S 1098 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.-ELKCTRICAL PFSII'r NO.,
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING,-MECHANICAL J 10 9
"r.qi,"'s'r BUILDING PROJECT IDI{N'1114CSFION J', '
BUILDINGADDRP_S : /\'� /�.� /5 _ SANITARY NO. AI'I'LICATION SIII{MITIAI,UA'I'E
Zoo-11 .SunScch �✓ Cr .�-F CA 9s° �� ,
OWNER' NAME: - - PIIONE: CON' RACTOR'S NAME: LIC NO: NIC co 'I'RD1,g
eta c"N aS3 -668$
717
I ARCHITECIENGINEER: - LIC NO: ADDRESS: ❑
" CONT-A-C�r':�O� - PHONE: - '-,(j "BU INC.PERMITINFO
S3 -6688 ❑ Consultant Fees Paid by Applicant(Initial) RI. G ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR 5 DECLARATION AliAT10N QTY. IELC'GIKIC'PERMI9/ r! t ('If VIL�� '
I he cby ffrm mal 1 m r d d p f chap) 9(comm s :. +.( JOB DEtiCKIPTION
MaIZ with t 700um Divi 3 n(1he Business and Pnfe. i .Cod and license NT I'
To w I'I RMIT ISMIANCC
F0,.. int ILC I ff t - 'OWL ❑KITCHFNREMODFL
�UU Lcwse Class Lich All LIANU,S-RESIULNI'IAL ]ADOITIpry ❑PLUMBING RLI'll'Ii
4.scW Datc Contractor SI
yah [I MULTI UNIT' ]MODIFfURAO
ARCHITECTS DECLARATION PANELS
z I.
Or'/rZ lunderemnd my plans shallbemttl as public records CHIMNEY
YREP
q UPT02(NIAMI'S ., ❑INTERIOR ❑CHIMNEY REPAIR
P.�M Llcened Pml'xs,laal - 2111-IfN10 AMPS IMPROVEMENT E]SWIMMING POOLS -
•.1 OWNER-BUILDER DECLARATION OVER lost AMPS
❑BATH REMODEIJREPAEf ❑DEMOL1'f10N
x C 6 1 herehy.af rat that 1 am exempt from the Con]racmr's Licence Law for]he
Li�S 6 U fallowing reason.(Section](131.5,Business and Prefexsimn Code:Any city or countySIGNS ELECI'RICAI. _ [I OTHER
I++aW
to which requires a Tamil m construct,alley,improv,demolish,or repair any structure
prior mits issuance,also requireslheapplimat formelt pvormt m file a signed,latenunt SPECIAL CIRCUIT/MISC. `
W} matu slimmedpnrsuam mthe provisions of the Conwemr's License Law lChap¢r9 COMMERCIAL'
��p30 (coulaxaming with Section700B)of DivisionJnf the Business and Profession a>veprt TF.MP.MGITiR OR POLE INST.
d l4.o IY
thin he is exempt therefrom nnJ the basis for the alleged exemplinn.Any violminn of ❑NEW BLDG/ADDITION ❑DEMOLITION
iLLl1 4. Stull ]NLS by any opplicllnt for a larinit snhjcc�the uppliwmt to a elvil ycnally of POWER DEVICE ❑TENANT ❑FOOD SERVICE
h I m]han five hundred dollars($500).F Q�s owner of the norm bees with wa their sole cora tion. SWIMMING 1'001.ELECTRIC OTHERVEMIiN'I'
Pl.pe Y YeI•P Y gex az pens° ❑OTHER
will do the work,and the slmcmm is not intended or offered forsole(Sec.700,Business
W d Professions code The Commemnm
rs Licee Law docs not apply an owner of OUTLETS-SWITCHES
-fIXTURP_S
m an
pmpcny who build,or impulses theme,and who docs such work hlnwelf or Ihmngh -
his own employees,provided that such improvements art not amended m ufleo:d far NEW RESIDENTIAL IiLIiC'1'R SQ PC
sale.IL howl,m the building or improvement is sold within one yevndrompletioulhc SQFI'.FLOORARRA S/SQ.17
mer-builder will have the burden of Towing mat he did sol bund nr improve for par- CE T< >r�
,,sc ofwaf,.) TOTAL.: �L/1 V r4.
I,as owner of The property,um exclusively malluning with licensed commemrs to
marvet the t(Sm.9644,Business and Professions Code)The Contract r:1 OCT
^T q O ����
p i a' l� I O
L de.- I apply mvnawnerofpmpeny who bouts., npmves them d QTY. I r LUMBING PERMIT � .,Wt FE
,hucmd.wl,mr.ach protect, ah.corarmon0luetscd purvaarua the Contm".1I
License Low. PE T' .'SUANCH
❑ I am exempt mmOsm. ,B&PC far mi—r-on '
AL - &VENT-WATER(EAT
- Owner_ Dote A
// WORKER:S COMP.NSATIO DECLARATION BA K FLOW P .'T. ICE V D
f� ❑ I hereby allimt under penally Perjury one of The following declamlinn.:
I hese end will maimelnu Cenificele of Cnnmmmnelf-inurefor Worker's Compel- DRAINS-Ir OR.ROOF, EA,CO SrIOR ES TYI'I!CONS'TRIJC'I'ION
sot ion,as provided for by Section 3700 of the Labor GWe,for the performance of the
work for which(his permit is issued. FIXTURES F: AP
] I have and will maintain Workers Conare...too'Ituutvfee ns rcquhed by Section
37foofthe Labor Code,fomheperformance ofthe work forwblch In,roman ix issued. GAS-1?A.SY STEM/IN OUT 1.IiTS OL'C.GROUP APN
My Workers Compensation Insurance carrier and Policy number ere: ,
Carrie,: Policy No
GAS-IIA,SYS TEALOVF.R :A
CERTIFICATE OF GXI/MPT10N FROM WORKERS' GREAS191NDUSTRLWASTE INT?RCEPTOR
COMPENSAI ION INSURANCE BUILDING DIVISION PEES
(Thissscdonneednolh,molmincd iflhepemth isforonchmoredd.11m,($100) GREASFTRAP
or les.) PhANCI1ECK LLE
I certify that in the perfurnanceof the work I which his permit is issued,l shall SEWER-SANITARY-STOR M F.A.200 FT.
all employ any parson in any ouram,o tss m become subject to the Workers'Cahalan- ENERGY FEB
,Z sation Law,of California.Dam' WATER IWATER W/VENT/ELECHR
z2 APPlicetn ONAIJINGIIiIi
NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTEMITREATINC
I,, SOILS FEE
' WI' beamvr snhjcel to the allp',si,sasnsmionprovisions of the Labor Cale,you mus
fnnhwith annmly whM1 such pmvlslon,or lM1ia pennh shall he deamW rcvokul. WATER SERVICE
6, CONSTRUCTION LENDING AGENTWOCY NEW'RESIDENTIAI.I'hMB. SQ.17. IU -)all Rccciptp '
I hereby mmooduuhem iso emstrunion lending agency for line Isafammuce of
U 2
Dd Fthe work for which this Tenant is issued(Sec._BEG,Civ,C.) TOTAL:
Ixmdefs Name
O UTOTAL
r �
LeradeesAddres, 1 _ .
y n CY'but 1 base read fats appl t a I state'hot the M f ]mum Is BUILDING FEE
LF. V] arrellg tcnsplywith all city.,ad tY N'm74
dtlel .mxngm QTY MECHANICAL PERMITI FEE
U Z huldi g t tsactin,and hereby mthrr,locac,,am' sof]hsely m cm anion the r., • 's SCISMIC FI:1:
asset-mrnlioned property for inpectin l purposes. PERMIT ISSUANCE ELECTRIC FEE
(We)agree to save,indemnify and keep harmless the City of Cupertino against
ti liabilities,judgments,costs and expenses which may i n any wayuccm:against.said City ALTER OR ADD TO MECH. PLUMBING FEE
In cansequcnce of]he granting of]his tenon.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT -AIR HANDLING UN1'POO 10,000C17M) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER IILNXI CFM) CONSTRUCTION TAX
Signnlum ofAppEcam/Can alactm, Dao EXHAUST GOOD(W/UUCP) HOUSING MITIGATION LITH
HAZARDOUS MATERIAIS DISCLOSURE
WAIilaopplicomo,future huildingueltPamsorem handle htomelo ,onnerial HEA'ONG UNIT GO'I 14),6441 B'IID
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cede,Semon 25532(a)'I HEA'T'ING UNIT(OVCR IOO,l11X1Ifl'U)
[:I Yl, C]No VENTILATION PAN(SINGLE RESID) PAID
Dull Rcmipt N
will he applimmorfuture building..Part use equipment or devices which BOILER-COMP OHP OR KITONI RTU)
rah husardous air camuminants'as defined by'the 13ay Area Air Quality Mmagetalm }t Jl'AL:
� D11111rlP BOLLI?It-COME(OVER Fall BTU)
(]Yes Fl No
,have had'be
haaurdon lmamm requirement,dale,Chapter 6.95 of he Cali- AIR CONDITIONER ISSUANCE DATE
Carola Health&Safely Gale,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL.MICU. SQ.Fr. O " 30� 4
huilJing docs nomurrendy hove.manor,that it isaryrc,ponsialo" ify lhwo.'apom (((
of]he mquimmems which most be nut prior to i....ale of s Ce,iticme of O cll1mw1. _ /`�as
Owner oramhoriud agent Dam 'TOTAL: ISSUED BY: `•'"' �� ^� D
OFFICE