S 2677nPPLICANT--TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING. 1!LECTRICAL PFRMITNO.
-,APPLICATION/PERMIT 111,UMBING� MECHANICAI. C 7
y. RUILDINC. PROJECT IDuloorr '(CJ 2 67
ATION_ G v 1
BL�.DING DIVISION
a SZ&- II&CJI
prom
ADDRESS:
❑ Consultant Fees Paid by Applicant (Initial)
Signmum of Ap,li.nUC.r,.claf Dae
HAZARDOUS MATERfoi DISCLOSURE
Will the millimml or Iglu M1uilding occupant from in Kandla haenMnas natterid
as defined by Ilse Cupenino Municipal Code, Chapter 9.12, and the Health and Safety
Ode, Selina 25532(a)9 (oaf
D Yes gyms
Will the applicant nr future building ar ups in u C eynipmenl ar'levim which
6ueafmus air comarearmyn defined by the Buy Arco Air Quality Management
Damim? _.Ta/1`.1.
D Yes
I have rend the hu o rdnns materials acuircmenls under Chapter 6.95 of me C� li.
fnmia Henab Ar Safety Cod tions 25505. 25533 and 255311 understood that if the
building dues no current) ,snook that iii ` spmsiM1ili,y lr nmify the ocapam
of he requimmenu w' mum fel prionsxmRiom,cj a Cenificate of Q`bancyn
NO.
I.ICRNSEDCON'IRACIOR'SDEL'LARAIION
QTY
,cZ with
Ny�WO—
4UU
I hereby affirm that I not licensed under provisionx of Chapter 9 (commencing
Section]UNl)nf Division 3aflhe Rminesnand Portfolios Crde,mona, license is
in full once and cfmcl.
License Class Lich
JOB DESCRIPTION
RESIDENTIAL:
DSFDWI.
❑ADDI'T'ION
DMULTI-UNIT
D KITCHEN REMODEL
El PLUMHING RI -PIPE
[D STRUCTURAL
PERMIT ISSUANCE
h G W
Z O y z
OZ -4q
Date Comracror
PANELS
ARCHI'I EC SDECLARATION
1 undrismad my plans shall Mused as public recoils
MODIFICATION
F � F" l+l
�so �;
C C Q
xdx O V
a13 Lao y
1❑❑—�m0
Line cut Prideoional
OWNER-HUHLDBR DECLARATION
1 hereby affirm that 1 am exempt from the Contractors License I.aw for the
following moron. (Section 7031.5. Businessland Pmm,%inns Code: Any city nr ammy
which coulee, n pcnnil to ennr.Iue, alter, improve, dmnnfi.h, or repair any suucmrc
micro, inslseuam�c,alf-re,ours me applicant brsneb Nuouto file a signed statement
201.1000AMPS
OVER 1000AM1'S
FIXTURES — PER TRAP
SIGNS ELECI RICAL
FE
all no
A., p�j, C
W (^„
F
W ^ m
to
flat, heislicensed pumuanIto, be provisionsof the Connanm:s License Law (Chapter 9
(commencing with Section Thin)of Division 3 of the Business and Professions Cldc)or
that he is C,mmpl therefrom and me fuels for the alleged exemption. Any violation of
Scullion 7031.5 by any apploam far it permit nuhjo,v IM applicant to u civil penalty of
I'man Eve hunrodred dalluw(S5W).
no l es ownertd /lie pperty, on my landayee, whom wages musale cnmpmssio n,
oche work. and the structure is not intended oroRereJ for sale (Sm.]014, Business
and Pmm,sim, Gxln: The Commmors License Luo, does no, apply I, an owner of
prnlx ty who huildvmnnpmvf,mereml, trod wan dnus xaab wick hinlsdlt lhmngb
SPECIAL CIRCIA UMISC.
APN
GAS — EA. SYS3'EM-OVER 4 (EA)
TIiMP METER OR POLE INST.
COMMERCIAL:
D NEW BLDG/ADDITION
0/1)1 U
[]DEMOLITION J
his own employees, provided mal such improvements am not intended rr offered for
POWER DEVICES
DTENAN'f
IMPROVEMENT
sale. If, however, the building or inuprnvemem is sold within one year mcomple,ion, the
SWIMMING POOL ELE.C'I'RIC
ner-builder will have the burden of proving that he did not build or improve for pur-
ENERGY FEE
of noway
0
❑ I, Its nweeroj flue property. am Pronasions with Ii eCanomers m
E]1
GRADING THE
The
S Business and Professions Code:i The Contractors
construct the project ISse. nano
or Centro.and
Luwdoes nsuch plyman owner of who and
eL
QTl'.
SOILS FF.F.
sedds
ith. clfpropeny
1...II the
whnnmwcts fnnudl projects wilhacnntractar(s)IicensW pursuenuo me Cnmmmnr's
o
'
Lice law.
❑lan, exempt order See /__7 .B&PClirzmierenxnn
PAID
NEW RESIDENTIAL PLMB SQ. FI'.
WO ER'S C< (PEI ON O LNtA'TION �7 �� f
Iaereby,dju under pennyofp,inyousul tlm fullowmg dirinm. Ions:
I have and will maintain a Certificate of Concern m wir-imine for Worker's Compen-
sation,.as provided for by Section 37W of the Lahr GNP, for the urfarm ince of the
work for which this Permit is issued.
D I have and will maintain Workers Compensation Insurance, as required by Section
3700 oil the Labor Code for the perfnnnmcs ui ort work liarwhich this pnnnh iv issued,
My Workers Compensation Insurance tamer and Policy another am:
Carrier. Policy bmi
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
('I m, welinn m:ed nm M crmpleted it liepermit -v ro one h ial... dollino ($100)
less)
I mnifymal in file Performanceof the work for which this Penni, is issued, l shill
nn, rad., Cry pecan in any Ian u Workmi Comp:n-
Z
xaiion Lit"of California Do�/ ]r r
z O
Applicant `7 4%A
NOTICE TO APPLICANT L cher m ins beam emption, you should
bosoms snbjmt m the Wrr ars Co. ion pmv aloof of the Lahrt Gldf. you mixt
forthwill comply with such provisions or permit shall he deemed revoked.
ON LENDING AGENCY1 hereby agency
CONSem is a construction
thispemili isaed(Seeu30 len ding agency for me performance of
the work for which this permit is issued (Sm. 300]. Civ. CJ
work
y
a
Q
UO
0 U
>o,
F-' h
i,z
Lcnders Naim
Lendcrx AJAmas
I certify that I have mad this application and mate Routine base infummtian is
correct. I agree to comply with all city and county ordinances and state laws relating,,
building construction, and hereby:mthodm monisenmlives of this city to enter open lbe
QTY
at v-oundored pmpcny frr ur,,,lina pmp lls.
(We) ugrec It, seen, indemnify and keep honalf-I the"m rf Cupcnino agaiml
fl
liabilities, judgments, costs and aue expenses which may in any wy accragainsl said City
in consequence of the graming of this p art
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1. NON -POINT
SOURCE REGULATIONS.
Signmum of Ap,li.nUC.r,.claf Dae
HAZARDOUS MATERfoi DISCLOSURE
Will the millimml or Iglu M1uilding occupant from in Kandla haenMnas natterid
as defined by Ilse Cupenino Municipal Code, Chapter 9.12, and the Health and Safety
Ode, Selina 25532(a)9 (oaf
D Yes gyms
Will the applicant nr future building ar ups in u C eynipmenl ar'levim which
6ueafmus air comarearmyn defined by the Buy Arco Air Quality Management
Damim? _.Ta/1`.1.
D Yes
I have rend the hu o rdnns materials acuircmenls under Chapter 6.95 of me C� li.
fnmia Henab Ar Safety Cod tions 25505. 25533 and 255311 understood that if the
building dues no current) ,snook that iii ` spmsiM1ili,y lr nmify the ocapam
of he requimmenu w' mum fel prionsxmRiom,cj a Cenificate of Q`bancyn
NO.
TOTAL
V ❑
❑ ❑
1999
ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
DSFDWI.
❑ADDI'T'ION
DMULTI-UNIT
D KITCHEN REMODEL
El PLUMHING RI -PIPE
[D STRUCTURAL
PERMIT ISSUANCE
APPLIANCES —RESIDEN'I'I Al,
PANELS
HACK FLOW PROTECT DEVICE
MODIFICATION
U1110200 AMPS
❑IN9'IiRIOR DCHIMNEY REPAIR
IMPliOVEMENT E] SWIMMING POOLS
D BATH REMODEUREPA1R ElD17MOLITION
Cl OTHER
201.1000AMPS
OVER 1000AM1'S
FIXTURES — PER TRAP
SIGNS ELECI RICAL
OCC. GROUP
SPECIAL CIRCIA UMISC.
APN
GAS — EA. SYS3'EM-OVER 4 (EA)
TIiMP METER OR POLE INST.
COMMERCIAL:
D NEW BLDG/ADDITION
0/1)1 U
[]DEMOLITION J
C.RHASE TRAP
POWER DEVICES
DTENAN'f
IMPROVEMENT
❑ FOOD SERVICE
SWIMMING POOL ELE.C'I'RIC
DOTHEk
ENERGY FEE
OUTI-E'1 S— Soil TCHES—FIXT zery
0
NEW RESIDIiN'I'IA
TOTAL
MAR 0 4
Y
1999
PLUMBING PERMIT FEE
PERMIT' ISSUANCE
ALTER — DRAIN le VENT— WATER (EA)
VALUATION
O
HACK FLOW PROTECT DEVICE
DRAINS— FLOOR, ROOF, AREA, COND'
S'fORlli$
1'YI'Ii WNSTRUCfION
FIXTURES — PER TRAP
GAS —IiA. SYSTEM -1 INC. d OUTLETS
OCC. GROUP
APN
GAS — EA. SYS3'EM-OVER 4 (EA)
OR HASMNDUSTRL WASTE INTERCB190R
BUILDING DIVISION FRES
C.RHASE TRAP
PLANCHECK [ZEE
SEWER—SANITARY—ill ORM EA. 200 FL
ENERGY FEE
WAI'HR HEATER WIVEN'I/HLECTR
GRADING THE
WATER SYSTENITREATING
SOILS FF.F.
WA I'ER SERVICE
PAID
NEW RESIDENTIAL PLMB SQ. FI'.
Date Receipt M
I'OI'AL
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER ORADD'10 MECIL
Arlt HANDLING UNIT (10 111,0110 CFM)
AIR HANDLING UNIT (OVER I(ZU00 CPM(
EXHAUST HOOD (WMUM)
1117AI ING UNIT ('10 100,000If'I'U)
HEATING UNIT (OVER 100.000 RTU)
VEN iLATION FAN (SINGLE RESID)
BOILER—COMP(3HP OR 101,000 BTID
BORER —COME (OVER 100,00) BTU)
Arlt CONDI 'I'IONFR
NEW RESIDENT [At. MECH. SQ. FL
BUILDING EEE
FEE SEISMICFEB.
ELECTRIC TH
PLUMBING FEE
MECHANICAL FIN, 7,
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Dale Rece"a 0
TOTAL
ISSUANCE- DATE
rJ 1�0
!V PO i'A Pi
eaeld�a�NgW
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r
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E'd TB12-966 (STB)
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GPO't
i
MAR 0 41998
BLDG. INSPECTION DEPARTMENT
CITY OF CUPERTINO
etu-`0JTle3 UWHA 021:0I 66 92 9a-A
SM `-dOOH9 3NIHSH3A3 <= L912 996 9lb 122 11 '661921Z :PaAT80.H
f1rpR0 FD
IN ACCORDANCE F.'ITH THE CITY Of,
CUPERTINO CCC`S A6D ORDINANCES
} I UATE�
SIGNED
this set auoi a3n
be keo' j it is un
lawfu, drn)tions
)n r,r, from
he
'lie 014l)1,97108 )EW0 SNgA31S
}!At' be an
sora. provisio6s
s
OFFICE ,
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