S 1557 (2) APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PI:Hp11T NO. 1557
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 5
RUILDING PHOJECI'IDEN'I'IFICATION
IIIIILDINGADDRIi55: SANITARY NO. APPLICATION SUBMITTAL DA'I3
OWNER'S NAM y' \ PHONE: CONTRACTOR'S NIsMR LIC NO: NIC CONTROLp
Asm tl £ o685'32i(� I DVEIGL
05
wnscr$�I.e'Tdw AND/ESSd, LIC NO: n ,� f�RNLbAJGTYI'.b•vr ❑
CONTACT: PHONH. BUILDING PERMITINFO
�Q, L�UNT(7/V Jw����7aZ ❑ Consultant Fees Paid by Applicant(initial) BLDG ELECT PLUMB MEC
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PIiRA71T FEE
1 nonny dfima that I an Beenam n�a:r proviamns Ir enamor 9(elinatneaeinag JOE DESCRIPTION
O fqZ with Selina 2aXBof D,,Won 3 otitle Rusinc,TumIPli...on,Cndc,and mylicenew is RESIDENTIAL;
full fierce and effect. Aq I'BRMI'I'ISSUANCIi
ceUV License Class LIC.M \ \ ❑SEUWL ❑KITCHEN REMODEL
y_W Dmt Gmtmctor \� APPLIANCES-kLiSIDHNTIAI. El ADDITION ❑PLUMBING RG-PIPE
F,Dm
ARCHITECTS DECLARATION \ MODIFICATION
PANELS ❑M111.T1-UNIT ❑STRUCI'UI2A1.
Z O'r'Z l undersand my plans shall be used os public records
OZ—,m '� UPTO210AMPS _ ❑INI'F.R[OR ❑CHIMNEY REPAIR
Licensed Professional 201-IOBOAMYS IMPROVHMIiNT (]SWIMMING POOLS
OWNLik-BI111,DER DFCI.ARA'I'ION OVER ItXXhAMPS ❑BA'T'H REMOUF1/Rlil'NR ❑DEMDLI'T]ON
I hereby ulTrm that I am eacmpt from the Caron rs LieenscLaw for be
Lily O C U Indust,ancon.(Section 70315.Rosiness and Pmaecsious Code:Auy city arcanntY SIGNS PL.EC1'RICAL ❑OTIIFR
w 3 Wye which requires a permit to consrucl,ale,imprnvv, k,ouI xh,m rcpuir aniyAulmctum
F-�OJ
prior o its issuance.also requires the applicant for such permiuo fie a signed smtenvi SPECIAL CIRCUIT'/MISC.
99W6�
that he is licensed pursuant the provisions of the Commidor's License Law(Chupter 9'
oc 0 conn mating with Stiction 70so of Doeion 3 it an Bnsincss mA 11 Intme,0uh,oa �� 'r IiM P.M MPR OR POLE I NSI'.,, COMMERCIAL'
a LL C that he is exempt therefrom and the basis for the alleged exemption.Any vioa uou Ifs ❑Ny W BLDG/ADDITION ❑DEMOLITION
Xmw Section 7031.5 by any applicant for a peorm subjects the applicanrto a civil pendtyla \ ,pOWER DI;VICES r \ X*x/NI1
W^m F.NANT ❑FOOD SIiRVICE
�Spnot mom Than rise hundred dollars Woo).
❑ Ln.owner if l he pmpcny.or my cmmlyecs with wagcs.as their sole cml,adgomion, , WIMMINO POOL BLECI'IHC 1 'kOVEMIiNT
C F-owill do the work,and Ne structure is not intended orolfered for sale(Sec.9044.Busine ❑
ss OTHER
W m cem
and Nu sions Code:The Contmm's License Law docs not apply to an ownTLETS
owner of OU -SW�TCHP_S.UI%TURES
3^ propmy who buihlc orlmpmves theme,and who doe,,meh work himself m donnish
his own employees,provided that such improvements am not intended or offered for NEW RESIDBNTIA`.ELECTR .Q y'.
sale.If,however the building or improvement is sold within one year ofcumpletion,the \� \ \`� SQ.IT.FLOOR AREA $/SQ.lel'.
owaremilder will have the burden If proving that he did not build or improve for par. s P A 1 D
pose of sale.). t
I,m nwnerof the progeny,am eadmively aammcting with licensed counmcro ,\, TOTAL'.:
coot t theproject is '044 R : ss d I reasons e de.)16 'a
t cors I - -+r✓ ��� O
c I J Iapplyt 1, p ny h Faulds 1 .tl s) . : htfir PERMIT'. PEE AI
4 MS!g
LiiI toe(f a hg ; t ,1 aa� t (,1 matt tbeG Connote a pearl G,p an c ec comple on
License CITY OF OUHth I l 0
❑I cscmgtnnJcrS c. ,B&I Cf tMss.
r Date r arR V Wner�accep imp VALUATION
t WORK HR:S COMPHNSA'I'ION DECIARATION 8 nS,
r po aa<corre' +n a
1 hereby ufllrm under penalty ofparjury one of the following Jcdvraduns:
I have and wil l maintain a Certificate of Conant toself-insure for Worker's Cum ISSI nSllan .(rdBV 8R61A aED.1\\1 STOEGRS TYPCCONSTRUCTION
cation,as provided for by Section 3210 of the Labor Cale,for the gerforromwof�h£ ' • - \
work or which els permit is issued. o
1 trove and will maintain Workers Compensation Insmvnce,ate rnryired by Se' n ay�a�
37004 the Wise Cash.far the perfnm:aace of the work forwhich Nispermitiaics TIO{ �ryS RJB' �/ �r -� p� CCC.GH0 AI's
My Wodsces Compensation Insurance career and Policy number are:
Cnrricr: I'nlicy No. GAS-EA.S ' V' 4(P )
CERTIFICATE OF E%CNIM ION FROM WORKERS' Fr \
COMPENSATION INSURANCE O \
IlU DING DIVISION_P_EILS
ffhis aedinn nein not tewmplGrd if the permit is Grt Ane hunJrW dollen lSl W) GRCASB"RAP Y \�
or IessJ PLANCfIF.CK §s
I certify Nat in the performance oast work for sahijM1 Nis thele is issued,l \
not employ any person in Any manner so as to hcrnme subject to the Wnrkern'Cnmpem ENERGY FEC
O z scOn Luwc of Culitorniu.Dao ER IFIAT I \
Z 2 Applicant : GRADING PI31i
H rA NOTICE TO APPLICANT:If,after making this Certificate of Exnnption,you sh
lecone suM1lem na the Worker's Core, euon IF..s in eof 4 SOILS FEE..
LA belhwith comply with such provisions or this permit shall M detned revoked WATER S17RVICI:
� z CONSTRUCTION LENDING NEW RHSIDLNTIAI.PLMII. SQ.IT. PAID
i
U O I herehyaflinn thw tbereis a auodrooinn lending Agency liar de,Felt....naneenl' �'D's, Res iptp
[L FP: the work for which this Permit is issued(Sec 3101,Cih,C.)
O ULender's Name 'TOTAL:
Lender's Address TOTAL
F0. I cenify that I have lead this application and slnln sm the above immolation isI.. - BUILDING FII\
(A Conten.I agree to comply with all city and county cminances andante laws leading to QTY, MECHANICAL PER MIT FEE
U Z building construction,and hereby authorize represcumlives ofthis city sonow.pon the SEISMIC FEB \a
uww nuntionesl Pmpeny for inspection purposes. I'CRMI'T ISSUANCC
Wd agree to sale.indemnify and keep harmless the City of Cupertino against EL.BCTRIC FEF. %
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD T'O MECH.
se<ryenee of the granting of this pumilt. PLUMBING FET; 'N
APPLICANT UNDER STANDS AND WILL ONIPLY 'LTH ALI..NON-POINT AIR HANDLING UNITTO II no CPM)
SOUNCF REGUI NS. MECHANICALITE
AIR HANDLING UNIT(OVlik In,Ofl(1CFM) CONSTRUCTION TAX !
pglicunV Ins or pec BKHAUST HOOD(W/DUCD HOUSING MITIGATION FEE \
9ARDOUS MATERIALS DISCLOSURE
Still Wu lthcu team or uurc haddingakalpantsoe or handle hazanlous madriul 1113ATINCUNI'B'fT01(q,NX)BTU)
as defined by the Cupeman Municipal Cotte,Chapter 9.12,and the Health and Safety
Cade,Section 25532(aU HBATING UNIT(OVER 100,1X0 BTU)
E]yes C]No PAID
VIiNTILA'TION FAN(SINGER RES]1)) Date Receipts
Will the applicant anon building occupant use equipment or devices which BOILER-COMP QHP OR 100.000 BTU)it hazardous Air contaminants
ants as dehnN by the Bay Arca Air Quality Management TOIAL
❑Yes C]No 1301 L1:12-COMP(OVER IIX),INNI B'I'U)
I have raid the meandous oeterials requirements under Chapter 6.95 of the Cul6 AIR CONDI'I'IONI3R ISSUANCE DATE
Iorma Health&Safety Cade,Sedin:n 25505,25533 and 25534.1 understand Into it the NI:W RFSLDF.NTIAL MPRH. SQ.FT.
building does not cumently c oalam,area is my resrydsibility to notify fhciccopenl
entsw ' m t t or issuance of a Cmifcae of 'upon
Z
A maul r agent 1 c TtlTA 1.: ISSUED BY:
OFFICE
f '. .
- Inspection Query* Specfic Permit 6/4758
PERMIT# ITUS ST SITUS`=STREET Cot# INSUESCRIPT_ InsT.yp UATEDESIREsDateDone Inspecto. Units:P_as5/Fail SCotle_
S1557 10300 TANTAU FOUND./REBAR 4/28/98 4/28/98CC 2�P IP
S1557 10300 TANTAU IFOUNDATION 4/27/98 4/27/98JS 2P
S1557 10300 TANTAU REBAR 5/4/98 5/4/98 CC 2P P
S1557 10300 TANTAU REBAR 5/5/98 5/5/98 2 P P
S1557 10300 TANTAU REBAR 5/6/98 5/6/98 CC 2P P
S1557 10300 TANTAU STORM LINE 5/8/98 5/8/98 CC 2P P
1557 10300 ITANTAU I REBAR 5/14/98 5114/98JS 3P
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