99080152 w,APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY `"/ '1 Oq O 1S Z
CITY OP#CUPERTINO BUILDING.ELECTRICAL
-� BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
8,. GU[';Ij,BUILDING PRf3JEIT,IDEN'1IF'ICATION( sj('dLNtI"}
BUILDING ADDRESS: SANITARY NO, At DAl'I2
dD199 5aisan Drive,
O ER:S sl /g a PHOy CONTRACTOR'S NAME: LIC NO:
/Iva-My-•N140�fi.{I RIC CONTROL#
CHI"I'ECT/HNGINEER: LIC No ADDRESS'. El
CONTACT. PHONE: 3'f' I'D of,BUILDING PERMIT INFO';ll;dt-1i;':'
C5�o8')3106-2y 2 Consultant Fees Paid by Applicant(Initial) BLDG ELECT P[UMB,11ITIECH
t v ! i 1 F H f ! t 3 ftr" I t 0
LICE NSI:U CONTRACTOIIS DECLARATION QTY Y {'!'1�IPLECTRIG PERMIT' t lq ld L +1�PP I:li-�3
In rayaffirmutat 1not tented. I r' rehapmry(tnmme g r •., ,,, .f r t. , ,,,r. latait ! ! :h .I," ,+' JOB DESCRIPTION
DoZ withS f ]000) fDivuinnJ tithe Busi a nJi nfesmons CadcenJ my hcenms
F„OO fallfre aJeffect. PERMIT ISSUANCE
lit' '. SI'DWI. ❑KITCHEN REMODEL
QZW Lanni Class LIcN APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBINGRE-PIPE
yGL Dale TSConDECLARATION
ARCHITECTS DECLARATION PANELS ❑MUI.I'hUNIT []STRUCTURAL
ZONZj- IunJcnwnd any plans.Thula be used as public records MODIPICA'f10N
OZ-� Up TO 211(1AMPS ❑IN'FHR10R [I CHIMNEY REPAIR
; Licensed i'mfcssionzi 281-1000AMPSIMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 1000 AMPS El BATH REMODEUREPAIR [I DEM I.I N
yy W st 1 hereby affirm Thal 1 am exempt from the Contractor's License Law far the
p(O L U following reason.(Section Oro 5,Business and Protestants Code Any city or countySIGNS ELECTRICAL L1OTHER
Iv 3 W y which requires u pm
permit to d"111111111..1111,Intptve,a 'fracturecmollvh,nr moull any'fracture
C'
prior prior u)its issuance,also requires the applicant for such permit to fie u signed statement SPECIAL CIRCUIT/MISC.
that he is licensed pursuant to the provisions of the Commodes License Law(Chapter 9
�CCpO (commencing with Section]00Tivi'Oivision rifthc Business and Professions Coded or TEMP.AIRIER OR POLE INST.
c y' that he is romps therefrom and the Basis fnr the alleged emmptinn.Any violation of ❑ BL /ADDI IOPN
: Section]011.5 by any applicantfor a permit sdoccoithe applicantln a civil penury of MWI!R DEVICES '
not"not in Eve hundred dollars($500). <00
q-rZxd ❑1,as nwnm or the properly,it'nrycmployees with wants,their solcutmpeortinn, SWIMMING POOL ELECTRIC PROVE
OTHER
FO will Ju the work.and the structure is not intended at offered for sale(Sec.]04f.Business ❑OTHER
W m and Pm es.eions Cede:The Contractor's License law Jav not apply to an owner of OUTIA31 S-SWITCHES-FIXTURES -
a 3 property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECTR SQ 14. 1� -
-
solelfh+wever the bdldngur inprovemet is sold within one yearol completion,the SQ.FT,FLQQR AREA /SQ.FT.
owner builder will have the e t l did t h p [ p [,j—� D
pose of sale
E]I as owner of Ibe pr pc y exclusively lyI B h licensed t f s f
n.t of DOTAL
construct the project(SeeflH4 B d I t Code:)Th C t t L III I
t i hit
U
AUG 2 0 199
teLaw does not apply fp pony h builds J PLUMBING PERMIT FF
who contracts for such projcns with acontractors)licensedpum In theContraenrs
LacsneLow.
❑ lam#scop under sea. ,B&re Etnhia reason PERM ISSUANCE 9
RI
cr Date ALTHR-DRAIN&VENT-WATER(BA) L
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 herchy affirm under formyof perjury ones(the Al Inwirt holamtiont:
I have and wil l maintain a Cedi fume of Consent o self-insum lir Worker's Coni DRAINS-FLOOR.ROOp,AREA,COST). -
7E]
wn,as provided bar by SeeEon 9'100 of the Lobo Crude,Far the performance 0 tut S'I DRIES TYPE C' 'T CTION
rk for which this pandit is issncd. FIXTURIS-PER TRAP
1 have and will maintain Workers Comrasmion Insurance,as required by Section00aftfie LatorCode forme pedormacre,ifthe work for whichthis permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APy Worker's Compensation Insurance tender and policy number are:rrier: Policy Nm: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICA'I'I OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASDINDUSTRI,WAS 1'E INTERCIJ"IDIt _
(This second need nm Be completed ifhe permit is for one hundred dollars IS l BE s NUILDING DIV1530NP +'
or levo.) GRF.ASB'IRAP PLANCHECK FEE
I certify that in the sufomence ofthe work for which this permit is issued,Ishall SEWER-SANITARY-STORM EA.200 FT.
not employ nay person in any im nnertt
so as to become%objeco the Workers Compete ENERGY HE
,7., smian Laws ml Cah Eurnin.Duro WATT?1211EATf3R W/V[IN'1'II!LI?CTR
Applicant GRADING HE
.12
= NOTICE TO APPLICANT:If,otter making this Cenilicam of Esanption,you should WATER SYSI'EM?RENI NG
a > become subject us the Worker's Compensation provisions of the Labor Code,you must SOILS ITE
W
forthwith comply with such provisions or this p:nml shall be deemed meeker. WATER SERVICE
0
UO CONSTRUCOON LEADING AGENCY NEW ItESIDENTIALPLMR SQ.TT. PAID
I hor hith Its permit
a icacamdmel30leading agency Toch#performanceof Dam Reecip#
W N Londe,
I'nr which Wis permit iv dotard(Sm.3119],CE.C.)
Q Lone N TOTAL:
L) Lend r AJJ TOTAL
0. 1 dedify that Ihave mad this application and state that the h frmahn is 1 -un 1 iI I (' @I frPPT( �.�" BUILDING FEE
ti
V) rorrect l'S n ply with all city d my Nrearic ard.st la lati 6s QTY.'(It sMFCHANICAL PCRMIT i ( ( (�
balding st.rhmn,atdh nhy'tuthmifc pm vnufvev<f th's c'ty to enter upon me r- a .¢,s' I w.. s" SEISMIC PEE
.hove-memloned pm,thy fnr Inspection purposes. PERMIT'ISSUANCE
(We)agree to save,indemnify and keep handles,the City mf Cupertino it,mad ELECTRIC FEE
liabilities.judgments,costs and expenses which may in any way accrve against said City ALTER OR ADD TO MUCH.
in .sequence of the granting of this permit. FLOWING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,1100 CFNU
SOURCE REGULATIONS. MECHANICAL FEE
s AIR HANDLING UNI"I'(OVER 10,000 CFM) CONS'I'RUCTION TAX
Signature of Applicam/Cnnlracror Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hwardous material HEATING UNIT(TO I fli).00 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,anti the Hwhh and Safety
Code,Section 25532(01 HEATING UNIT(OVER 100,000 BTU)
Yes [-1NoPAID
vEN'I'ILAI'[ON PAN TRINGLE RESID) lute Receipt#
Will she applicant or furore building decupam use equipment or devices which
crit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP QHP OR 100.000 BTU)
TO AL:
etrictl
Yam Fl BOILER-COME(OVER 100,0(8 BTU)
❑
I have read the hamrdnts materials requirements under Chapter 6.95 of the Cid- AIR CONDITIONER ISSUANCE DATE
Arm Health&Safety Cole.Sections 25505,25513 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.PT.
buildingdoes nm currently have a tenant Nat it is my responsibility to notify the pecapanl
of the requirements which auto be met prior to issuance of a Certificate of Occupancy.
Own it ora.hntieed.gent Date TOTAL: ISSUED BY:
OFFICE