S 4446APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - KLECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING- MECHANICAL. S 4446
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
1 X 355 t}tJ v Uwe. 7n q0
OWNER'S NAME:- PHONE: COIyTRAj OJt'S NAME:�D� LICNOO�
•qqpp}b� ,,L1 ,s /f, ����rs�f�� /��� �'7 W/A'.F,I�}, I46N�� 1W 77X11` l/(_ NIC C`ONTROOLp
!`RCnI /F GINEE�i*L_Jee*4VWu'1 I �: C� A� II✓1'x a•t"r I! �l E` % ISL wni)C 111 ✓Z ❑ J 33
CONTACT. `L'1PHONE: BUILDING PERMIT INFO
�Wt DE-_' 4{5-556) A-3(a ❑ Consultant Fees Paid by Applicant (Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE W \
1 hatchy aflinn that I oat licensed under provisions of Chapur 9 (commencing JOB DESCRIPTION
with Sactian7003)af D*�Locr:a'
Bus d Profession: Code, dmy license is (T� RESIDENTIAL,
xz J
00PERMIT ISSUANCE. -
� � m full forte and eStt,. D s ❑ SFDWL ❑ KITCHEN REMODEL
aUV LicenseC pppLIANCPS-NESIDENTIAL ❑ADDITIONPLUMBING RE-PIPE
WDateConwmnrCTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
Z FO y Z 1 understand my plans shall be used as public records PANELS JJ MODIFICATION
OZ�O UPTO 200AMPS RIOR ❑CHIMNEY REPAIR
F��, Licensed Professional - 201d1000AMPS ' 1 PROVEMENT EJ SWIMMING POOLS
OWNER BUILDER DECLARATION OVER I(pO AMPS ❑BATH REMODELRtEPAIR [I DEMOLITION
a 1 hereby effimt that I am examen fnnn the Conlreaor's License Law feta the
ad O S V following reason. (Section 703 Li. Business and Professions Cole: Any city orrery SIGNS ELECTRICAL - ❑ OTHER
FLLO ^ which requires a vermil to construct. alter, improve, demolish, or repair any structure
pp �_d111 prim to its issuance. also terl the applicant for such permit to file a signed stmcuram SPECIAL C I RCUIT/MISC.
i y that he is licensed pursuant to the provisions of the Coroacmrs License Law (Chapter 9
`qp (commencing with Section 7100) of Division 3 of the Business and Professions Code)or TEMP. METER OR POLE INST. COMMERCIAL'
t q e a that he is exempt therefrom and the basis for Nc allegW exemption. Any violation of ❑ NEW BLDG/ADDITION D DEMOLITION
W H Section 7031.5 by any applicant fora pamah objects the applicart to. civil Tandy of 1 POWER DEVICES -TENANT ❑FWD SERVICE
2
1 more than five hundred dollars (55001. /'�l �- MOVEMENT
=a D has owner of lhC property. or my employtts with wages as Meir sole romp Biomass SWIMMING POOL ELECTRIC
� O will da the work, and the slmnurt is oat intend.) nrolfercJ fnr sale (Sect 91104, Business ❑OTHER
63m and Professions Code :'fhe Contractor', License Law does not apply to .."at
nr OUTLETS-SWITCHES-FIX' FS
property who builds or improves thereon, and who docs such wark himself or through
his own employees, provided that such improvements are not intended or offered for NEW RESIDENTIAL EL SQ ET.
sale. If, however. the buildmIroulmprovemenlissold within one year of comp........, the SQ. FT. FLOOR AREA S/SQ. FT.
ovancolarlder wIII have the burden of proving that he did not build or improve for pur- �--y,4
pose of sale.). AL: '''^^^��� //-^mss '^
I, as owner of Ne pmpeny. am exclusively contracting with licensed contractors m .� I �A
..sumer Ne project (Sec. 70TL, Business and Professions Code:) The Canoactor's Li. - 1I Li= \
cense Law dines not apply to an owner ofpm,croy who builds or improves thereon. and QTY. PLUMBING PERMIT FEE t
who contracts for such projects with a comuchadsd licensed pursuanno the Contractors 10
License law. PERMIT ISSUANCE AUG 1 1999 1
D l um escmpt under 5ce. , B& P C for this mound j
Owner Dote ALTER -DRAIN & VENT - WATER (EA)
fa VALUAT
I
O
N
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT. DEVICE 6l�
KI hereby otlirm under penalty of perjury one of the following declarations:
I have and will maintain o Certificate of Consent to self-insure for Worker's Camper- DRAINS- FLOOR, ROOF, AREA STONIES "TYP RUCTION
sin as provided for by Section 3700 of ,he Labra Code, for the parf num nce of he
work far which this permit is issued. FIXTURES - PER TRAP
D 1 have and will maintain Workers Compensation Insurance, as required by Section
37W afore labor Code, for the performance of the work for which this permit i.issued, GAS -EA. SYSTEM-I INC. 4 OUTLETS OCG GROUP APN
My r�o funlmh�C mecPa yNo.Yner'—
GAS-EASYBTEMOVIROLEA)
CFRTITCATEOPEXEMPTONFROMWORS
GREASFJINDUSTRL WASTE INTERCEPTOR�JJ ILS �1G JJ
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Ta,wcuou need no, be completed iftha puri, is froom hundred dollen(51(10) GREASETRAP
or less.. NCHECK FEE � �I
Irectiry no, in the pcom-nornceofthework for which this a unit is issued. Ishort SEWER-SANITARY - STORM F:A. 21111 FT.
not employ any pen.a in any manner so as to bem
scramcoe subpar, m the WorkersCarmen-Coen- ENERGY FEE
� Z
Applicant
L.... f Culifnmia, Data WATER HEATER WNENT/ELECITgFEF
ADING
z
tiNOTICE
NOTICE TO APPLICANT. IL eller making this CeniO000f of Exemption, you should WATER SYS'TEM/I'REA'TING
M1..ome subject m the Workers Compensation provisions of the labor Cwle, you mus ILS FE
� 6nhwith comply wiN such provisions noble petmil shall he declined revoked. WATER SERVICE
0.
UO CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ. FT.ID4—
to RettigM
1 hereby alfimt mm there is a cons,mmion lending agency for the perfomuntt of
the work for which this it is issued (Sin. 3097, Civ. C.) eG
H Landers Name _Ai. TOTq 1.
O V Lender's Address .l\ TOTAL:
FM, I cenify that I M1 w mad this application and sure that the above information is - L ILDING 0
H entree,. I ngme m comply with all airy and county oNinances and state laws relating to QTY, MECHANICAL. PERMIT
V Z building constmnion, and hereby authorize representatives of Nis city m enter upon the ISMIC EE above-meminned property fur inspection purposes. PERMIT ISSUANCE E(Wed agree to save, indemnify and keep harmless me City of Cupertino against
liabilities,judgments, costs and expenses which may in any way acerae agai ns said CitygLTER OR ADO TO MF.CH. U G E
in conseyuenc. miNe grunting ofthis permit.APPLICANT UNDER ' \ND AND MLL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT (TO.Q(IWCPM)SOURlC`-B—RE�GUL�N. �/.{� ECHAN ALFEE\/ /Y[(/� Ai+h 1 AIR HANDLING UNITIOVER 10.1100 CFM1NS CTION TA%
Signa�App.ican0 mractor o� EXHAUST HOOD MMUCT) USIN ITIGATION FEE
HA-LARDOUS MATERIALS DISCLOSURE
Will the applicator car future buiahn, are upausmreorhandle hazardous matmal HEATING UNITITO 100.000 BTU)
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Coda, Section 255320)!`� HEATING UNIT (OVER HILL 1BTU)
El Yes �y
VENTILATION PAN(SINGLE REBID) PAID
Date Rc¢iptM
�I
Will the applicant or future building ..par use equipment or devices which BOILER t COMP (3HP OR IOO,IIOU BTU7
emir haraNcontaminants ous air aminants Defined byy the Bay Area Air Quality Management TOTAL: 11i
District? BOILER -6OMP (OVER 100.000 BTU)
CI yea o
2 I have mold the hazardom materials requirements under Chapter 6,95 of the Cali- IR CONDITIONER ��,fff''''''))) ISSUAN EDATE
rmnia licahh & Safety Code, Sections 25505, 25533 and 25534. 1 andersuumd that if the NEW RESIDENTIAL MECH. SQ. FT. 'V rt 9] /g
buildingd atom current rot all. it iemyrespnasibilirytono'yNe cupanl D / ^ 7 /'.'^"
of the call t m insuance.1 a Cro
Vl
Owner nr mah rued agent Date TOTAL: ISSUED BY:
OFFICE 1