99080108 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-KLKCIRICAL loasiont Nu.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING FRO.D?CT IDEN'1'I'ICAI'ION
BUILDI GAIDRESS'. SANIIAItYNO, APPIACAI'ION SUBMI'I'IAL DATE
035 pro-ml6tiecom 4A - �17
OWN ITS NAME: /� i/'I qP{[_ � MU/%MI!/NSA OR'S �/A 1^�/�./ter �O N/C CONTROL k
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CONE'ACE': PHONE: BUILDING PERM11 INFO
❑ COnsaltanl Pecs Paid by Applicant(Initial) BLDG ELECT PLUMB MINCH
bo,6�i- I14F.L P 5 27 -07 7 ❑ Fat� ❑ x
LICENSED CONTRACTORS DECLARATION E
ELECTRIC PERMIT 17EE
1 hereby afmn mm 1 am licensed ander provisions of Chapmr 9(cr,mmcnrins JOB DESCRIPTION
140, with Seetinn 7000pd Divi%ion3oOhe Husinasand Pmf,s,ions Code.andmy l amore iv RF IDEM I
140, tL-7 IT ISSUANCE
i FK� In full loran:nnJ cffcc -'0 OtFlf7 :I�DWL ❑KITCHEN RIib10UEL
QUU hlccn%c Class Lic.M ANCES-RESIDEN'HAL. ❑ADDITION ❑PLUMBING RE-PIPE
Doc Gnllnamof
HQa ❑MULTI-UNIT ❑MODCTURN.
AHCHI ECI'S DIiCLARAT )N
f,❑rn LS MODIFICATION
ZOyV'jz lend,-tend mY glom zhall be usnl ax Puhlic record, 21N)AMI'S
O Z^O ❑INIFiR10R ❑CHIMNEY REPAIR
F�_W 4ram.ced l'rufec,i(nnl .NI AMPS IMPROVEMENT SWIMMING POOLS
Ir :F- OWNER-BUILDER UECLAIIA'I'ION IfNN)AMPS E]HATH REMODI? REPAIR C:1))It 0L[TION
x C Q I hemM1y affect that 1 ion exempt from the Contractors License Law bre the /
xa O M V following no(Section 7031.5.Business and Rofessions Craw Any city m county ELECTRICAL QQTHER orf—r1N1-/Y`y^
LLl�+LL y xhich reyuirc%a pennil m cunstrua,alcor,improve.JcmnlisM1,ar report any slrucmrc
F�OQ pr I I I. 1 th ppl If hfw 'It 11 '6 J'r rcnlenlAI.CI RCUII'/MISC.
yp��y th:tl JI II p t'h C I' I I (Chpm,9
I�a11O) (em amity wilt Section 7000)or Do,t'i 3slthc Buk us% dlofsirt:C'sk)nr Mh1 ER OR POLE IIsST. MER
a a e 1, that he is exempt mcrcfont and the hasis for the alleged exemption.Any violation of El NEW RLUGIAUDITION ❑DEMOLITION
Section 7031.5 by any applicant for a pennitsubjeas the applicant a civil NouliyorR DEVICES El TENANT
❑FOODSERVICE
wt more than Ine hundred dollars($500). IMPROVEMENT
~Z6 C1 mowner of the PrOlsem.or my cmpinyses With wages as their.side ctmgrcmatinn, MINGPOOLELECIRIC'�� Idrd,work.and the Mmcatmisnot mended or offcmd frrnle(Sel.AWa,[3usncs% ❑OTHY;R
nd 11 icssfsm Cor�C'Ilty Contractors Liccnm Law aces not opp1Y m anowner ofJi1F-SW]TCI{I?S-Il%'NR
6 3 progeny who build,or improves themon,and x hit dries such work himself or through
his own employees.provided that such improvements am not immnded or oRered for NE\4'RLSIUGNTIAL ELEG:R SQ
sale.If,however,the building or improvement i,sold within one yumofcompletion.me SQ.FI FLOOR AREA S/SU I°f.
unbullJcr will have the burden Ot proving that he did Dol hard ur improve for poo-
pow ,I oda.).
❑I,m rmner of the proliso am exclusively contracting will licensed contracts-h. 'IY)IAh:
ammo the project(Sec.70W.Business and Profession%Cute:)The Cmormons LL
Iselaxdoes not apply to an owner of progeny Who build%or improves thereon.and QTY. PLUMBINGPERMIT FEE
who contracts for such pnricci%with a contractor,)licensed pursuant to the Contractors
License Law. ,li&P C tirnhi.,reason PERMIT ISSUANCE
Ll I am exempt under Sw.
ALTER-DRAIN k VENT-WATER IIIA) VALUATION
.Owner Date
W'ORKER'S COMPENSATION DECLARATION RACK FLOW PROTECT,DEVICE D O
I hereby alfa.raa Crmhyofal Coaonealthehillnwins Jorker'C
s
❑ Ihuvennilw111 nminlumu Ccnilicalunl CanscnOOsell-inxurefor Worker',Cninprn- DRAINS-FLOOR,ROOP.ARI3A,COND. S'IOltlljg TVPIi CONS'I'Itl]C'I'ION
,alio-,us provided lin M1y Section 37k)of the I.m.,Cod,ler the pcif ranee of the
for%Lich this penial is issued. FIXTURES-PER TRAP
x I have and will maintain Porkers Compensation Insurance,as myuired by Section
3700 of the Labor Crile.for lrerfenna������rrrnrrrce of the work for which this Permit is isueJ, GAS-FA.SYSTEM-I INC.J OUTLETS OCC.CROUP / y'N O y
My Wnrke'a Ompemwi r tnmA Policy nn n �O(�
ji6o
Carrico 't Jpgtce c' r Policy Nu.. GAS-EA.SYS'PhY['rvRR9'fEA
CERT E IGO6FOEM PION PROS W R ERS';
L-UMPENSAIIUN INSURANCE GRGSUINUU I�I. , ASTPf�),'TLf�I'IOH ^r ( BUILDING])]VISION ITIS _
(']Tis section need roil he completed if the permit is forone hundred dollars(SIM) GREASETRAP w I�
nr Iexe.l - I'LANCHECK PEE
I«roty litrnl bepeHinm:mccul the work to, W11,his permit A..sued,[,hall SEWER-SAN[ kY-S,' :IiA FI'.
Dol enNloy any pe ns onyx, ranee a, ,became"Piecl is the Wode"COotpem ENERGY IIiI?
m in stn -
Z cation Laws of Califumio Date WATER HHA'IE '/VENT/IiiECIR GRADING FUH
Z O Applicant
NOTICE TO AYPLICANI':IL afar making thi%Cenifame of Rxemplion,you should WATER SYSTEM TING
^n.4P SOIL S mE
rr become%object to me Workcr%Compemanon provision%of me Labor Crrae,you must M
WInnnwimonn:ply with such,arO,inr1oI hi,pennfLrhall nudecmedrevoked.
Q PAID
DZ CONSTRUCTION LENDING AGENCY LMB. SV.I?. Dale Receipt
U 0 l hereby afGnn that there is a conswetion lending agency for the Nd()" ce of
D. h the week for,Lich his permit i.e.issued(See 3097,Civ.C.)
TOTAL:
p U Feaala,e Name
Lcndcr'x AJdross 'IY)TAL
� 9 1 e tify the,l limn, .it his application and Mute lint the ahnve information isIt111LUING TIiIi
F-' 4' sICAL PER FEE
y rornct.1 agree to comply with all city and county ordinances and stole laws rclmin m $Ii1SM1 P
L.)Z building construction,and hereby unhorirt representative%of this city'to enter.,.,he
aMrveanentiorcd property nor inspection Purposes [LEC PEIi
(Wc)agree ar.,avo,Indcmnffy and keep hamileu the City of Capons agaimt
liabllllic,jmlgmcme,a....andexpen%c,Whicbanay In any wayce,orm ngainxt,md City ALIEROR ADDTOMECIL IIIAPv1131NOI;III
owynance sf the gnmting of this Penni.
APPLICANT UNDERSTANDS AND WILT.COMPLY WITH ALL NON-POINT AIR HANDLING UNIT OO I0.0000:14) MECHANICAL
SOURCE�hGULATIONS. kkl��4 /`/�
f-16 y�l AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Slgnnwrc of ApplicunuConu.nmur Urate EXHAIJSP IIOODIWIDlIC17 IIUI]SING MI'1'IGAfION PL'li
I IAZARDOUS MAIIi A_ )ISCLOSURE
Will the applicant or future h tilding oompam store or handle M1aruNOm nmterial IIIiATING UNIT LTO ItNkIXXI li'IU)
as defined by the Cupertino Municipal Code,Chapter 9.12,..are HcNIM1 and Sareq HEATING UNIT(OVER Ilp,(MM BTU)
Care.Section 25532(x)'! �-yam
C)Ye, '�"" VENT LAI ION FAN(SI NO.LB RP_S I DI PAID
Dula Rccdplq
Will the app)icant,or future building cecupam use eximpmem nr devices which BOILER LHi'OR 1 W.,nif B'N)
mil harurdous air contnminams as defined by the Bay Arca Air Quality Menagemem Tf-,\L:
District?
BOILER-COMP(OVER 100.000 ITU)
❑vn, CRo
I hove reudtlm hamnlno,inertial,mart to undo Chapter 6.950 the Cali- Alit CONDI'I'I ONER ISSUANCE DATE
u 533.
romia Ilcalm not
comm Calc.e I alm .that i 25533 atu12553J,I undo-sand teal tf Inc NEW HESIDCVI'IA1.A1EC11, SQ.FT.
building&e,noaurmnlly M1avea¢nanr.IM1m it is mr rcsrymsibility%%notify Inc cecupunt
of mem I mem,Wmen mast t,pd�lo- - eofa -rra�e a�w
Ownmluehurvnl ngcnt l �an IYt TOTAL: ISSUED BY:
OFFICE