99070055 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 97411 10 Pro 07..7
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMI
H"71,DING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIF'ICAT'ION
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMI'1'I'AI.PAT
Ia94Q/4 NoQ7HGLW SG , CEJ`69Z7)d0 �-
CWNER'S NAME PHONE
PaHONE: CONTRACTOR'S NAME: LIC NO:
ILN9 y.L 0LV11 #Oo 777076 y N/C CONDROLa
qWCHITECDENGINEER: LIC NO: ADDRP_SS: ❑
CONTACT': - PHONE: BUILDING PERMIT INFO
❑ Consultant Fetes Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
�� (�' ❑ ❑
LICENSED COMIRACTORIS DECLARATION QTY ELECTRIC PERMIT FEF,
I hereby affirm that I am licensed under pookinns of chapter 9 mnmmeneing JOB DESCRIPTION
WOZ wish Section 9tX1s I)iviainn3 al the(Easiness and Pnslesians Cndu,unJ myliccnsc ix RESIDENTIAL:
W p p I'IiRh11'1'ISSUANCE
a<Uy Lcenefall Classnd elfcct. ❑SFUWL ❑KITCHEN REMODEL
zo License Claes hien APPLIANCES-RLSIDENTIAI. ❑ADDITION PLUMBING RE-PIPE
F ZQ Ed Date Contractor
stn ARCHITECTS DECLARA'UON PANELS ❑MULTI-UNIT [I STRUCTURAL
Zcmz I undcrsnmd nay plans shell hemiduspublie rcucrds MODIFICATION
p y:p UP'102WAMPS ❑INTERIOR [I CHIMNEY REPAIR
F.NF W Licensed Professional 201-I(XOAMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODF.IJREPAIR ❑DEMOLITION
o-s�71 Q 1 hereby affirm that 1 am cnensn from me Contractor's License Law for the
xx s+yU following reason.IScnlan 90315,Bnsinr,,md ltnrcxaoas CWC:Any city ter county SIGNS ELECTRICAL ❑OTHER
al a las 41 0,0 U1471--
IA which¢quires u permit m conswct.alter,improve,demolish,or repair any swemre
5 primin its issuance,also requires she apslicum forsuch permit m filensignedsatcmem SPEC1ALCIRCUIT/MISC.
E t2} that he is licensed pursuant w the provisions of me Contractor's License law(Chapter 9
=yy'<C) (commencing with Section7")of Division 3 of the Business and Proleusiuns Core)or TE MP.METER OR POLE INST OM
L 1,e C that he is exempt therefrom and the Nasi,for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W-N Section 7031,5 by ansy applicant fora permit suhjcets the applicum m a civil penalty of POWER DEVICES
n more than Bic hundred dollars(15(X)). El TENANT FOOD SERVICE
�ZG I.as uwnerof me norm employees with solea as their sale compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
f20 prase Y Y P Y B Penni OOTHER
[- saldothcwark,and the structure isnnts License ded
awdosnotapplyt for nale(Sec. an
`
i 3 ness
°—° and I`rnfcssians GSJe'.Thc Cnntracusr's Liccnne Law macs not apply m an owner n( OUT
LETS-SWI'fC11F.S-FI%TUR s�4
propcny who builds ora iproves th ocon.and who doe...such work himsdrar mroragh
his own employees,provided that such improvements are not intended or offered tot NEW RLSIUEN'IIAh ELECEN •✓
sale.ILhowever.Nehuildingorimprovement ismldwithinoneycwl)fcompletion.tbc SQ.FT.FLOOR REAS ASQ.FT
.-builder will have the burden of proving that hand oat build or improve fur pur- /�r� �`•)\\.`
pose of sale.). I
❑ I,as owner of the proiterty am exclusively contracting with licensed contractors tet TOTAL' is r 4999 ,
construct the project(Sec.)0W.Hminess and Pmlkrminns Cntle:)'The Contowdo,Li- �)„5 r�
cease law docs not apply tet an owner of property,who builds or improves thereon,and QTY. PLUM ING PERMIT Emit
whocumrens rorsuch srojcas with uconnetortJ licensed pimuanuo the Carucc ors \�
License law. PERMI"r ISSUANCE �� J
❑ l am cxemptinder.Gr > /�T»/�_.B S P C for this reason
Owner Dole J
ALTER-DRAIN&VENT-WA'i'ER(EA) \\\ VALUATION
/ WORKERS COMPENSATION DECLARATION BACK FLOW PROTECE DEVICE ) l�
I hereby affirm under penalty of aUtaq one of me following declarations: ) v
t1 I have and will maintain a Cerebrum of Comunnrself-insure for Worker's Compete DRAINS-FLOOR,ROOF.AREA.COND. `' S461RIES TYPE CONSTRUCTION
,cairn,as provided Icor by Section 3](X1 of the Labor Cade,for the performance of the
work for which this permit is issu.J, FIX'PORES-PHRTRAP
1 have and will maintain Workers Compensation Insurance,as required by Section
3700ofthe Labor Code,Iota the Performanceoftee work for.Inch this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS C.GROUP PN
My Workers Compensation Insurance carrier and Policy number Arc: C� 3 y/
Carrier: Policy Na: GAS-EA.SYSTIiM"OVER 4(EA)
CCICI'IIICATEOFESIiMPDON FROM WORKERSO
' GHFASEINDUS'I'RI.WASTEIMIERCEPIOR S
COMPENSATION INSURANCE BUILDING DIVISION FELS
Obis sectionneed not becompleed ifthe pemsit is formic hundred dollma CHoO) GREASETRAY
PLANCHECK FEE
ser Less)
I cenify that m the PsKmonanccot the work ba which this penin is issued,[shall SEWER-SANI'T'ARY-STORM IiA.2001"T.
not employ any person In any runner so ms,,become suhject m that Workers'Cnnapem ENERGY ITB
Z anion Laws of California.Date WATER HEATER W/VENT/F.LECR
ZApplicant GRADING FEE
NOTICE TO APPLICANT:IL alter making this Ccmiftcae of Exemption,you should WATER SYSTEMrtRFBTING
V) SOILS HE
heen F� fortm,th c Object m air
Waderro Comp,or DiN mail stealons of the Coban Cale.you must
(nnM1with cnntply wllh such pmvisians or this pernlit chat(he deemed revoked. WATER SL'RVICIi
Q
;Dz CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FC PAID Date Receipl X
U O I hereby affirm out there is a conswction lending agency for the performance Of
V. F-' the work for which this Permit is issued(Sec,3007.Co,C.)
O U Leede,.Name TOTAL:
lender's Address I
TOTAL:
O. 1 cenify that 1 have read this application and.rate that the above information is BUILDING PEE
Fat,, correct.(agree to comply with all city and county ordinances and sone laws relating to QTY. MECHANICAL PERMIT FEE
U Z building construction,and hereby uumorize representatives ofthis city to enter uponthe SEISMIC FEF;
above mentioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE
We)agree In". indcn nify mW keep harmless the City It Cuierino against
iabilities.judgmems,cn.a and expenses which may in any way acme against said City ALT ER OR ADD TO MECIL PLUMBING FEE
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT CTO 10.000 CFM) MECHANICAL HE
SOURCE R[GUL 'f10
(�l(J •7 h AIR HANDLING UNIT(OVER It1.UfIfI CFM) CONSTRUCTION'TAX
ipream N AppliesusConnralur Data -1 EXHAUST FOOD(W/DUCI') HOUSING MITEGA11ON FEE
HAZARDOUS MATERIALS DISCLOSURE
Will be applicant lir future building Occupant store or handle humnfous material HEATING UNIT LTO lo0JKK1 BT U)
as defined by the Cuporino Municipal Code.Chapter 1).12,and the Health and Safety
Code.Section 255320)! I IHAFING UNIT'(OVER I 0iBTO)
❑Vets pl JJ Na VENTILATION PAN(SINGLE RESID) PAID
De¢ RmciptX
Will the applicant or future building occupant use equipment or devices which BOR ER-COMP(3HPOR 100,008 BTU)
emit bmutdous air contaminants as refund by the Buy Area An Quality Management T'OTA M.
District'I TOILER-COMP(OVER l00.(fN)BTU)
❑Yes Cad'
Ihavc radthe hazardous maadals requirements under Chapter 6.95 of me Cali- AIR CONDITIONER ISSUANCE DATE
fitmiu liealm&Safety Gde,Sections 25505.255)3 and 25574.I unJemmmd that ilthe NEW RESIDENTIAL MECH. SQ.FT. �-Y
ftaJklmg a ((J hmvealcnan60atitlxraym.Ponsibilit,nananydrac,up:ntl
mer as qfN w ast It met faro.miswamenfa CenlOcune Li Occu
I/ 7
)wnc mroa nizcdagrnt Dec TOTAL: ISSUED BY:
OFFICE