99120135 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY q9 1 - —o S
CITY OCAL
F CUPERTINO ITU°'DINT'.ELF.LTNICAI. PERMIT'NO
BUILDING DIVISION APPLICXFION/PERMIT PING PROJECT:DENrIFIC
I{1111A1NG PROJECT IDEN'1'IF'ICATItIh'
jSNIPnRYNfl. AYI'LICA'fl(1N SUBMI'IT'nl.UA113UILUING ADDRESS: ��� E
2SNAME: PHONE: WN CTOR:S NAME: N(T CONI'NOLN
WaaIiCl/ENGINIi13R: LIC 77 I nal /�
oNT'ACII PHONE: BUILDING PERMIT INFO
�� ❑ Consultant Fees Paid by Applicant(initial) HLrnDG/, IiLECI' 1'LHh1N Nil iClI
G�iLG X155` Gt3 1Q 5--'-
LICENSEDCONTRACTOR'SDECLARA'nON Q'1'y FUECTRIC PFRMiT FEE J013 DESCRIPTION
1 hereby inion That 1 am licensed under provisions of Chapter 9(commencing
QaZ with Swint700TOfEmoon 3ofthe BiOmeomad Professions Cads,mi license is P TI
FSB in lull lim'c:nW cffua. PERMIT'ISSUANCE pDWLl KITCHEN REMOLD,
=UU Liana,Class lank APPLIANCES-RES]DEN'I']At, ❑AUDI TION O PLUMBING RE PIPE
F-ZIa1 Date Cant.cmr ❑MULTI-UNIT ❑ST'RUCfURAI.
m Q 1 ARCHITECTS DECLARATION
F y Z 1 understand ar, 1 h ll bt used as blit¢curd., PANELS h10U1PICATION
ZOy- YPnnssa public UP TO 2W AMPS
OZ�Q [DIN'fERIGR ❑CHIhINF.Y HIiI'AIR
W Llaoscd Prof oo-I 201-I0OXIAMI'S IMPROVEMENT ❑SWIMMING POOLS
OWNHR-BUILDER DECLARNJ]ON OVER IIXXIAMPS ❑BATH RENRUFJJREPA1R DUEMOLII]ON
C Q 1 hercbY affirm thin 1 am exempt from the Cantreatnr'a License Law for the 00 ❑OIHIIR
x'O y U following reason.(Section 7031.5.Business and Pmfessionv Codca
e:Any city ar unty SIGNS ELECTRICAL
1+13 a 1- whim requires a Permit to vanswm,alter,improve.demolish.or repair any stmcwn
Eqq"'u'O-5 prior its issuance,also rcynim.c the ap,twml forsmh permit.file asignedstatereat SPECIAL CIRCUITIMISC.
2�te.d that he is hat,,rdpursunma,the pro kit sol'the Commemr's License Low(Chapter 9 COMMERCIAL:
qty�i (mmmeneing with Section]tXXgof Di ,ion 3ofthe Bminesxand Professions Code)nI '1'ENIRMIDERORPOLEINS .
a d c C that he is esempl therefrom and the has,,for the alleged exemption.Any viddian of ❑NEW RLUGIAODITION ❑DEh101.1'I'ION
�"^-I` Section 7031.5 by any applicant for a permit subjects the applicant w a civil penalty of POWER DEVICES ❑TENANT []FOODSERVICE.
.F. not are than five hundmddollars E500). IMPROVEMENT
50 01.aenwner ofthe propany,or my amployms with wages as their sole cmnlwncntion, SWIMMING POOL ELECT RIC
F,
ill dm work,and thcmmcmrc is on intended rfoftcnl I...sine ❑O'THER
Wit:se and Professions Cade:The Comracim'e License law does notaa rose -I S
property who(wilds ser improves Nercon,and who does such aur .1 T
his own tmployees,provided that Orth improvements me unions, SQ.PC FLOOR AREA SISQO FT.
sale.If,however,the building or improvement is sold within one year ofco npledan.the
e er-hn'dder will have do harden of proving that he did nut build or in 3 kat 32- V ( 4lbo2
Ossa Of sale.). TO'I'nh
❑L as owner of the property all exclaa,cly utmraetinB wan iicenw �n-
construct the project(Sm.1(W.Business and Prafesoon,Ci c., �� 3 J l Ofj fes'
c mLaw does notapplybh an owner Of property who builds or improves Nemrn.and TY.. PLUh1BIN PERMIT FEE
who commeu for inch projects with a cantdmras)licensed pars
Lianssc Law. S
Ia 1am exempt under Sec. i Mot
> VI3 1 VALUATION
netDae 3 d D o0
NORKT:R'S COMPENSATION DECLARATION BACK FLOW PROTECT.UIWICE
I hcrchy affirm tinder penalty of perjury one of the following declardlons:
I have nnd will late inlninaCcnificulcufConvenua sell'Insurcpit WrrkcLs Compcn- DRAINS-FLOOR,ROOIr,ARRA,COND, STORIES 'I'YI'li CONS'I'ROIL'ITO
abort,as provided for by Section 3200 of the Latin Code.fsn the pedilli arta of the
work for which this permit is issued. FIXTURES-PER TRA('
O 1 have and will maintain Workers Compensation Insurance,as required by Section GAS-PA.SYSTEM-I INC.1 OUTLEI:S
3]1X1 Of the Labor Cade,for the performance ofdw work fon which Nie permit is iccued. OCC GH(I(1P AP11F1
My Worker's Corntnxetlaniti.cumnceennierand Pallcynantberam: GAS-IiA.SYSTEM-OVIiR1(F;A) lJl
Currier: Policy Na:
CERTIFICAII..OF EXEMPTION FROM WORKERS' GREASE%INDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCEBUILDING DIVISION PefS
(This section need not he completed iOhe permit is(Drone hundred dollars(SIM) GREASETRAP PLANCHECK FEE
or less.)
Toy an,perhat inJ,vin poymannncutl s,wsIntrk far namwhichNie the Worker,
Cormul1 ' ' ' -SANITARY-ti MEA.21101T. ENBItGYII11!
nm employ unY person in any manner sat as na heunnc sWjcct ha the Workers'GInhIPCn-
Z alba,laws of California.Data WATER I e ' IVE T/Ii1.EC' GRADING FEE
C) O Applicant 1
rN. NOTICE TO APPLICANT:If,afar making this Certificate of Exemption,you should WATER S\.- M TIN SOILS PEE
[-� bcahme subject m Ne Workers Compen.cminn provisinns of the Labor Calc,you moa
ai{k7 CORSTRUCI'IUN Its purmil shall lc leaned revoked. WATER SH ICE
fnrNwitb cntnply with.vnah provisions at tab
Q PAID
G ENDWGAGENCY NEW RESIDENTIAL III. SQ.FT.
U Dam Receipt p
U O Thereby aBinn that there is lending agency forthe Performance of
ILI"' the work far which this permit is issued(Sm.3(197.Civ.C.) TOTAL:
O Lender'.,Name '(OVAL:
r Lelet's Address BU1LD1NG FET!
6. I credit,that 1 hint read this application and ewle that the have information is
L. chrect.I asrcemahmply wiNall city'and county ordinances and state lows relating w QTY, MECHANICAL PERMIT FEE SEISMIC ITE
V Z building construction.and hereby authorize representatives of this city ph enwr upon the
above-mentioned property for inspection Porlm¢s. PERM I T ISSUANCE ELECTRIC FEE
(We)agree to save,indemnify it keep harndcvs Om Cal of Cupun'mo against
Iiabilllicr.judgnenae.ca.as and expcnaes which any In any wary aceraeagaimt.,aid City ALTER LIR ADD'[O MECI L I'I.UMIUNG FE
in onseyuence of the standing of this psmot.
A PPI.ICAN'1'UNDERSTA NUS A ND WILL COMPLY W'U'H ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCT ION TAX
Signahmvul A,IdsuNCnnou of Date EXHAUSTHOOD(WIDUCI) IO USING MI'IiGnfION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building meupam store or handle himamloux material HEATING UNIT(TO I00.000 BTU)
as defined by the Caperton Municipal Code,Chapel 9.12,and the Health and Safety BEATING UNIT(OVER 11X1.1100 RTU)
ala,Batton 25531(x)1
(]Yes 7 N VEN'IILA'I'ION FAN(SINGLE RUSIU) PAID
Data R...its#
Win he applicant ser future bulling occupant rot equipment or devices which BOILER-COMP(3HPOR 100,000 B'HI)
Isolations air contaminants as defined by the Bay Arca Air Quality Management 'I OTAL:
aria^ BOILER-COMP(OVER[00,100 BTU)
New ❑NO
\ AIR CONDDIONER ISSUANCE?DATE
V I have and he M1amNuw nw Jos S,25533
i 533 i under Chapter
,oland'at if th-
biddigdoesaSafnyllyhaSatires .that.25533and 25531.1 to notita the,
Net if IM1e NEW RISIUIiNT1A1,M1fECfi. SQ.17.
Of the re Jmx tier currently have atoned.Nato is sea ce of a responsibility m ratify cc aTupant
Of the requirements which amt be and prior m issuance of a Certificate of(kcupancy.
Owner ser autharieed agent
Ude 'TOTAP.: ISSUI7D BY:
OFFICE