S 2968 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RUHA)INC-ELEC'I'RICA I. PERMI I'NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MLCBANICAI.
BUILDING 1'Rlljl!Cr IDR„1l'14'ICATION
BUILDING ADDRHSS'. SANI'IJ%BY NO, APPIACAI'ION SUBMITTAL DATE;
pE�t� TF-EE LAS _ Z 3-9j
OWNHWS NAMli VPHONE 2 CONTRACTOR'S NAME LIC NO:
I/IC -J I WC CONFROI,p
ARCHII'ECUENGINEER: LIC NO: ADDRESS: ❑
CONTACT• pilONp BUILDING PFRMI1 INTO
❑ Crnsultanl Fees Paid by Applicant(initial) dL�IIG/,ArM PLUMY M1IIiCIi
ld ❑ ❑ ❑
I.ICFNSHUCONFRACTOR:SDIiCLARAIION QTY ELECTRICPERMIT FEE
I hearty alfir t that I not licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
QUO wilt Scednn]INXI]orilivision3of the l{uvinrsr and l'ndcsxinos Code.anJnry license ix PURSUE ISSUANCh RESIDP.NTIAL:
Cm' in full core,and eked. ❑SFDWI, [:1KI'I CI{EN R17MOD171.
aUF U License Class I,ic'N APPLIANCE-S—R11SBAiN'rIAL ❑ADDITION ❑PLUh1BING R12PIPE.
FZW Lou Gmmuun
.QM OMUL1l.UNIT ❑STRUC -RAI,
ARGUE ILC["S DECLARATION
Fpm PANIiIS MOUIhICA'1'I(lN
O Z�
zo.z I understand my plans shall M..it as pontic records UP 10 200 AMPS
❑IN'fLk10R ❑CIi1MNEY kEPAIR
,C4tED LieOm"i Prof,....nail 2101-1000AMPS IMPROVEMI?NI' []SWIMMING POOLS
OWNEIR-BUILDER DECLARATION OVIiR IWIIAMI'S g4ir li RIi.VILDH1/REPAIR ❑DE;MOLIIION
CL C 6 1 hereby from that 1 am exempt from the Commanr's License Law it the
x�x d U I'ollnwing mason.(lection 7031.5,business and Prote%ams Code:Any city or county SIGNS ELECT RICAL ❑QTIIER '
1+131x,N which requires a permit to nnnlrurl,akar,improve,demolish,ar repair any sawlura
pQ prior to its issuance,also requires the applicant for such permit to file a signed stalemem SPIhZ1AL Cl RCUITIMISC.
�at,j . that he is licensed pursuant an the provision,of Commemrs License Low(Chapter 9
I�i1�00 cationneeei ag w all Section]WII)if Divisimt 3 of I he lhi6acssnad Pat csams Code)or '1'17M R MEIV R OR 1.01,1:INS COMMERCIAL:
a a e C that he is exempt ehcrefront and the basis for the alleged exemption.Any violation of ❑NEW BI.DGIADDITION ❑DIiNlou'rION
X-ti Section 7031.5 by any applicant for a permit subjects the applicants a civil penalty of POWIiR DEVICIS []TENANT ❑hOOD SERVICE
not nonlethal ve Or dreddoll...(55(X). IMPROVEMIiNT
2 01,m ottarroflhe romeny.in all employers with wagewes their sole landrnsutinn, SWIMMING POOL HIXCI RIC
F will Jo the work.and the stacmre is not intended or offered toru]c(See 70al.Bminess ❑Oi'111iK
1.'3 w and Pntfessiom Gale:The Claimant's License Law dans not apply to an owner of OVfLETS—SW'ITCIifS—FIXTURES
pec,n,who milds or im,nves thereon,and who does such ,,,it himself or through
his own employers,provided that such haprov inentv are not intended or oftered for NIiW RHS IUEN'lIA1.1?a: R SQ IT.
rete.
If,however,the building or improvement is sold within one year ofcompletion.the SR IT FLOOR ARRA S1SQ.IT.
ivater4cilder will have the burden of proving that he did not build or improver for put-
,v t of sulcal
E]L m mvner of the Pmpeny,am exclusively contacting with fcensad...tactors m 'r TA h:
mswe the project(See.11144,Business and Prohas,]ons CoJeBTBe Commcatrs I i
ml.aw docs nolapply roue owner of propeary who huddsor lntpooes mrmm,and Q'I'Y. PLUMBING PERMIT FEE
who russets for such prnjeas with a annhacmr1.v11icemeJ pursuam m the Conuallo",
License Lave PBRMIT ISSUANCE:
1 nm ecentpl under B h P C fur this
reason
AI;i'lik-DKAINX VIiN'r-WAIIiN(FA) Pte.----•-VA I:IJATION'I
Owns Dam // ONSI
M
IRKIER'SC PP: "IN DECLARATION HACK FLOW PROTECT'.DEVICE v)•\v N
I hcrrny a0;na tinder Pcnalty of E JuD one of w
the follow declaration%: I' �— `J 1.
I have and will nmimoimaCcnikcatcot Consent self-insure far Worked%Coepcn- DRAINS-11.00R.ROORARI:A,COND. � it S'rOINII. T$PII COIN Sri RUC'I bus
cation arrovidtaifor b,Sternal]71X1 fthe TrM CNc I th I+tf rat of the Ifs APR 2 3 1999 .�N a
work) 'h huhk, conit J II\'I URLS 1117R TRAP
FlIhave d vallon...I W Ike,',C ploalleal 1 .- dbySection
3700ol the LeMa Cade.lor the q.nornmi,ruffle wod.fitfwhmhtlfspean,,ixssueJ GAS t,A.SYS'TEM IINCA UII'I'hErS OCC.GB(lUP oU
My N'nrker's Comprnvtion Issuance carrier and Policy nwnber arc:
Currier:
Policy Na: G,\S—EA.SVSTEhLO1VHft4(IiM n„
lcli
CI:BPICAI'13OpHXHMPIIONPROMWORK17RS' GHIiASHIINIIIJSTRI.WASTEIN'TERCIE19OR L._
COMPENSATION INSURANCE: BUILDING DIVISION IT.HS
(Ilhsccdourard nm becmuplmediftheparyou is fornnchunJraddellm(SIW) GREASETRAP
lPLANCDECK Hit
m est
Iamily that in Hteperlinmaneeofthe work forwhieh mosprmtil i%tesued,I shall SHVER-SANITARY-S1'ORM RA.200 IT.
not employ any Person in any manner so as to become,object to the Workers'Compel- ENERGY ITeE
Z .stint Laws of Cullfrriu.])are \NATER HHATIiR WNHNITIUMjiCR GRADING ITB.
0Applicantz tn NOIRCH TO APPLICANT:If,afar making this Certificate of Exemption,you should WAFER$YSTEM/1'k EiAT1.NG SOILS FR
F bttomc odjeG m the Wodce%Cmupcnsatinn pnvosim%of the Labor Crede.you must
Icoliwith comply w.In nut.provisions orthio pa;u.it dull he deemedrevoked. WXI PR STRVICE
y 0 PAID
CONSTRUCT ION LENUING AGI;NCY NEW RF_SIDHNTIAI.I'hMU. SQ.FT. Dote great,4
Thereby affirm That there is a conamctlan lending agency home yerf.muree of
�. the work lir which this Mrmit is is sued(See s?1097.Civ.C.)
0 Lamhr+,Name lI Tl'AI,:
V Lender's Addreve 'I OTAI:
r W I cenify,hat 1 have read thin application and%tree Ibm the above infonnmion is BUIL G FEE
F' 2.A comecl.I agree moo.aid,wkh all city and armnyord...... and qam lawsrenningto QTy.. MECf1ANICAI.PIikMI'P PIr,E SCIS (CITE
U Z building constitution,and hereby authorize representatives of this city to enter.,in the
utovenmmacted propeey for inspection purT,wc% PERMIT ISSUANCE ELF,CI' CFHH
f We)a8ree rat,ave.ndantnd,and keep cants%%the City of Cupertino against
liahilitio.judgn¢mz mus:rod expert%eswhich stay lately wit?.xa eagainst.md ChY ALTER OR ABDTO MHCU. PLUMBI 'FFB
in n,elucnce of the granting of this permit.
APPLICANT'UND17 RS'TANDS AND WILL.COMPLY WITH
ALL NON-1'(IIN'To ATH HANDLING ONI (To IIIjXXICFM) MECIIANICALF1117
SDkt N('I:RECUT DIII��A{{111DNS. (� P*I?-3/�—1
�T( � Ir `� ���/ AIH HANDLING UNII'(OVHN Il1.UIq CPM) CUNSTHUCr11lN'I'AX
nnmrc IdAI ItmVConnveor Dam HXUAUSI'HOOD(W1DUCp) HOUSING MITEGA'I ION FUR
HA%ARDOUSNIAITRI .:DISCLOSURE:
N'ill the applicant ore future building occupant sere or hamllc hmudnus material IDEATING UNIT fHI IIXLIKKI IiTW
a%del fined ray the Gmertino Municipal Gale.Chapter 9.12,and the[]catch mN Strait
Qnl4 Section 25532(a)P ,,,/ IIHA'I ING UNIT'(GVHR IIN),1000 BTU)
❑Yrs LTw VIiNTILN'ION FAN(SINGLE RFS ID) PAID /
Dtt
ale Receipt TO
Wal the appliamt or tunas handing oce.pam ase eq.ipnmm era devices which B(ITLHl1—COMP(3111'OR IITT(XX)BTW
mit hmmd uic air conl:umnear,as defined by the Bay Area Air Quality M;m paccOul '1'
DistriG' BOILER—COMP(JIVER 100,000 BTU)
Yrs �f{✓
AIR CONDITIOINI!R ISSUANCE DAT E
I have mud the farmers,oe,Sc nmmrie 5 tequi 533 an under Chapter 0.95 of the Cel'r I i-s
form."doesr Safety Cocle,ea,,I,25ani 25505,25533 and 255A.I undmmml]hut if the NIiW RESIUENTIAT.AIECIT. SQ.Ell 2 J • Y
building does not cu rEly ich to
ttemm,that it l%sty,vol ibilitymaotily thwxcviumt
t
06 yuir nN ichm a �na pdnr It issuance nfgC+xlikame nil Mupancy �p
xOwner or nntht tla8mtl Ilam JG' TOTAL: ISSUIiD BY:
OFFICE