99120062 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY !� qJ Z aJ &2—
CITY�F CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PF.RMIT PLUMBING-bB:CHN7[FIC.
RUILDIN[:PROJECT IDENTII'ICATIUN I'lawww"r imp
RUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAI
1021 I g <79
74 Z � � —.
OWNER' AM` PEON': , 1 NTRACIOR'S NAME: LIC NO:
SIC CONTROLp
RCEI TECT/ITNGINEER: LIC NO: QD R"SS ❑
Co PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BIAG ]itIiC'1' PI UMB Mlicil
s LICENSED CONTRACTOR'S D.CLARATION QTY ELECTRIC PERMIT FEE
1 hereby ofarm That I am licensed under Provisions of Ch.pt„ ntu
9(.memcing JOB DESCRIPTION
CZ with 3oObe B.Jon,ard Profe,,,i ns Cr Je,nnd my license is RESIDENTIAL
1+lOwt /q 1'ERMI'I'ISSUANCIi
nlullftorce un0 SSE 'a1� '1HK� ❑SFDWL ❑KITCHEN REMODEL.
U F Licence Class C- YnL Lic.N
Q U APPLIANCES-RP_SIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
y Q L Dar, Contmr
F7w ARCIIITECI'S DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
ZpwZ IunJenwndmy don,bell be used ospoblic ...rk MODIFICATION
--4— UPT0200AMPS El INTERIOR ❑CHIMNEY REPAIR
E-�1='y1 Licensed ProNssinual 201-1000AMPS IMPROVEMENT [I SWIMMING POOLS
CQ y pER Iqq AMPS ❑BATT]REMODEUREPAIR ❑DEMOLITION
Y� OWNER-BUILDER DECLARATION
C C M1tomb flirm That 1:un exmn I Iron the Contractor, Ave...I,iccnxc Law fur the
k3 a U following consort.(Section 7031.5,Business and Professions Cole:Any city or county SIGNS[LF,CI'RICAI. []OTHER
W a H which reyuires a permit to construct,alter,improve,demolish,or repair any structure HiQ
pQ prior to its issuance,also rectums the applicantfor such permit o file a signed statement SPECIAL CIRCUIT/MISC.
that he is licensed p...unit nothe p...monsof The Contractors License Law(Chapter 9
al E51(m......eneing with Section A)0)of Division 3 of the Ruxiness and l4nfsxi.ns Cide)or TEMR METER OR POLE INST. COMMERCIAL:
a a e a that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
WMa pen
Section]031.5 by any applicant for a permit subjects the applicant a civil penalty of POWER DEVICES� tmone than Ove hundred doll.rs LIMIT)), 1 ❑TENANT [I FOOD SERVICE
�>' IMPROVEMF.N'I'
gSQD �I,axnwncr nffhcpmpvly,ornrycnlployreswith wugas nsthciy xuL E
to eomp...alion, SWIMMING POOLECTRIC
2p. willdo the work.andthe suucmrelsnot inrendedornBemi forsale(Sce.70HU Business ❑OTHEk
tW m and Prokr,mirw Code:Tho Contractors License Use docs and apply to an rentor of OUTLETS-SWITCHES-FIXTURES
property who builds or improves Wood.and who docs such work himself or through
his own empbyees,provided but such impmvemen s arc not intended or offered for NEW RETS I DENTIAL IJ,ECT
P
SQ IT.FLOOR AREA
sale.IL however,We budding or improvemm�t is sold within one year of completion.thAREA $ISQ. I'.
wrsu.milde,will Itinerate Immen of proving that he did act Wild nr improve for pur-
pose of alc.)y
1,as owner of the property,am exclusively contracting with licensed contractor,to O
construct(be project(Sea 7044,Business add Professions Code)The Cmutionne,Li-
verve Law does of apply,.trimmer of property who builds or improves memos.and QTY, PLUMBING PERMIT do, 'EE
who a,mmas for such projects with a vordmasr(s)lianmd pursuaauo rhe Contractors
License Law. PERMIT ISSUANCE
O 1 nm,xmom under See. ,B&PC for mason
Donner nae ALTER-DRAIN at VENT-WATER(EA) VALUATION
W'ORKF, COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby afOrmunderpenally of
o,perjuryoneof the following dedlser's ns:
nin. ,andwillrtto,byection 3cae of the LaOo Cod.for Cher Wurkseace mpen- DRAINS-FLOOR,ROOF,AREA.GOND.
saint,us provided Inc by Section J]ql of me labor Cudc,for the performance of the S'1DRIFS TYPE CONS"TRUCTIC
work for which this permit is ismN. FIXTURES-PER TRAP
1 have and will maintain Workers Compensation Insurance,as eximmd by Section
3700 o(,he L.bnr Coda for,he I'd. mmceof,he work frr whichhItthhlx pmmil is isrurd. GAS-ITA.SYSTEM-I INC.4 OLI1'LETS OCC.GROUP /�fP /1
CarrieraMy rk r.0 peu'i ran a cy NoPolic.:q,ypyeJ/w-31 GAS-EA.SYSTEM-OVER 4LEA)
5 7..J l/
CERTIFICATEGI�t (EMETION FRO YlCG+tt*' g79
COMPENSATION INSURAN h 7��9•' GRGASEIINUUSTRL WASTEIM"ERCEPTOR
BUILDING DIVISION PEES
is section need not hu,mutdcud if the perou Is fortune hundred dollars 151 W)
nr less)(ThGREASE TRAP PLANCEIECK FEE
I certify that in the performance oflhe work for which this permit is issued,l shall SEWER-SANITARY-STORM F.A.201 FT.
not employ any person in any summer so as m become subject o the Workers'Conifer- HN'ERGY HE
z ,Z at i Lawsof Culllnrm,Dam WATER HEATER W/VENT/P,LECI'R
2 Applicant I GRADING FEE
py NOTICE TO APPLICANT:IL after maki.,,hix Cortisone of Exempt..you should WATER SYSTEMTREATING
become snhjoct is me Worker's Compensation provisions of the Labor Code.you must SOILS FEE
W
forthwith comply with such provisions or this permit shall he deemed revoked WATER SERVICE
a �
= Z CONSen isacONLENDINGAGENCY NEW REy1DENTIAL PLKIB. SG,FT. PAID
I hereby whicaffirm,hauhem isaco (See,30lending agency for the performance of Date Recciptp
�� the work for which this pemtit is issued(See,3119],Civ.C.) �
U Lender's Name TOIAL
I.cndcLs AddresslilLA
TOTAL:
1r' CL. 1 certify mat I have read this application ani state that,me ubsve inf.rme,ion ix BUILDING FEE
N ,naecr.l agree ntcomply wnh allnry and county ordinances and seem laws relaingm QTY. MECH NICAL PERMIT FEE
V Z building construction,and hereby authentic representatives offhis city tnamernpnnme 'SEISMIC II!E
abmo-mentioned mnpery for inspection pm,,,,w,' PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against In� fil=RIC FEE
liabilities'udgmems,cos¢andexpenus which may in any way acme againa said Cis ALTER ON ADD TO MECH.
nay n o fhc goo sisof tutu permit, EUI PLUMBING IEE L� Irl}
APPLICA 'I C UI?kSTANOS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT LTO 10.000 CPM)
SUURCG i .A'TI 'S. W�UNICA§Fli '! IJ
AIR HANDLING UNIT(OVER 10,000 CFN) fin
CONSTRUCTION
HAZARDOUS
II
gnaw plicuRDate EXHAUST HOOD(W/DUCT)
IIAZARDOUOUS MATERIALS DISCLOSURE Al HOUSING MITIGATION FP,6—i"
Wilby the Cupertino forum Wal Code.
Chapter
armor handle Health
and Safety HEATING UNIT(TO 100.000 BTU)
E de,Seel by the Cupertino Municipal C,da Chapter 9.12,and the Ilcahh and Safcry
Code,Section 255121n1^. HEATING UNIT(OVER 100,0Cq 111 U)
❑Yes F1 No VENTILATION FAN(SINGLE RE,SID) PAID
Will no,applicant or future Wilding occupant use eyuipmem or devices which Date Reedit N
,hma.duus air cemarriamr,m defined by me Bay Area Air Quality M....enter, BOILER-COMP(3HP OR 101.000 BTU)
UTA
istricL❑ ❑Nn HOLLER-COMP(OVER I00,000 BTU) �
I re, aJ t -haraNnes materielsAIR CONDITIONER
requirements under Chapin 6.95 of the Cali- ISSUANCE DATE
forma Hcalrh t y Cast .ectinnx 25505,25533 and 25574.1 understand that if the NEW RESIDENTIAL.MECH. SQ.FI', / )
buildingioex ;rvca former,,hut it is my respnmihpa
ilhyto notify the occun, G
of the require ¢h most M me,prior It,issuance of a Cerifica,9 of Occupancy
r aahofiond.gent Date TOTAL: ISSUED BY:
OFFICE