S2979 APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUH.Umc.FILECTRICAL PERM]'NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICALpq 7,q
BUILDINGPROJECT IDENTIF'ICA'TION.
BUILDING ADDRESS SANT I'ARY NO. APPLICATION SUBMITTAL DATE
/U /Ll 'hod,, fir. qIu 199
I OWNER'S N ME: P ONE: CONTRACT'OR'S NAME. LIC NO'.
OWNER'S �� \t� 2 I i -.-NIC CONTROL#
I ECT/eNGINEF,R: LIC NO: ADDRESS ❑
CONTACTJ: PHONE: BUILDING PGRMIT.INFO
WdI A
.4 52 (hL� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB W, i
❑ ❑ ❑ Ix
LICENSED CON r RAC FOR S DFCIARAI'[ON QTY. ELECTRIC PERMIT FEE
I beech,affirm that 1 are licensed d prol,lIon,Of Chapter 9 Rucluerany, -.. JOB DESCRIPTION
OZ with Secicn 7kP)ofDr,,aa 3 oflhe Bourconel,and Prof n..too,C ndnyhceme. RESIDENTIAL:
O p PERMIT ISSUANCE
in full force and effect [ISFDWL El KITCHEN REMODEL
WUF License Class Lie#
Q U APPLIANCES-BESIDES I'I AL (-1 ADDITION [-1 PLUMBING RE-PIPE
1-CW Dale Commemr
ARCHITECTS DECLARATION ❑MUI.TI-UNIT ❑STRIICTIIRAL
ZO-ZI understand my plots shall be used Its public records PANELS - MODIFICATION
024ass —
O 1 LETO 200AMPS [-1 IN I PRIOR ❑CHIMNEY REPAIR
Fd+,ml„1'"„W Licensed l...local 201-1000AMPS IMPROVEMENT' ElSWIMMING POOLS
C Y W;
OWNERBUILDER DECLARATION OVER'IOOOAMP$ [I BATH REMODEL/REPAIR L1 DEMOLITION
K C C 1 hereby affirm that 1 ant exempt four the Rtumaamde License haw for the
3 eI U c4lowing reavnn-(Section 703 1.5,Ru,.inus and Pmfessiory Code,Any sty or county SIGNS ELECTRICAL OTHER
y which .....s a pms
permit to construct,al ,improve,demoli,l,or repair any ztmcmm
F.u.�4 prior m its isswmce.al-OvEires the eppi, I fa-,h p,miuo file a,tenedstnmmcnt SPECIAL CIRCUIT/MISC.
that he is licensed puuuem to the pmvisiens of the Conteuvefs Licence Lvw lChap¢rY
W MC) (Commencing with Section 7000)of Division 3oftheIntemsssonJ Pmfecsians Cwle)or TEMP.AFTER OR POLE INST. COMMERCIAL'
0.y o0.' that he is exempt(need fnnn and the basis far the alleged exemption.Any violation Of ❑NEW BLDG/ADDd HON ❑DEMOLITION
W^m Scotian 9031.5 by Any appGenm font permilsuhjOcts the upplicunnousvil penuhy of POWER DEVICES ❑TENANT ❑FOOD SERVICE
not more than five hundred dollars G50(p. IMPROVEMENT
1,a,over,of the Dopenyor my re,imsmswith wage,az their sale compensation, SWIMMING Pool.ELECTRIC OTHER
E• will dothe work,andthe structure is not insndulorofferd fa,de(Sec.7044,Bosmcss
W 3 m and I'mfersions Code The Commdor,License Law dee,not apply to an ewer Or OUTLETS-SWITCHES-FIXTURES
poTcay is to bui IIx or IFIIPtherseenuard who does suelha work h"creeper through
his own employee,provided that such improvements t: ren I'amended or offered for NEW RESIDENTIAL ELF.C'R SQ FT.
Calc.if,b the bold a(aunp un t s,.1d vanne ),artf e'letien tic SQ.ITL FLOOR AREA $/SQ.I-1.
ownct,hailder will have the bander of proving that he did net build Or improve for pur-
pa,eOLwlc).
1,as owner of the prupeny,am exclusively Convecting with liceni it umvncmu to TOTAL:
conIcu,the prince((See7046 Business andP f::' ,(TraciTh Contractors I
e. Law does not apply to in ass tier ofproperty who builds Or improves m,canand QTY. PLUMBING PERMIT PEE
who contracts for such pmjco s with o ronnamor(,)Iimnscd per Herm,,the Commctor's
License Law, PERMIT'ISSUANCE
I ane exempt under Sec. ,B&PC lonhis II -
ALTER—DRAIN&VFW—WATER(EA) VALUATION
Owner Dun,
WORKER'S COMPENSATION DECLARATION HACK FLOW PROTECT.DEVICE
.Ihereby affirm under penalty of p Jury one ofthe following declarations:
�Ih-rand wif mlmorn enilicmeofCnnzem mmlf-insure far Workers Cumiam DRAINS—FLOOR,ROOFAREA,GOND. STORIES 'IYPH CONSTRUCTION
sation,Its provided!for by.Section 3700 of LaborGde,for has performance of the
work for which this permit is issued. FIXTURES—PER TRAP
❑I krve and wdl maintain Workers Compensation Induranm,as reynircd by Section _
39011 u[thc lethor Code,for tic perfnrmnnmofthe work fnrwblch this pcnnil is inzucd. GAS—EA.SYSTEM-1 INC 40UTLETS
OCC.CROUP APN
My WorkgG}CnneponsuIiou Insurpria c crier and Policy rmmber arc' -
Cacri,: Iain Of'c a VSlc hhiF!-� - Policy No.:t Ijk�Zk. I Im'IZICbI5o GAS—EA,SYS'ICM-0VER4(EA)
CLR'I1'ICATF.OF EXGMYI'ION FROM W'ORKIiRS GREASIDIN DUSTRL WAS TI71 N'TERCE17OR
COMPFNSATIOR INSURANCE BUILDING DIVISION FEES
('Esserdonnacdnmbceomplecel iRhe permit is foron,hunJmld.lims(S M) GREASETRAP
or less) PLARCHECK FI!13
Icenifythatinthe perfimninsured the work forwhmhthis pennitls issued,Ishai1 SEWER—SANITARY—STORM LTA 21q FT.
not rnnploy tiny,On in any manners..ns to become subject ,,We Worker,Course- ENERGY FEE
Z {� -cation Lawsof Gdifecia.Date WATER IIFATERW/VIIN'I'/Hs7.FCTR GRADING FEE
Applicant
NOTICE TO APPLICANT:Ir,Alter rucking thia Cedificam of EvIalm on,you should WAT HK SYS'FEMOTEA'I'ING
(•` become subject m the Workers COrepm onion Provisions Of the Labor Code,you moa SOILS FEF:
Wforthwith coneply with such provisions on this penal t shall be deemed revoked. WATER SERVICE
a CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLh113. 5Q,PIL PAID
=1 Z
U C) Ihereby affirm rent therelaa wnarumion lcrelmg agency for the penfr
oonea,of War liecniptp
U Newark for which this Permit o esmcd(Sec.3097,Co.CJ
O U Lc v Name
VrEC
IAL:
r 4 Lc 1 :Address ` - TOTAL'.
I .fydtIl 'duh':oppl' i d:,aid thtd ON - r t
y core,t 1 m greet a comply with all city and my and tante d nate laws el ting to Q'I'Y. 'MECHANICAL PERMIT FEE
U ze huildingeonswctioqund hereby amhnrim eepre"cruile,into,sty reenter open the
above-.....minced property forniv,yion p.Fell. PERMIT ISSUANCE.
(We,)agree m save,indcani fy and keep harmless the City taCupertino against _ IIiab1'tes,]adgnmms, a and expenses whch mayn any way ognnssairlCiry ALTER OR ADD'10 MECH. '\nnseqummc of the grating ofthL,permit,APPLICANT UNDERSTANDS ANO �C LL COMPLY WITH ALL NON-POINT AIRHANDLINGUNIT TOIO,oWCFM) I t SOI CEREGULATIONS. -
AIIt HANDLINGUNIYtOVER 10INI0CPM)
efA liamycontrecto, 'I1�IOa�ml EXHAUST IIOLD(W/DUCT) I �F�
o Pp HOUSING klUl
I IAZARDOUS MATP.RIALS DISCLOSURE lujis
Will thein,nienntor future huildingoccotram store or handle iai.rbal material HEATI NO UNIT fro 100,000 BT U)
it,defn,d by the Cupcnino Munispat Cod,Chapter 9.12,and the Health and Safety : 1/
Cole,Sccelnn 25532(a)'! HEAPING UNIT(OVER FeldsIH)BTU) 1
[E Y" TO - VENTILATION PAN(SINGLERESID) Date PAI Receipt#
sort h.Will the apPlicaet nr future bedding Occupant use equipmem or devices which BOIhHR—COMPCHPOR 100,0001DU)
...runs arc
inmmnmauts as defined by Its Bay Are.Air Quality ManngemeIf TOTAL'.
Dlnrin' - BOILER—COMP(OVER 100,0001THD -
LlY, DATE
'I1No
I lass read the hazardous materials requirements under Ch,a,,c95oI h,Cali- AIR CONDITIONHR ISSUANCE.
jor,a Health ltl &Safety Cord,Sections 25505 255'and 25534.I 1 d :1 d that if he NEW RESIDENTIAL MECH. SQ.IT.
on Iocstrituntlyo- a acnart,d t it is my responsibilityt tify the Occupant
11 on
t.wmm,moa rte met pr .dance ora ren ueatL of oact p n _
( inc a amhoriecd agent Dme T PAL ISSUED BY
OFFICE