.savq indemnify and keep mmol"the City of C-Iftino against
liabilities,judgments,costs and expenses which may in any way creme against said City ALTER OR ADDTO MECH. PLUMBING IEE
in ...sequence of the granting of this pcmtit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONTOIN'1AIR HANDLING LED(TO 10.000CFM) MECHANICAL FEE
SOURCE REGULATIONS,
AIR HANDLING UNIT(OVER IU.(XO CFM) CONSTRUCTION TAF
Signnwm of AppEcanBCnmmnor Dam EXHAUST HOOD(WIDUC) HOUSING SH 1'I GRI'ION FEE
HAYARDOUS MATERIALS DISCLOSURE
Will the applicant or to am buikhr,occupart,uninr handle bazunlous mamrml BEATING UNI'1'C TO I(0.000 BTU)
as defined by the Cupertino Municipal Cade.Chapter 9.12,and the Health and Safety HEATING UNI'P(OVER 10.(0f)BTU)
Cash,lection 25532(x)?
❑Yes FI No VENT(LATION PAN(SINGLE RESI D) (AID
Uulu R¢ciPt x
Will the applicant or future building occupant use equipment or devices which BOIL ER—COM('(3HP OR 100,(00 BTU)
mil hazardous air cnntmmimams as defined by the Bay Atha Air Quality Management 'roT
District? BOILER—COMP(OVER 1110,00 IITU)
❑Yes F-1 No
AIR CONED IONER ISSUANCE DATA
1 have read the hmtdom materials requimmenls under Chapter 6.95 of the Culi-
I'nmia Hwhh&Safely Coda Sections 25505.25539 sold 25534.1 andentaod I If thc NEW RESIDEN'HAL MECII. SQ.TTI'. / Q -7
building dreh not currently havcamsant.that it is my resDmsibility,,nmily the rccupanr ` f
of the requimmenrs which must b:met prior us issuance of a Cmifcee of Occupamy.
Owner ofaxthooualagem One IOTA.: ISSUED try
` `� ! O
OFFICE