S 2987 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL I'IiRMIT NO.
BUILDINGDIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL
_BUILDING PROJECT IIIENTIFIC'ATION'
IiCd,U1NG ADDRESS' SANITARY N(l. APPLICATION SUIIMITI'AL DATE.
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NC:: CO RACI'(OH'SN �T LICN ��
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GFRTECT/F,NG ER: 1.11 NO: )DRIB ��/ ❑ 43 O
CONT PITON'
PHON�y'Js'� r—/� {•/ BUILDING PERMIT INPG
„`Q/llc /�-�✓ ❑ Consultant Fees Paid by Applicant(Initial) IiLDG ELECT PLUMB MECU
❑ ❑ ❑ ❑
LICENSEE CONTRACTOR'S D[CLARATIO QTY. ELECTRIC PERMIT P88
hereby umrin Nat i am licensed under provisions of Chapter 9 aammencing JOB DESCRIPTION
a�O00 with Section SBfgB ofuivisinn 3 ofthe Business dProbe...... h,ralmylicame is
� n full fnrccomod! 3 CJD PERMIT ISSUANCE R - ID NTIA n
QF.VV License Class_( Lic.M �O ❑SFUWL [I KITCHEN REMODEL
NQL Dam_!! Contra APPLIANCES-RESIDENTIAL ❑AUDITION El PLUMBING RF,-PIPE
ARCHITI3LT5 D:L R ION PANELS ❑MULTI-UNIT ❑STRUCTURAL
C z y 1 unJersmnJ my plans shall M used as public recnN. MODIFICATION
UPTf13BBAMPS ❑INTERIOR ❑CHIMN17Y REPAIR
W LmenseA Profesvonal 201-1000AMPS IMPROVEMENT [I SWIMMING POOLS ,
g Ym,',j OWNEIn lawLDERmda,CosFT10N OVER I000AMPS ❑BATH REMODEUREPAIR [I DEMOLITION
yy C�Q 1 hereby affirm thw I am exempt from the Cnnirudnr's License Luw for the
X 34U fallowing reason.(Section)BJ L5.Business and Profession,Code:Any city or county
YY1I tr-y which myuires a permit to mnswe.than,ins SIGNS ELECTRICAL []OTHER
.LL.Oa prove,demolish, fi it ar any structure
lin.J prinno ns isxunnee,also rtgwresthe applicant forsuch perminntilcatigneJ sraement SPECIAL CIRCIIIT/MISC.
y dm'he is licensed Pursuant no'be pmvisiomol'the Conouelors License Law(Chapter 1)
x-00 (comntrating with Section7000)nfl),oxion J ofhe Busine—ral Professions Crde)or TEM#METER OR POLE INST COMMFRCl�
d y o that he i,exempt therefrom and the iasis fon the alleged exemption,Any violaion of ❑NEW BLDG/ADDITION ❑DEMOLITION
iLLCI y Section 9131.5 by my allklnm fora Prmitsuhje Ynihu applicant to a civil penalty of POWER DEVICI!S
not more than low hundred dollars 55W) ❑TIiNANT
F Z is l ) ❑FOOD SERVICE
�_� ❑L as nwnersef Ne property,"my employccs with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
C will do the work,and the structure is not intended oraffered forsale(Sec.](H4,Business OTHER
6 3 and Professions Cale:The Counselors License Law docs not apply n,1 an owner of OUTLITI'S-SWITCHES-FIXTURES
properly who builds or improves thereon and who does such work himself or through
his own employees,provided that such improvements am not intended or refined fon NEW RESIDENTIAL El=R SQ CE
sale.ll',however.the building or inlpowemaa is.sold within one yeundmnlplsinn Ne PSTORIF-STYPECONSIRUCTION SQ.IT.
wnc
r-builder will have the hurden of proving that he did not build no improve fur par-El 1,us none,nl'the property.ant moditavely contracting with licensed.rnaaehas to TOTAL:ohomet Ne pnljcet(Sec.](N4,Business and Professions Cale:)The Cnm__...i-
c�s Law docs not apply to an owner ofpmKny who hadde or improves thereon,and QTY PLUMBING PERMIT FEEwho contracts forsuch projects with a contractors)licensed pursuant to the Conhaculr's
Lice se Luw.
❑lamexemp'underSec. ,ii&PCformisreason PERMIT ISSUANCE war, Dae ALTER-DRAIN&VFW-WATER(EA)WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE1 hereby. irm under penalty of perjury one of Ne following declarations:I hnve:amd will nalnmin a CenifimneofConsent to sell-insure lin WorkersCoun,th- DRAINS-FLOOR,ROOF,AREA,COND.cation,tx pruvidcl lot by Scction 3700 of Ne labs Csxic,fm'he etri mence ofWe
for which this pemlit is issued. FIXTURES-PER TRAP
w 1 u c and will mnimain Worker's Campemation In mma.,as remained by Senior
d the Lamm-Cade.fonhe performance ulthe work forwhiclnhis warrant is issued. GAS-EA.SYS]EM-1 INC.4 OUTLETS
My Work Comsat fo ,Tin a carrier and Policy Thcr tm: OCCGROUP APN
Ca�eo Policy No. GAS-EA.SYS'I EM-OVER 4(EA)
CkiR'1'IF1CAi'E OF f?XEMPI'ION FROM WOR'aare
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
(Thissceflannced not becampletedRohe permit is far one hundred dollars(5100) BUILDING DIVISION_ PBBS
ur Ites.) GRI7ASE TRAP
L cenify that in the pefformancenf the work for which Nis PLANCHHCK FIFE,
Permit W.,issucd.LehaB SEWER-
nor employ any oc,on in any manner so as m Mcume anhject m she Worker.'Compete SANITARY_STORM PA.200 FE ENERGY FEE
Oz scion Laos of Cnllfomi:l.Data WAI FR IIEATI;R WHEN I'MLECI'R
z NOTIAWliant GRADING FEE
h became i TOAPt)the AMPWaker's Compensation
Nisoseumcmf the
Eatmptiook.yen
WATER SYSTEM/TREATING
a ^ become object m it Workers Compensation pmvisiom of Ne Wlpr rest
you must SOILS FEE
G I'onM1wiN comply with such pmvirion,or this penNtehJl he denncd revoked.
4 Q WA'1'IiH SERVICE
az
CONSTRUCTION LENDING AGENCY
ggy eocrmuansxdaNEW RESIDENTIAL PCMB. SQ.FT PAID
)Q IbercbYuIimmaltharcsu cuvwch...
Date NeeeiprM
[lr F the work for which this permit is issued(Sec.JI)9'!,Civ.CJ
Lenders Name Al
G I=rx Ad lies err r�l� TOTAL:
0. 1 certify Nm av read tti1 applicmion and state that the amse information is TOTAL. BUILDING FEE
rq correct l agree to comply with all city and county ordinances andsrate laws adatingto QTY. MECHANICAL PERMIT FEE
UZ building consrrvc'ion,and hereby au'hanze reprcsena'ivesufthis caymenterupon tine SEISMIC FEE
above-anamianed property for int,ce inn puHlusu,.
(We)a PERMIT ISSUANCE
( gree m1 cove,indemnify end keep ha in an the City of Cupcnst s against ELECTRIC FEE
inemastaljudgments,msoan ofthisspaes rmi.hmay in any waymrneagninet mid City ALTERORADUTOMECH.
APPLICANT
cn N11 NogranANIA AND WILL C 'I,Y WITH ALL NON-POINTAIR HANDLING UNIT 10, 000 CFMI
SOUR �R GULATIO �f MECHANICAL FEE
•�J/L• AIR HANDLING UNIT(OVER QBfp CFM) CONSTRUCTION'TAX
rgn nfApphcmuJContst Data MIAUSTHOOD(W/DUCD
HAYARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will theapplicant or future buildin6occupanl stare orhandle hazardous material HEATING UNIT LTO Hp,M)BI'UI
ns defined by the C.,aremo Municipal Code,Chapter 9.12,and the Health and Safety
Coil,Section 25532(a)" HEATING UNIT(OVER 100,110 WFU)
❑VasNn
VENTILATION FAN(SINGLE RF_SID) PAID Dae Receiptp
Will the applicant t 'mum building daemons use equipment or devices which
at hazardous air contnmiiva as defined by the Bay Arca Air Quality Management BOILER-COMP(3HP OR I(X),IXXI BTU)
Disriel'1 TDTAL:
❑Yos -dNn BOILER-COMP(OVER 10,!1(X1 BTU)
1 have rend the hazadlem,materials reyuiremar,under Chapter 695 of Ne Cali. AIR CONDITIONF,N ISSUANCE DATE
hlmia Health&Safety de, ,tions 2550.5.255 J and 25531.1 umkmanJ Net if the
building tlslet of cu by attract
'ch
rcsgvlcibilityto n a- the uccupunt NEW RISIUT;NTIAL MECH. SQ.FT.
(exterI the/�v Jr authorized 1 1el,rtFilr}et erlilic:duoy(Z�1-
u6em/ CC�I � ((((�`
[).,a1)tTOTAL: IgSU[D BY.
OFFICE
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PROJECT: WALGREEN5 #4416 REVISED:
LV®�ESCO LOCATION: CUPERTINO, CA
SCALE: NOTED SALES: DESIGNER: RANDY W.
LIGHTING a SIGNS D.N.
® DATE: 4 16 99 ,
72g3-99
N• LOS ANGELES • PPHOENIXgppROVED BY: FILENAME 87253-99 DRAWING <: R_
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