99120078 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY U
CITY OF CUPERTINO BUau1Nt:-ELECTRICAL �" PL MITNO
BUILDING DIVISION APPLICATION/PERNIFF PLUMI;NG-MCC IAN ICAI. �Ip�q}pJ/1��y�]
it I BUILDING 1'It(1.IilCT IDENTIFICATION SAA rAIf NO APPLICAr10N SORNITTMU.DAYE
HUILIIINGA RFSS. A - - / q
OwNER'S N M� u' _ l It IM Ll CON(tA�F N�� -;m LIC NO
G 1 Gl1 NIC CONI'ROi,#
1 UI GPENGI lilili, I.IC NO ADORES ❑
l ie'k Pee [ alcla�l �I _9�Gloo7
CONTACT' 71 API{ONE: ' I FUILDINGPERMIT INFO
I/ ❑ Consultant Fees Paid by Applicant(Initial) I ELECT PLUMB MECH
El El
LICENSED CONTRACTOR'S DECLARATION r
QTY ELECTRIC PERM1BT ' ITC
1 h«eny.dfirm min l am 1tien,«I Under provlslan+ol cnarmr 9(emlmmencnns -. •'. ' • � JOB DESCRIPTION
DaZ with Seavnn]INIU)OfDwlaonJal the Buaness and Pmfessimn Ctde,soil mylmen+c is RESIDENTIAL
Fop in 1u 11forceanJelfed. I'IikMIT ISSIIANCIi
❑SFDW. ❑ BiNREMODEL
I I.Iccse Cl. Lic." APPLIANCES-RES1lENAL AUDIfiON ❑PLU hNING RE-I'll'E Q U T
EM One Cottonton,
ARCHYIECI"S DECLARATION ❑MULTI-UNIT ❑5'fRUCI URAh
ZpyZ IunJemm�J my plans shall heated a+punba re eoN, PANELS MODIFICATION
0z - UI'TO 201 AMPS ❑INTIiR10R ❑CHIh1N1iY REPAIR
Lurm,d Professional 201-IOBIIAMPS IMPROVEMENT 0SWIMMINGPOOLS
(IWNER-BUILDER DECLARATION �. -
_ aVlik 1111111 AMT'S ❑Ngl'11 kIiM01]I.I.IREPAIR HCIATION
Q 1 hereby alBnn Thal 1 am exnnpt from the Convenor',L¢clr,e Law for Ili_
,�('0 M U following reasmn (Section 70315,Business and Professions Case:Any city or county SIGNS EI.1iCYRICAI. ' OT{IE!
1+134 hush requires a perms to construct,alter.Improve,demolish,or repair any so eons-
�� pour rod...... .e,eh.rcgmree0m o"Ine in for snch......un You acted slacroart SPECIAL,CIRCUITIMISC -
r�} that he is licensed Pursuant the pureisionsof the Counselors Liana Law(Chapter 11
n1�G00C Bommenemg with Sema)a]((ay.fDnnsmn3oflhC BO,mv,wnJ Professions Cwlq nr I 'THMP.NIL3PR OR POLE INST I COMMERCIAL:
P.a c LL that he Is erennpl therefrunm and the basis for the alleged exemption Any vmlauon a• ❑NEW BLDG/ADDI'YION ❑DEMOLITION
best 0]131.5 by anyipphcam[or a permit sublens the applicant meamt penahy :VICES
t more Then I've noodled Jallau lSANq L ❑TENANT El POOL SERVICE
Sp ❑I,s owner of the property,or my c'mpinYen with wages us llmmrsole ammpen+amn, SWIMMIN '.ECTRIC 0THER F.MLiN'I'
e
is ill do the work,and the aru<wrewnm intended Or OBeredfnrsalelSec.T(Ipl.Iti noes ❑OTHIiP
W 3 m and Probe aaonc Code The COmmewr's Licence Lew does not apply ,,nn Owner 01 OU rI.EY _y; !1(.(_- .K ITRES
property who birds or improves thereon,and Mot doe,such work nunsell or Ihrnugl
his mwn employees,pawneA That such improvements are not mmoded nr oliered for NEW RESIDENTIAL.HLECTR Q� 22ff�� J
ale.If,howeser,a cbmidnngonmpmvemenussold within Oncycmnf eampleuon,the ^ �\\ �
SO IT FLOORARIeA SISQ 14
r-lmider will have the burden m1 prating that he dud not build or improve for pur. `�'Y
f I"calaalc.) ' ��\� ,10
❑L as nonce Of the Pnlperi am esOnveely containing x ith heenxd comtmclmn I )
curwuuct the Praw(Sec.](IW,Hmmess and 1'naoanns tilde)The CommmOr+LI
we Law does not apply to an mu net of propeny who builds or Improve,thereon.and\d(]"I •' PLUMB �t
ln`contracts l or such looects will n contraclan l s)I a used pursuant to the Contfaahlr 4 d =
Licence latw. ERMI' NCFa„
❑ I am eser,a under Sec .B&P C for don,reason
1
1A.TF 1 Attt•4VENT-WA )C i VALUATION
Owner One
WOR KER'S COMPENSATION DECLA RATION � PPP
BACK P ICI
Ihaehy al mat under Certificate of foliating deductions ka. CJ per,mr,ore�In,sti uuadfidby eCion 370Ot,h,Lahr Coda. a for Workers Coml¢n- 1 .COND STORIES(' TYPE CONSTRUCTION
morn,us hick this for by Session AOB of the :nhmr Qnlc,for the pem,nnancc 01 Ih,.
work for which ihls pcmut n ncueJ, �I PV! -PER'(ItAI"
Fl 1 have and will maintain Worker's COmpen,.nion Instion as reymreJ by Suetin.. 1
J]W ofthc LaMrtCWe,for the perfonnance Of the work for whmh thl,Permnnnwcd, GAS-EA.SI'STEM-I INCd LEI'S LICE.GROUP �APN�
My Worker,Cnmpemniou Insanmce earner and Palsy nunlhe'are.
Canner Policy N- GAS-IiA SYSTIiM1�,/VV gIIiA ka..,,��
CERTIFICATE OFIi ATION'IINN FROM WORKERS' I GREASEETNDUSTRIKA49- F ffiRRi 1 BUILDING FAVISION 111i11-S�
COMPENSATION INSURANCE 11
1'fhnc sechnn need not Ile nnnpleted rtihe pennnnfnnme hundred dollars(S IIN) Y -
GREASH'rkAP
or Ices m (�, PLANCI IIiCK PGIi
I certify that In the perfnnnana of the unrA fnrwhmh this perms nnweJ,l shall I SEWER-SANITARY-STORM IiA 2(4)17. d!
not employ any person m any....v,,,,a m become offer,to the Workers Compen- jT'1� ENERGY FEE
Oz savor Lawsof Canfmnia.Dal^ WATER f 1EATERWNEN'UELECTIR (.f�ADING FEE
Z O Applicant N, --
Ey NOTICE TO APPLICANT If,after making dos Cemficate of Exemption,you should WATER SYS'1'EM7RIiATING 1
accurate subject the Worker's Compemauon provisions of the Leber Code,you ma,l SOILS FEE
� � funbwnh comply with suchpra,,um,or this perms shell ire deemed revoked WAMRS1iRVICE -�
In
z CONSTRUCT ION LENDING AGENCY NEW RESIDENTIAL PLh1B SO Pr PAID
.UQ l hereby aRmm thanbere is a emstrucunnlending egeney fort he Pcpamance Of Dam Rccapl#
W. the work for which this perms i,Issued(Sec 314)].Ctv.C.
TOI'AI:
0 F Lender .a
's N ,,,
U Lcnder'+AdJre,c 'I'(IIAL 1 -I
,YI Ltd BUILDING FGI3
1«mfy that 1 have read his city 4nd county and dia¢thus the shove sus elsmoa I.
wFi hz correct.Llgree t0 comply unh all my and mwuy Ommances and acme laws relatm6 m (QTY, s MECHANICAL I'F.RM1fIT FEE U'R haddnngamarmeuna.:nod nereny awm•nae repremmmive+nnnl,eny Olemer arms ore - IsElsnuc FEE
.have.mca iomd p..pcny IOr m,poclum ramose+. PERMIT ISSUANCIi
(We)egree w save,Indemnify and keep homeless the Coy Of Cupertino against lSLF.C'I'ItIC FISF. -
Imbllnms.judgments,casts and expenses wh¢h may in anywayaccue a6alrolsald Ca, ALTERORAOUTOMITCH I (PLUMBING FEE
in n,equente of the granting at this permit _
APPLICAN T UNDERSTANDS AND WILL COMPLY WITH ALL NON-PIIIN'I ilk flANpL NG UNII'(TO III,INItICFMI
SOURCE RITCULATIONS Mh.CIIANICAI.I lilt
7pyp AIR HANDLING UNIT(OVER 10.00 IMI CONSTRUCTION TAX -
/ Si6nmure nlCApp/Imn'nUCOnmumr Dam IiXHAl1S'I'fi00DIWIDUC'h I IOUSIN .MITIC.A l ON FEE
/ HAZARDOUS MATERIALS D19CI-OSURE
Will the appllcmt Or future building occupant score Or handle ham Alan,materiel HEATING UNIT(TO 1 00,0(4)RTU)
a+dullned by the Coalition Municipal Cal,Chapter 9.12,and the f{cellh and 5efery I _
Cade,So', 25512007 HEATING UNIT(OVER II4l,lilq BTU)
❑1'c+
NO
VENTILATION FAN(SINGLE'RESIDI PAID
I Dais Reccipt#
Will the applicant or future building occupant use equipment or devices is Inch
In hamnlmu+air oniannmami a,dif ril by the Pay Area Air Quakily Management HOILER-COMP(3HP OR 1141,0111 BTIJ) �+�`6"'?g
❑YC, ❑No' BOILER-COMP(OVER 100.411 BTU) /� -
1 _
AIR CONDITIONER
I have maa the h ar,On,m.as coils
255 5,25533 an u255 Chapter,rsto of Ina Car- ISSDA NC.E DATIi
bona,d &Safety glyha Sec don,25535,25533 and 8534 un.CnlanJ that iform NIiN'RIiSIIlENT1AL M11EC11 SQ FT
bwlJing Jllc+nrn curicndY ha+eeionwi.ibauus my resiminnhlhry mnnufy the mcupanl — �•
or ereymreme is which an be tp,onolssuance Ofo Cemfcam ;(k�cfmancy.
lam
wiser Or amnonmd u6em Data TOTAL ISSUED BY
OFFICE