S 1967 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PH ETNO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 1967
BUILDING PROJECT IDENTIF'ICAT'ION
RUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL PATI?
o? ERroRb lD"iP. C u Fc-ICiaie .CA.96d! t{-zl-ks—
iR:SNAMLa: ' I'1{ONE: CON TRACI'OR:SNAME:Alp
ZE LIC 30D
NIC CONTROL It
•ARCI111'ECT/ENGINEER: LIC NO: ADD' k1 O ❑
CONTACT: PHONE: C.1 Aw+p13aLL BUILDING PERMIT'INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLO B
LICENSED CONTRACI OR'S DECLARATION QTY ELECTRIC PERMIT FEE
O 1 hereby affirm,hal Iran licensed under pmvisi0ns of Chapter 9(commencing JOB DESCRIPTION
Z with Second 7000)of Division3 of the Be...mssand Pmfev,mr,Gde,andmy license is /,`+ RESIDENTIAL
W PERMIT ISSUANCE .- J
F in full I'o¢e unA dTea t ❑SFDWI, [I KITCHEN RF.MODEI,
aU License Class 4'
Lic.N APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
yZW Date Contractor
-
i,,, DECLARATION ❑MULTI-UNIT ❑STRUCTURAL.
F-7 h 1'ANfihS MODIFICATION
ZOy7-- Iundemmodmy pions short he useJu public records
OZ�p UP T02(N1AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F�FW Licensed Precessional 201-IMMAMPS IMPROVEMENT SWIMMING POOLS
C om;
OWNER-BUILDER DECLARATION s License Law fur the OVER I(NN)AMPS ❑BATA REMODEUREPAIR ❑DEMOLITION
y C Q I heathy affirm third]am exempt font the Cnmracror'
x C 6 FU- following reason.(Section 7031.5,Business and Prefessiens Code:Any city of county SIGNS ELECTRICAL ❑OTHER _
ul u.y which requires a Permit m comwet alter,improve,Demolish,or repair any structure V M 7
F-LLO� Labor it)its issuance.also requires the applicant lot such permino file a nignedsrammcnl SPECIAL CIRCUIT/MISC.
(!(Ny Ihat he is licensed pursmtm m the pmvisil nfil,Commences License[,aw(Chapmr9
adFs (commend ng will,Section 7000)of Division 3 of the Business and Pml'esaions Calc)or TEMP.MEPI1R OR POLE INS1'. COMMERCIAL:
e6W o C Nm m
he is exept nhere(rom and tia th
he basis Ie alleged credential.Any violation df ❑NEW BLDG/ADDITION [I DEMOLITION
LL 1Syyy tion 7031.5 by any applicant cora permit subjects me applicant nr a ciail Penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
•�� more than five hnndreddollars(5500). IMPROVEMENT
FRE I,nn nwnend O,c a SWIMMING POOL.FIAT ERIC
�FQ prope,gar my e,nployccs with wngnwts theinnle amtpmtswlon, ❑CHILE
R
will do the work,and the structure is nm intended oroffered for sale(Sec.70,bi Business
aadro and professions Cut,:The Comanche,License Law it,..,na apply man owner of OUTLEI:S-$W'ITCfllis-f IRfS
p,,,,by who heilds of improves thereon,me]who does such .it himwl(nr @mugh
his own employees,pmvidcd due such Improvaments arc nal inomdcd ur oRereJ for NP.W NI3SIDIiNTIA1.El.li SQ IT.
rule.It,however,the heildingur into ecmmn is slid wfludone y.rol'co.nple.ion,the SQ.W'.FLOOR AREA LSQ.ET.
owner-builder will have rhe burden of proving that he did not build or improve for pur-
r pnm of sale.). AL:
El 1,us owner of the pmpeny,am exclusively contracting with licensed commetms to t, / s Q
mtmm the projrO(Sec,7844,Business ,it Professions Calml I'de Contractors li-
censel.aw does net applyman owner of property who builds or improves he...add QTY. PLUMBING PERMIT FEF.
who commers far such pmjeen,with a contraclumd licensul pursuanuo the Commetoe,
License Luw, PERMIT ISSUANCE
I and axetnpt many,Sec .B A P C for this reason
ALTER-DRAIN&VENT-WATEll(EAT VALUATION
Owner Dam -
WORKERSCOMPENSATION DECLARATION BACK MOW PROTECT.DEVICE ,^^.
1 heryby af0on under penalty of scent ry one of the fnllie ing d,derands: VVV
I have and will nwinmin a Cenifcamof Co i,emlewiftouduref..Worw,,Compel- DRAINS-FLOOR,BOOR AREA,CHILD. S ORIPS TYPECONS'I'RUCfION
sarion,m provided far by Section 3900 01 the mbar Com,for he WrOmnmuce of the
work far which this pe.,it is i...eft. FIXTURFS-PER'I'RAP C
1 have and will maintain Wader's Compensation In.mnmce,as required by Section
3700 or the Lahor Code,for Ilia performance ofnhe work ria which this Permit is issued CAS-IA SYSTEM-I NC.40U'H.HTS OCC.GROUP AI'N
My Worker's Coni ensal on Insurance vier and Policy number are:
Carriee Policy Nd.: GAS-EA.SYSTEM-OVER 4(CA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEIDSPUSTRL WASTE IN'I ERCEPTOR
COMPENSATION INSURANCE RUILDIN I DIVISION FRES
Tihissection need not he cnmpletW ifll,e pemtll Lv lbnme hunUrcA JollumlSlmq GRCASE'TRAP
nr less.) I'IANCIIIiCK ITE
Icenifylhat in the performance blithe work forwhich lhispennit i.cissuN,I shall SEWER-SANITARY-STORM CA.200 Ff
not employ any person in any manner so as no become subject to the Workers'Compen- ENERGY FEE
OZ ration Laws of Calitinair,Date WATER THIN]Ell W/VENT/ELEC9'R ITIi
z
Applicant GRADING
py NOTICETO APPLICANT:IC after making this Certificate of Exemption,you.should WATER SYSrrysin RUNTING
becmne subject m the Worker's Compensation provisions of the father Code,you marl SOILS 1 E,
(Zl G forthwith comply with such provisions or(hi x permit shall he deemed revoked WATER SERVICE
0. O
CONSTRUCTION LENDING AGENCY NEW RF_SIDIiNTIALI'hMB. SQ.PC PAID
7 z Dam Receipt p
UpIhereby wlt ypt lo,perm i,iisaed(Seeconstruction30 lending agency for flue performance of
F rhe work for which thin permit is issued(Seo.3119],Clv.C.)
V. Lender's Name 'f0'IAI.:
Lyndon Address TOTAL:
P. 1 certify that I have mad this application and state that are aMwe nomination is BUIL PIi13
ZI correct l agree to comply with all city and county ordinances and slam laws reining or QTY. MECHANICAL PERMIT F17H
U � huildingmnaunninn,add herebynurhorimrprcremmivcs of thiscitymemerupn,,the SI?IS I' E
abuse memilead nrd,rty for inspection purposes. PERMIT ISSUANCE [� s
(We)agree m mless save,indemnify and keep harthe City of Continued against EIEC TF.
Iiabilitics,judgmems,costs and expenses which may in any way accede against said City ALTER OR ADD TO MECH.
1'LUb GPlili
' asequence of lhegmming of this permit.
APPLICANT UNDERSTANDS AND Wil-L COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(1010,000CPM)
MIiCI ANICAI.FEE
SOUnRCE REGULATIONS. � �( Q' /_ py AIR HANDLING ON]['(OVER 10010 CFM) qo
T /AO�,/ ,6/ -' a� /C CON.
S�,gnuuucof Anpli, llCmodryur Dam EXHAUS'T'HOOD(W/DUCT) 1 IOUSINGMETIGATIONFEE
HAZARDOUS MATERIALS DISCLOSURE
Will flay.,ficlart
le
HEATING
ns dcfided by lloc CuperrimfMu uc pal Code,Ch pmt 9,12(nddthe hHea h and,S,�y HEATING UNIT(ONIT OVFNIIOI,000 BTU)
HE
Code.Section 2553200 G
❑Yes Nn VENTILATION FAN(SINGLE RPS IU) PALO
Date Receipt
Will rhe applicant or future building oecupmnr use equipment or devices which 1{OILER-COMP(311P OR I00,IXq BTU) G�
emit humrduus air contaminants a defined by the Buy Arca Air Quality Mannganeul TOTAL: /Q�
Dhtdn 70
Yes Nu BOILER-COMP(OVER 1(10,0(10 B'PU)
I have read the hamrdommm
ntials mgairemm
es undAIR CONDITIONERer Chapter fi,95 of the Cali. ISSUANCE DATE?
4,min Ig tire,,&Scurry try have
Sections t,that,2s my and 25534.1 undommnd that if the NEW RG9IDEM'IAI.MUCH. SQ.Pf.
building Jces ern currently have n mount,that it is my respnnsihil Ery m nrnily the accupum
of nhc reyuiremcnts whicp must Meet prior u,issuanre of a Ccnitica�uf Ouuryypgy,� ^�-
._ems t �JJe 5j / C/�( J e- Y4Iv7k9Nt.t. ,
Ownernnwthnaaa neem Irate TO I'M, 9-90 ISSUED BY. UO
e-