99120107 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PENON�LY
) ELECTRICAL
CITY OF rUPF.RTINO IP IT
BUILDING DIVISION APPLICATION/PERMIT TING PROJECT EDEN I MECHANICAL
BUILDING PROJECT'IDF.N'1'IFICATION
SANI'I'ANY NI', AI'I`LICAI'If1N SUHMII'IAI.DA'1
BUILDING AUDRCSS:
15� 4 fPo\Dv
&RCHTTCCTMNGINFFR:
PHONTRACfOR'1 NAME: LIC NU: NIC CON"IAUI.X
LIC NO: ADDRESSTACT: 1.1111orc BUILDING PERMIT INFO
�`` 8 yg�� ❑ Consultant Fees Paid by Applicant(Initial) RLOG HIJECT h R MECClll
LICENSEDCONTRAMOR'S DECLARATION Q'ly ELECTRIC PERMIT FEC JOB DESCRIPTION
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
�pZ with Section 9(XX))IdDivisinn 3tflhe Ruslncs,mm Professions Code,and my license is ' PERMIT ISSUANCE RESIDENTIAL,
F O in full foam and effect. ❑SFDWL ❑KI'ICl TEN REMODEL
Licca Class Lica APPLIANCES-REMDENTIAL 0ADDITEON ❑PLUMBING RISPIPE
U Da¢ Conlmclor
ARCHITECTS DECLARATION PANELS ❑MUCI'1-UNI"T ❑ ODIPTURM.
M
v Z I undeMand nn ,Ions shall he used as Politic records OZ`—n� y pu'ic«cord h10D11s UP TO 2(X)AMPS El[N1 PRIOR ❑CIIIMNEY REPAIR
W Licensed Po4cvsi ed 1111TlN )AMPS ,,rrff IMPROVEMENT SWIMMING POOLS
(1WNL'WRI111.DER DIiCLARA'1'ION OV TL
SAMPSPq& y(6 ATI I REMODEL/Rh:PAlli �DIiMOLITION
C,uW< 1 hereby affml that I and exempt from the Courtrai License Law for the wOTHER
4x d O following ream.Son...17031.5,Bmincss and Protea......Coda.A_y city sur county SIGNS HLES RICAL
W 3 LL F' which ex vires a unit t0 construct,alter,improve,detnolixh,or repair any structure
�.a--0; prior to ill i.'snmce,akso requires lheapplicunl for such permit u file a signed statement SPECIALCIRCUIT/MISC.
f, y that he is licensed pursuant to the provisions ofthe Conhacbr'License Law(C ,n `, COMMERCIAL,
LLyO� (commencing with Section A1001of Diviosm3 rather Folinessand ProlessionsCWe)or 'ItihlP.h11TGR OR roLE INST. 00,
O. o C thin he I'exempt therct'mm and the hasis fur the alleged exem,mtn.Any Oolmion of ❑NEW BLDG/ADDITION ❑DEMOLITION
W^vLLi Section?031.5 by any applicant for a Permit subjects lire applicant a civil Penalty m POWER DEVICES ❑TENANT El PLO[)SERVICE
F Z y am more than five hundred dollars(E500). IMPROVE hITINT
h (lir pup ny Y PIY lir g.nslh P'ns'I n, SWInIMINGPOOLEI.ECfRIC ❑OTHF;R
Co wild me voik.mid,heormatio,ism' t rid ff d for-le(Sce.9R1Jbusiness
W m Tal P I C d Ili G I I :L L d a n t pply t +wit of / OUTL[TS-SWITCIIES-FI% n
a 6^ p open y who Im Ids n Improves Iherton and who does:.,[I work himsell or li
his own employees,provided than such impmvemems are not imenJN or offer or N ih 'R S
SISQ.f4.
sale,It,lmvevcr,the buildingorimprovemenum
nt is.,uld within c yu'rideo ,ledo the I II II SQ:FT.BOOR AREAE
erbuilder will have the burden of proving Ill.,he did non build 1 IIVIFU-// DEC 2
past ofsale.). o � � + O 1999
FlI,as owner d the property,am exclusively contracting with lice_ n+ varier r v
conswn the projrel(Sec.ZfOJ.Business and Prof wo ns Ccde:) r s Li-) -
scLatw doors nm upPlY n+on owner of PrnlunY who builds nrimpn .)67il or,and, PI M GP. FEE
who commits forsveh pmjee0 wimncnnvacmgd liconwd,ursa ,It �Couractar' , By
License Law. li MIT ISSUANCE J
Inco Interim,under Sec. .B&PC hl o
ALTER-DRAIN&VI?NT-WATER(EA) VALUATION
Owner =Dam 90
s WORKER:SCOMI'IiNSATIO e ere .AR[)am RACK PLOW I'RIJt'E 'T D
CIiVICIi
1 l I hereby uffimlunder Pcnalryofperjuryoneofthe 611nwingecalamtiorsi .,y
Y I haveand will mainmin uCenilice Consent loself-insure for Worker's Crmpen DRAINS-FLOOR.ROOF.AREA.COND. STORIES YPIii- NSTRUCIIO
sadion,as provided for by Section 3]1X1 of the Labor Code,for me pension one oI the
work fur which this permit is issued. FIXTURES-1'ER TRAP
I have and will maintain Worker's Compensation Insurance,as m4dred by Section
t7M tf the LeMn CN0.frnhe perfonnanee of me work far which this pen_it is issued. GAS-EA.SYSTEM-I INC.a 0U1"I,ITfS OCC,GROUP Q AI'N �(
My Warkcr's Ctmpenonion Insurance carrier and Policy number um: _ GAS-ITA SYS'TTM OVER a(EA) `••'���/0-/ v
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' C.REASFYINDUSTRI,WASTE INTfiRCEPTOR
COMPENSATION INSURANCE: BUILDING DIVISION FRES
• (Thisneelion nerd mubecompleted if dM1C Permit is for one M1uledld Joll:ux(SI W) GREASETRAP '
I,,Ices.)ceI'f.ANC1IF:CK PER
I nify that in the peni_rance oflPc work lot iwhich this permit is issued,:shall SEWER -S
1ARVT1X1
ORM EA.21'1'.
not employ any Penn In any manner sr m ue+becomsubject to the Workers'Compen- ENERGY ITIIi
Z 'Minn Lown II California.Date WAT17H HEATER W/VEM'/Ii1.ECTR GRADING FRE
z Applicant
NOTICE TO APPLICANT:If,after making this Cenificam of Exemption,you should WATER SYSTEM/TREATING
F ? SOILS PEE
Partner subject In the Worker's Compensation provisions ut dee Lar Cade,you nmst
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE:
6 0
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB, SQ,PI'. PAID
I}m IiesiplM
L) p I hereby affirm that there is a construction lendingagency for the performance of
W the work lin which this perisneer
m:, 'mcd(S3097.Cls.C.)
F
pU Lender's Name TOTAL:
Y' W Lemar's Address BUILDING FILE
y 1 cenify that 1 have read this application and state that the above information is
(^ h affect.l agree to comply with all city and county ordinances anti laws relating_+ QTY. MECHANICAL PERMIT FEE SEISMIC FIB:
C) Z handing comxwdion,and hereby utnmd,e represemadvca ofmis city_+enter oqm me
abovo-lnenliomd pmpeny for inspection puryoses. PERMIT ISSUANCE ELECTRIC i+l'eE
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments.costs and expenses which may in any way accrue_gaimsssid City ALI'17 R OR ADD'IG MECI I. PLUMBING FEE.
in consequence of the granting of this pec t.
APPIJCANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-VOLNT AIR II ANDIANG UNIT(TO 10.0u)CFM) MECHANICAL FEE
SO' CE REGULATIONS p
`U AIR HANDLING UNIT(OVER IILgU CPM) CONSTRUCTION TAX
Signature rf ApplicanVContracmr G/ Uam EXHAUST',HOOD IW/UUC'q DOUSING MIT'IGA'1'I(1N 191E
IIAZARDOIIS MATERIALS DISCLOSURE.
Will the applicant or furore building uccupam sae nr handle he,rdous..medal II EATI NO UNIT 00 100.000 RTII)
as defined by the Cupcnino Municipal Code.Chapter 9.12,and me Health and Safety W
IT(OVER IU9.IX10 BTU)
Curtis.Section 2553210)7
❑Yes ACNn FAN(SINGhERESID) I'AIU
(� Dam Recripl a
Will the.,lieem or future wilding tpcu,unl use equipneem tar device'which P(3HP OR ITOOM1 I3"I'U)
_ n haimdous air contaminants as dented by the Bay Arca Air Quality Management 'l OIAI,:
District? E(OVER IpoNg)BTU)❑Yes "AlsoONEN ISSUANCE DATE1 have lend the hamnlousnmmriuls mc,m _mnds node,Chapter(05 of the Califnmim Health&Safety Cede,Sections 25505.25533 and 25531.I undentalld dal if the NTIAL MECH. SQ.FI'.buildn"dol'nod currently little a renanl.lhatd ismy ric,mobility,,notify theocem r tfl reyuiremcros which musbemm pdnnnissuance'if.Ccnilicam nl Oaupaa,.
Oxror aulhrriecJ ugrntDaleTOTAL: ISSUED BY:
• OFFICE