S 0198 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING. 1A,ECTRICAI. PI 11T No �I f1
BUILDING DIVISION APPLICATION[PERMIT PLUnIHING-MECRANICAI- J 0198
RGH,DING PROJECT]DEN'TIF'ICATION
SANTTANY NO. AI'19JCA'1'ION SUI{MI'ITAI.DA"
UILDI G S
O FSIS
eCN /�I'RA
NAME: LIC NO: N/C CONI'RULx
T i"ENGIN 1 LIC NO: ADDRESS.
C NACT: PHGNH:
F1 CoBUILDING PERMIT INTO
Consultant Faces Paid by Applicant(Initial) HLIX: ELI!�I' PLUryv{ ME H
I,ICENFIiI)CONTRACIORS UIiCLARAUON QTY ELECTRIC PERMIT FEE JOB pESCR/I 4F'"1LI'O`N
1 hereby affirm that I am limned under pmvisims of Chapter 9(commencing
0a'Z wnM1SmtionvlingofDis.cion Jnflhe B.,inexand Pmfexainn.Cure.andmylicen.ein RESIDENTIAL
in full fora and effect. ISSUANCE ❑ '.)WL [I KITCHEN REMODEL
at UL)li- Licxnm Class Tic.x APPI.IANCES-RESIDENTIAL DUITION ❑PLM
UBING RE-PIPE
.Z, Date Contractor I MUTA I-UNIT' ❑SIRUCTURAI.
m ARCHITECTS DECI.ARATION PANELS MODIFICATION
ZFpnZ lunderstand myplonTshall beeyedmpublicnecmds DP TO 200 AMPS ❑INTERIOR LI CHIMNEY REPAIR
OZ-0
(:.�Fy1 License]Pmlcssinnal 20JALC1AMP5 IMI'ROVEMEN"I' (]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER AMPS ❑BATH REMODEUItIiI'AR LI ON
Q J x_—
C 6 I hereby affirm that 1 am exempt form the Camrsema"Ureme Law for the ❑(yEliliR I
L,X O6 U following rcavnn.(Section 7131 5,th eincs,and Professions Code',Any cityor county SIGNS FrFC`PRICAI. .� ��-���
61'3 W F' which requires u hermit m conduct,alter.Improve,demolish,or repair any hairlineF'LL'OQ prior m its issuance.atm requires the applicant file such perminn file asigned,l mem SPF.CIALCIRCUIT/
f }•, Thad be islieexed Pursuant to the provision,of the Crntracmr'a Twelve law(Chapter 9 COMMERCIAL'
131�p0 (commenei,with Section 7000)Of Division 3 of the Business and Pndesdom Cndc)art TEMIt O VL- NST.
Q.X.ty y that h<is tempt therefrom onJ Ne basis for the alleged exemption.Any violin of ❑NIiW 11LDG/ADUI'fION ❑DF:MOhITION
.n 4. Secano FD l.5byany aPplirm fora permit subjects the applicant tit a civil lKnalty of POWER I ❑T1iNANT E)FOOD SERVICE
W m IMI1ROVEMEN'1'
manalmtban live hundred dollars($5(gp.=Q SWIMMING POOL .1; 'I'kl❑ I.as owner of the property,or my employees with wages lomeTule compenmtirn. ❑O'IHI:R
F will do the work,and thearucturc I,not intended ornrtclN for late(Set,7(144,Bu.sines. OUTIIT9 SWITC .S-FIXTURES
TWA m and Professions Code:The Comestibles License Law Jens nnl apply to an owner of
el'3 property who builds or improves thereon,and who does such work himself or through NEN'HESIDCNTIAL CLI!CfR SQ ET. '�
his own employees,provided that such improvements am not intended of attired(or �iQ�Ff FLOOR ARIA $ISQ,IT.
sale.If,however,the building or improvement is sold within tine year of completing the
r-hudder will have the burden of proving Nal he did oat build nT improve for pun V II -//O` //p /� ,
qct of Tale.). �%' �Vll l)
has owner of the n em sine s r I contracting 'N:)The
onmremom i- 'TOTAL: //o
e preps y, e y tiro rate ing w, I�
rnvauct the project(Sm.71DJ,Business xml I'mfessions GMs:)Thc Commnur's Li- FEE V 231997
nm Law docs nsnapplym an control property who builds,,(imp rovc,flummrrod QTY PLUMBING PERMIT X997
whocnnvumsI we mje is with nominate Iles)I'tensed pursuunttothe Comranrn'x /
Licca. FERMI'I'ISSUANCIi P
0I cr S' it do P C lin his las c
ALTIiH-URAINK VIiM'-WATER(HA) C� I, ball LUATION
Owner cess Dae
WORKE :COMPENSATION DECLARATION BACK FIAWPROUPEC..DEVICE
�F�UPERTiNI�rMtNl'
I rehy affirm under Penalty of Perjury One of the following declarations.
Ih a and willmainmin uCcniticutent Crosson self-insure iia Worker's Conlpcn- DRAINS-FLOOR,ROOF.AR EA,COND' STORIES I YI'I;CONS'I'RUCI'IT
ca,provided for by Section 3700 of Thu bather Cad,for the perfrmtnnctof the
work fill which this pecten I,i"nod.
FIX'I'UNI!$-PEN TRAP
Fl 1 have and will maintain Worker's Compensation Insurance,us required by Schism
3700of the I,hor Cale.(onhe lerformanceeffle wed for which this permits iseucd. GAS-IiA.SYSTEM-1 INC.J OUTLETS OCC.GROUP MIN
My Wnrkds Compensation Insurance currier and Pal icy number am: GAS-CA SYSTEM-0VER J(EA)
Carrier: Policy NOT
CERI'IFICA]'17 OF EX17MM ION FROM WOR KI!RS' C.REASE/INDUS'I'RI,WASTE I N I'ERCIi'l OR
COMPENSA'T'ION INSURANCE. Ol11LDING DIVISION 1'I!li5
(Iii wetionnealnmbecomplenddNe pc.itkforanchundreddollaolSI1XA GREASEI'RAP PI.ANCHECK FTE
tines.)
I Iccni(y that in the pertannameof the work for whicM1 this pcnnitis issucd,lshalt SLOWER-SANITARY-STORM F.A.200 ITT ENIiHGY FEB
not employ oily person in any manner so as to become subject o the Workers Campen-
Z 'Zion Lnws rl Culifam"a.Dula WSJ 17R fll!A'I"F.RWIV I!NrIELECTN GRADING FEE,
Appl '
'Zf.I y NOTIC6'1'0 APPLICANT:IL afit,making this Ccnifiche of Exmnption,you should WATER SY$TEM,TRUAIING SOII.S ITE
> become subject In the Wrrkce,Compensation Previsions of the Imbs,Cada you mush
[+1� forthwith comply with such provisions or this pemtilshall be deemed revoked. WATI!R SERVICE
Q PAID
CONSTRUCTION LIiNDING AGENCY NEW RISIDENTIAI,Mlsi SQ.FE Das Reemin4
I hcrchyaffirm Ihnnhere iso ennsmuch IIcndingagency for the perfomtame of
W2 the work Icor which this pcmtit is ivcuell(Sec.3197.Civ.C.)
O Isaler's Name 'ICTAL:
} Lt1 lender's Addlnss BUILDING FEE
1 certify that 1 have read this application and site that IM1e a,,information is
rF. N c rzen.l agree mmmply with ell city and county ordinances and ew¢laws mining to QTY. MECHANICAL PERMIT FI:Le SEISMIC FEE
1.,) Z building construetion.and hcrchy an Inaee re,w,vmrh,evdth,city R,calmpon the
ahuvo-meminncJ Property for inTPmdnn Fuqu,nes I'I!kMIT ISSUANCE IILIiC'I'RIC FEE
(We)agree m r .n mnify and keep harmless Ne City of CuFenino agoing
liabil'niex,juJgmems mu an expenses which may in ny way uceme against sail City qI TIiR OR ADU TO MIiCII. I'LUMHING FEG
In Of cgesmi of Nis permit.
APPIµANT I E S D .1 st WITH ALL NON-POINT AIR HANDLING UNIT 10.000 CFMI MLCIIANICALFEIi
CB '
AIRIIANUI.INGUNI'1'(OVER 10,0(XICFMI CONS'IRUCTION'I'AS
wumn TcznU npumar
EXHAUST HOOD(W/DUCP) HOUSING MITIGATION IgiE
HAZARDOUS MATER1AES DISCLOSURE
Jl the apphimat nr future buildingtetatem state or handle baaallous material HEATING UNIT(TO 100.0i BTU)
as de"ed by the Catarina Municipal Code.Chapter 9.12,and Ibe Health and Safety 111!AI'INC UNIT IOVI!R I(NI,gXI BTUI
C u.Scednn255J2(a)'!
❑Yes Fl No VIT LATION FA N(SINGLE REST U) PAID
Dare Receipt It
Will the aphieetnnr future building aeupant use equipment or devices which BOILER-COMP(IIIPOR IW,WD 11PUT
,.r hamNous air commitments as defined by the Bay Area Air Quality Management TOTAL.:
he'll W ITTER-COMP(OVER 11X1.00(1 BTU)
❑Yes [:1 No
Alit CONDIIIONER ISSUANCE DATE
1 have reod the har.IrJous tit)ns ds 5,255 3 under4,1 prod 6.95 tthe CaR-
amid Hcahh ne Safety Code.Sections 25505.is an,sad 255JJ.1 undcnmal Nm if the NEW RISIDENTIAI.MIiCH. SQ.I'I'.
ouilhe OT,ms net s,which have a tenet Print
o is ua nsof a Certificate
m ratify cc«cupam
of the nquirtmen&which must be met porno issuance of a Ccnificare of Occupancy.
Owner or authorized agent
Date 'TOTAL: ISSUED BY:
OFFICE