99120028 _ _p ANT TO FILL IN INFORMATION WITHIN REDLINES-USE BALL POINT PEN ONLY 4' Ov Z,r
Crl OF CUPERTINO BUR.DmG-ELEr.FRICAL PE 1T
IIUILIIING DIVISION APPLICATION/PE:RMIT . PLUMB ING-MECOANICAL
BUILDING PROJECT unwrIFICATIONP 'i-�:
BUIIDINGADD ESS: 7ANIClARY NO. APPWCAI'ION SUBMITI'AI.DATE
6OS/(y Z - 2 - qS
O NER'S N ME:
HONE CON'TRACTOR'S NAM E: I.IC NO:
Jin Ir CONTROI.a
CHITECI'IENGINIRiR: LIC=O: qJ)R��
CONTACT: PHONE: 3 BUILDING PERMIT INFO '
��� /tel/�iJ ❑ ConsWlanl Fees Paid by Applicant(Initial) BOG ELECT PLUMB ME❑CH
El
LICE NSED CONTRACTOR S DLCI ARATI_ONJ(J�f J Q ,Y ELECTRIC PER
Ineorny off_th . Ind p hapter (commencing y T _ _ MiT FEC-•�, ; EOR DESCRIPTION
OCz IM1 bent U,9trll»ofu'dkonioflnc Busiest,.Idl rofem� Ix p,d. uI lylc , 'x RESIDENTIAL '
COO celI'LItM1T ISSUANCE.
WT- 'Itfull force and cB ❑SPDWI. [:1 KITCHEN REMODEL
aUU License ass Lic.p APPLIANCES-RESIDENTIAL ❑ADDIT]ON w&PGUMBING RI:'1111,17
FZZW Das _ Comramnr
mQkc - - ❑MUMFUNTP ❑STRUCTURAL
ARCHI'I'PC I"S DECI.AR
p.:Ow PANELS MODIFICATION
OZti unenlamy ps pub
Z I dad lans shall he tried ass and records
,— UP TO 200 AMPS I C1 INTERIOR [3 CHIMN17Y REPAIR
Licensed Professional 201-1000AMPS IMPROVEMENT I]SWIMMING FOOTS
OWNER-BUILDER DECLARATION OVER IUIIf1AMPS ❑BATH REMODFUREPAIR El DEMOLITION
I hereby nffinn Nm 1 am exempt from fl a Contractor's License Law for the
°xx' a U following reason.(Section 7011.5,Business and Professions Cash:Any it,or county SIGNS ELECTRICAL OTlll.lt
W 3 LL Fy` which requires a permit to construct,alter,improve.demolish,or repair any smcture
MC) prix,1.it,l"monare,nN.ucquin,tire applicant for such pemn(to Elea v,psedamlemc.t SPECIAL CIRCUIT/MISC.
,pply', that he is licensed pumtthe provisions ofnhc ControLicense Law(Chapter J
apo (commencing with Section 7")of Division 3 oflho Business and Professions Code)or TEMP.MISTER OR POLE INST. COMMERCIAL
y y' and he is exempt therefrom and Ise basis fur the alleged exemption.Any viols inn of [INEW BLOOMED['I'ION ❑DEMOLITION
W 10 Section 7031.5 by any applicant for a penton subjects the applicant O u civil penuhy of POWER DEVICES
nonosethan Gve handred dollar,($500). ❑TBNANT El FOOD SERVICE
[10 Il
F.Z< (] I,as owner of the property,or my employees with wages as their sole rnmpenmmion, I 1 � 1 '
yf Sp
will do the work.and the structure is nm intended or offered for sale(Sec. Business ❑01111:0. _
Nal m and Professions Code:The Comnwmrs License I..doe,nal apply m an owner of T
LIRyo-i LL=
�' propnry who builds or Impmves Iherron,and who does such work himself.r through -
his own employees,Provided that such Improvelnems an not intended Or offered for 'W RT' )E ' E Q
sale.IL however,the building or improvement is sold within one year ofromple'ion.the D 0 AREA S/SQ.FF.
owner,builder%illh the burdert ofp g flumh did noth'IJ or'npn for Par- I INN
pus f ) Y)I
I f Ne PIYconnecting 'h licensed I to
construct thep j t(Sec.7044 BusinessI professions Ne)ThCouncil l -
cruse 'Ile I t apply to e fp nh h'Idimproves J M
who contracts tar such l jetswthlec.nl I (x)license lla intin(he
Contractor s
+ f
License Low. U C.
❑1 am exempt under Sec. .B @ P C for this reason
ALTER-DRAIN&VENT-WA'I'IiR IEA) VALUATION
Owner Dam
WOIt KIiR'SCOMI'ENSA'I'ION DECLARATION BACK FLOW PROTECT,DEVICII
I hemhyalTrtn under Aerially of perjury one of Ne followitrgdeclurelinns: Q� p
I haverrd will maintain liCerti0cte OfConsent mself-insurt for Workers Comper- DRAINS-FLOOR,ROOF AREA,COND. STORIES 9'YI'ECONSI'RUCI'IOP
'J s lion,us provided far by Section 99011 of the Labor Code,for the p.rinonanee of the
k for which this perill is issued, FIXTURES-PER TRAP
have ad will actuation Waj
d by
of l.ubnr Code,let he performfile ancCompensation
of lire work Insomniac,which thismanislsevs'
� ed. GAS-EA.SYSTEMA INC.4 OUTLETS
OCC.GROUP
My Work sy Insur lv.sumeruNPolicy GAS-F.A.SYSTEM OVER 4(13A)
' Cuniu:� - F'nlicy Na.
CER'1'IF OE EXEMPTION FROM W(IRRERS' GREASIUINDUSTRI.WASTE IN'ILRCEITOR
COMPENSATION INSURANCE; BUILDING DIVISION PEILS
(Thisuctiourne nolbec....1plaed if thepennitis Brom.hundred dol lnts(g I ad) GREASE'[RAP -
or Icer) PLANCI I I?CK FI!H
terrify than in i eperf.rmel .eof'hework�rwhich this pentyl is issued,la hall SEWER-SANITARY-STORM F.A.200 F1'.
not employ any -on a any la m R, me su 'n a the Worker'Contain- ENERGY PEE
O z amino Lnws ofC ifs la,Da . m r s WATER IIEATER WNENT/F.LECTIR GRADING FEE
Z Applicant .—
NOTICE'TO AP 1. NT:1, cr making t 's Certificate of Exemption,you should WATER SYSTEM/IRIiATING
become mubjecl to the Workers Comteak.a.� pmvlmi as of fl a Lahr Code,you mma SOILS PEC
forthwith comply with such provisions or this permit shall be deemedrevoked. WATER S17RVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL I'LMB. SQ.FE PAID
U O Iherehy nRnn lheuhere is ac.mwction lending agency far the terfnrmance of f.-s ole
pt art
w !-' the work for which this permit is issued(Sec.31X),Civ.CJ I I U TD AL:IundcrS Name
O lenders AAdresm '1(TTA.'.
I cenifY Na'I have react this application and mile than the ldi ve infomwnion is rl - - I - t
h7 cones.l agree to comply wish alleiny andeoumyordhmnees andstme laws relating'. QTY. MECHANICAL PERMIT ' .FEE IC FF1 `j 114JU
SEEZ
U huildingcoo-ruction.and hereby nulhmize mprcccmntives nflhis city locnterupml It, -
above-mcali red LIIA�RDO
mspeaion pa,,scs. PERMIT ISSUANCE E i'RIC PEI;
(We agreedemnify and keep llandess the City of Consultor against
l iabili'ies.j flamd expenses which may in any way accme against said City ALTER OR ADD'TO MECH.
seep; I,e.fgofilik,rmit PL ��_
IAPPL CA T UNDS A D WILI.COMPLY WI'T'H AL1.NON-POINT' AIR HANDLING UNI'I'(TO I0,0m)CFM)
MI;CI IANICAL IIB;
SOUR 'H 'EGU1
�•�_ AIR HANDLING UNIT(OVER 10.0010 CPM) CONSTRUCTION TAX
Signatl u Apphelo Dam EXIIAUS'I'HOOD(W/DUCT) ]MUSING MITIGATION PHI7
IIAZ RDO S MATERIALS DISCLOSURE
Will the applicant or future building lacrimal store art handle hazardous material HEATING UNIT(TO 110.00(111'1'HE
as defined by the Cupertino Municipal Code,Chapter 9.12,and he Health and Safety
Code.Section 15532(a)? 1 HEATING UNIT(OVER 1OOng1O FIND
El Yes E]No VENTILATION PAN(SINGLE RISK) PAID -
Umc. Reccipla
Will the applicant or future building rocuta oe equipment of devices which
til huxanlous air Conunninams ns dclineJ by th ay Arel Air Quullty Munugemenl BOILER-COMP L3HP OR 10B,IKK1 BTU) TO'T'AL:
OisaicT! BOILER-GGMP(AVER I W.f001 OTU)
❑Yes
El
1 huv trod the h' ardnus nudrnin,r Aril.. nus under Chapter 6,95 of the Cull- AIR CONDITIONER ISSUANCE DATE,
fou"Han" @
Solely e,Sections 255 s ary and 25594.1 undantand @m if OIC NEW RESIDENTIAI.MF.CH. SQ.FL 2--
."he
.
Aurid; dr note •n yhaveatcra lot atlt is my responsibility m notify the eventual
."he alu'cments ti h est he amt p'tm issuance tofu C• IEcmeaOccu c ,
Own t 'heti• I
Date TOTAL: ISSUED BY:
OFFICE