99090058 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPIACATION/PERMIT PLUMB NG-MECHANICAL 990 Ci'31F�C
BUILDING PROJECT IDENTIFICATION 7`!
BUILDING ADDRESS: SANITARY NO. APPLICATIONNSSUBMITTALDA'I'E
��d�,o75 OR in S L (i `� •-Q
OERS NAME: rl� ESS
h7'lv0�0>S��O�W Cl N'R OR'S�NAp1E: �n4 ;74341-1-
W NIC
CONTROL
CHII'HCI'/I:NGINI:I:It: /G 3& �CLiC No R_13) j) j rrar"144Y Saw ���/ot•�' ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fecs Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ ❑
LICENS17D CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE
I ncrahy adtrm mm I ant housed ander ao.i.inn.of chapter 9 aommer,ing JOB DESCRIPTION
OCz with Section 9(Xx))of UivisionJaf the Business and vrofcsion.c Code,ane my license is RESIDENTIAL'
,05 In PERMIT ISSUANCE
l— full fares end ehilR 36 63 /� ❑SFDWI. ❑KITCHEN REMODEL
5 U F License L Lic.k
i- V APPLIANCES-0.ESIDENTIAI, ❑ADDITION ❑PLUMBING RE-PIPE
yW Unlc TSDEC Counselor
F,7y ARCHI'TECT'S DECLARATIONPANELS ❑ h
MDLTGNIT ❑ L.
STRUCTURA
Z 0 r"Z 1 understand my plans shall he used as public records MODIFICATION
OZ=pB INTERIOR ❑CHIMNEY REPAIR
P.4t;cl I.Iccnwd Pmtcssiomd q j Q IMPROVEMENT (]SWIMMING POOLS
y _ OWNER BUILDER DECLARATION R I BATH REMODEUREPAIR ❑DEMOLH'SON
e C Q I hereby affirm that 1 am exempt from the Contractor's License Law for the
�L 0 Ar V bdLwving reason.(Section]0315,Business and Professions Code:Any city or county 5Ii ❑OTHER
tai a LL uO which requires a permit in construct,alter.Improve,demolish,or repair any strnrmre
prior to its issuance,also requires the applicant for such permit to files signed statement
S } that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9
t�n14G� (countersuit with Section 7")of DivisionJof the Business and Pmlcssi...Cade)or R E COMMERCIAL:
e.¢t a CC flue he is e,rnin uWmt and the h....far the ullegM cvcntption Any violation of ❑NEW BLDGIADDITION El DEMOLITION
ac N Section 10315 by any applicant for.permit,shares Neap,dwant m d p ❑
u ovenalty of TENANT FOODSERVICE
iv
H Z>, not more than five hundred dollars($5000. IMPROVEMENT
6 01.is owner of the property.or my employees with wages as US
Fwi 11 do the work,and the snucmre is not intended or offered for sale(Se,704-ones, OTHER
113 eco and Proles.cions Ctdc:'IJe Contractor's License Law, does not apply men owner of GUS'1,13R-SWI'I CUES-PIX'1'UR&S
prupcny who builds or improves flumccn,and who does such work himself or through
his own employees,Pntvided that such impmoanencs am not mended or oWred for NEW RESIDENTIAL ELECOt SQ FT.
nulr.lf.Nrwever,the M1ullAing or lntpnwemrnt ix sold within ane yeaondmtmplerinn,the SQ.FT,FLOOR AREA SISQ.FT.
crteildcf will have the burden of proving that he did not build or improve ho pur-
Pase.flat,.).
Fl 1,as tnet of the pepeny,am exclusively contracting with licensed counselors to TOTAL:
cow r
nNm,0c froje a(Set.9(14,Isrwi nes end Profession,Code:)The Commute,IJ-
crow
i-
law does not apply m m
an owner of ppeny who builds or improves thereon.and Q'TY. PLUMBING PERMIT FEET
wss who contracts for such pmjeas with a contfactogs)licensed pursuant to the Contractor's -
Liccncc Law. PERMIT ISSUANCE.
l am rxenyn under Sec. .B&V C Tar this reason
MDwnet Uum
ALTER-DEAL N&VENT-WATER(IEA VMAAT -3 }10
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECL.DEVIC I
1 herr by affirm under penult,of perjury,one of the following declarations. -, I ^
❑Ihavc and will maintain.Cutilic.le of Consent to salt-insure for Worker's Coutpen- DRAINS-FLOOR. D:' {1 S00.1E5 'I YEE CONSTRUCTION )
ratio00 n,as provided for by Section 39of the labor Cole,far the performance of the
r which this p,mait Wooed, FlXTURLS-P. _ I iG
w 1haveand willut,fin Warkcr's Componsthe work
roam rcyuircd by Section J 7q
391NIof the lAMrCwlc.for tna perlimna cwdlhc workf rwnich thisyr' ",I,syyyed. GASJi1 OCC.GROUP 3AS
�j
My Wader o pen tion race 'e rand Policy nufnhunru/ J�hould
IN-12,
• - - M R- �df(
c.rric 6 Policy No, /N-(T— 03
CERT IFICATE OF EXEMI'1'ION FROM WORKERS' I%� UST rr�lUR
COMPENSATION INSURANCE BUILDING DIVISION FLITS
(Thissection need not lx completed ifthe Permit is for one hundred G t
nr less) PIANCH[CK fiE
I cenity Slott inrhe ociromaneroftfie work for which this permit is S ER-. 1'1'ARY- T0RM EA.2(x1 FT.
not employ any person in myntmoulso as m hccomea ......he Work ENICRGY PtlL
,Z cationLawsofCahmmi..Date sR HEATERW O Applicant GRADING PEE
'2' NOTICE 10 APPLICANT:If,after making this Ceniticane of ExemptioWATER SYSTEM/T TING SOILS FEE
becomesubject to the W..for.,Colnpcnsiu I,pmvin....of rhe Lshot Coat-
forthwith comply withsach provisi...or this permit shall he deemed revoked. WATER SERVICE -7 Sir
CONSTNUC'1'ION LENDING AGENCY NEW RESIDENTIAL PLFtB. SQ.Ff. PAID
;D zV C) IherebyafRrm the,there leanmswalinn lending agency fit the performance of Date Receipt)
the cork for which this permit is issued(Sec.3097.Ci,CJ
0 U Lcnder's Name TOTAL:
l e tier's Arldress TOTAL: 5•
0. 1 certify that I have read this application and we that the above inlitnmtit is BUILDING PEE
F" to comer.I agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
(.) ,Z huildingeouswetion,and hereby authorize represenmtivesofthie city turner uponme SEISMIC FEE
ahnvwnemloned property for inspection Furposes. PERMIT ISSUANCE
ELECTRIC FEE(We)aglce b.love,indemnify and keep hamdeaa the City of C.pertlno against
habilities.judgments.crsis and expenses which may in any way acerae against said City ALTER OR ADD'10 MECII. PLUMBING FEE 9I qq
in consequence of the grunting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(10 10,000 CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCI[ON TAX
Sigrumrvol Appllca ✓Cocmetot I IDuro EXHAUSTHOOD(W/DUCT) I IOUSIN .MMIGATIONFEE
HAZARDOUS MANRIN,S DISCLOSURE
Will rheapPlicam or fmurchildingaruPam port or handle bvsrdno....'coal HEATING ONI'r(To 100,101 BTU)
as def nail by the Cupertino Maine,[Cede,Chapter 9.12,and the I lealth and Safety
Code,Section 25532(:)1 HEATING UNIT(OVER W.(WBTU)
Yes !4•Pr� VENTILATION FAN(SINGLE RESIO) PAID -
Dae Receipt p
Will the applicant or future building occupant use equipment or devices which BOILER-COMP OFF OR I(q.1100 RTU)
emit hvardous air nmtantinmes m defined by the Bay Area Air Quality Management 'TOTAL:
U'daietBOSSIER-COMP(OVER W,(W Bq U)
❑Yee pN
I have read the :trdonn ntacdu6 mina emcnts under Chapter h 95 of the Cali- AIR CONDITIONER ISSUANCE D E
fumio Health&Safety Code,Station,25505,25533 and 25534.1 uuti, od that if the NEN'RESIDIiNI'IAL MECII. SQ.IT. /,Tt
huildingdoesnos cuncmlyM1 wcnant.that it is my eegW
ireffir , wh' stMme ro"ouraceofuaulhngem AAS TOTAL: ISSUED BY:
OFFICE