99120032 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY cr,q I Z OOZ y
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PI.UMBING.MECIIANICAL
BUILDING PROJECT IDENTIFICATION'
BUILDING ADDRESS: I -SANI FARY NO. APPLICATION SUBMITTAL DATE
OWNS AMN f/J✓ Pfv�j G - CON'I'ItACTOR'SeN�C E: LIC NO:
pp'RA NIC CONTROL#
RCHITECT/F.NGINE : LIC NO Amy/S�e31- 993 �..SZ��1f�r3PF�-�-+ ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Pees Paid by Applicant(Initial) ELECT PLUMB MECH
El
LICENSED CONTRAC TORS DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affii in that I am licensed under provisions or chapter 9(cont rte tc,g TOB DESCRIPTION
EJ0z with Sceion 90 )oro n3afihe Busness 1Rnfeve'omC nd my l'eenseis I F L
la1O �?V PERMIT ISSUANCE
Fy�syU nafull forme �Q ❑SPDWL El KITCHEN RE-PIPE
E-PIP I.
6UV License Clas - Lic. PLIANCES-RESIOENTIAI. ❑ADDITION [:1 PLUMBING RE-PIPE
N d 4 Datc Connncm
ARCHITECT'SD ❑MULTI-UNIT ❑STRUCTURAL
b„D. PANELS IFICATION
Z O�z q 1 understand ,
nd my plana shall he used as public cords
OZ-p UPT0200AMPS ❑INTERIOR MNEY REPAIR
94
5il Licensed Professional 201-1000AMPS IMPROVEMENT EJ SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER Flat
❑BATH RHMOIIP,I.REPAIR E3 DEMOLITION I hereby affimt the,I an,exempt from the Commctods License Law for the
W a 6 following ream,.(Section 903 I.S.Business usiness and Professions Code 1:1Any city or aunty SIGNS ELECTRICAL of HER
F
fIl which rcyuins a permit an armarua.mem improve,demolish,sir repair any swcmre
FqFqrs fr� Tricot,it,i,auanm,vs.hougres theapplicentfo...chpermit to fileasigncolaudement SPECIAL CIRCUIT/MISC.
da p+ Ihet he is licensed pursuant to the provisions of Commences License Law(Chapter 9 -
(commencing with Section 9000)of Division 3 of the Business and Professions Code)or 'TEMP.METER OR POLE INS'I'. MMER IA
11 y m ye that ho is'
s exempt therefrom and the hosts for the alleged exempli,a Any violation of NEW BLDGIADDITION El DEMOLITION
'IP+C1 Yom• Section 7031,5 by any applicant for a permit subjects the applicant o a civil pemtlly of POWER DEVICES ZENANT ❑FOOD SBRVICE
Y not mare than five hundred dollars($500), VEMENTSWIMMING POOL ELECTRIC
writdothbework.and theawmum Isom imm�dedorofferedfor,ale(Sa.]1194,Business so H
ro and Pr.. sslons Com
Codi The Contractor's License Law does not apply en owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employee,,provided that such improvements as not intended or mlfm,d for NEW RESIDENTIAL ELECTR SQ Ur.
sale.If,however,the building or inamowemente,Fold within are car of completion,the SQ ORAREA $/SQ.EL
has ser-hailder will have the burden of proving that he did not build or improve for The,
poseofsalcJ.
1,as owner of the properly,am exclusively consisting with licensed mmrall.to TOTAL:
cons much the project(See.9044,Business led Prefes,ions Code:)The Contractor's Li-
cendeLawdoesamapplyroanmvnaof property who bund,chando,.ea meontn.and QTY. PLUMBING PERMIT PEE.
who commuts for sua,projects with v comic imN)licensed pomuanuo the Comme,r,
Linen,Law, PERMITISSUANCE
❑ememonmpol"mar Sec. ,B&PCforthisreason
Date ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby oftlrm Hainr penalty of perjury ane of the following declarations
C
aIcoconut will for by
3700 of Consent to Code,forthe Worker'soo of the
DRAINS-FLOOR,ROOF,AREA.COND.
ration,as provided Car by Section J900,f the Labor Code,for the perfnemance nr the S'1'OItIES TYPE CONSTRUCTION
r which this permit is issued. - FIXTURES-PER TRAP
me and will maintain Worker's Compensation Inman,os requited by Section
011 eftkh�c Labor Cade,for the pt lhor afthew.,kforwlhhiicghth�il,permitii,,7issed, OAS-EA.SYSTEM-I INCAOIITLETS OCC GROUP APN
crhmvr� t yen In 4ffJ eP,Icy Nlo.: J n
G fJ� OAS-BA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' �tl
COMPENSATION INSURANCE. GREASEaNDUSTRLWASTE IN'IERCBPIOR
_ BUILDING DIVISION PP.NS
(This section need not becoinpleted iffle permit is for one hundred dollars($100) GREASE'I'RAP
or less) PLANCHECK NEP.
I certify that in the Performance ofthe work forwhich this permit is issued,l shall SEWER-SANITARY-STORM EA.200 PF.
merger not employ any person in any se as to become subjmOo the Wmkeas'Compen- ENERGY PEE
,`L salion Laws ofcalifomia.Date WATER IWAIERWNENT/ELECTR
y�O Applicant 1 - ANG PER-m'�
q y NOTICE TO APPLICANT:If,after making this Cef ificae of Exemption,you should Wood HR SYSTENUTR LYFING
a � Income subject to the Workers Compensation previsions of the LoM,Code,you mus SOIH,,��PE`E\
LkI forthwith comply with such provisions or this permit shall he deemed revoked WAFER SERVICE
Q
CONSTRUCTION isa1'IONLENDING AGENCY NF.W RESIDENTIAL PLMIi. SQ,FT. - PAT
Q,
�'7" Ihereby whichaffirm that thmeissued( ao 30 lending agency for the Performance of GL D°
a, Obcoi
V� the work for which this permit is issued(Sco.3119'!,Clv.O)
QLenders Name
W4 Lenders Address _ TOTAL:
y I certify that i have mad this application and stole Hernia above information is ILDING FEE —
rn correct l agree to comply with an city and county mdines stat
aneand e haws relaliag tit QTY. , MECHANICAL PERMIT FEE
T..1 � bnilJing amst.antler,and hereby vmhorize representnlivesnf tbiscityto cnlcrup,nihe wSEISMICYLE
olwve-mentioned property far inspecli,n purpmse,' PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC PEE
Iiabilhies,judgmems,costs and expenses which may in any way accom against said City ALTER OR ADD'I'O MECH.
f the Scanting of this permit PLUMBING FEE
APpnsc T UNDERSTANDS WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CPM)
SO CE SGUI T NS. / MECHANICAL FF.F;
AIR HANDLING UNIT(OVER 0."00 CFM) CONSTRUCTION TAX
Sure of Appliwq�Omtmm f of x'77 Dotal/ 9XHAUS'T HOOD(W/DUCU HOUSING MIT'IGA'TION FEE '
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant...Form huildinicempumemaorhirdle hoaafdous material HHA'rING UNIT TO 100,000 BTU)
as dellned by the Cuperlin MumeI al C de.Chapter 9.12,and the Health and Sufmy
Code,Section 25532(,; HEATING UNIT(OVER 100,000 BTU)
Yes Na _
VENTILATION PAN SINGLE RBSID) PAID Date Rceelpt#
Will the applicant r future building occupant use equipimul or devices which BOILER-COMP(3HP OR 10(I,OIXI B'fU) `
at hazardous air,anomia nos au defined by the Bay Area Air Quality Management TOTAL: V
district BOILER-COMP(OVER 104000 BTI)
❑Yes
AIR CONDITIONER
I have need the h�- N,gs matedaLv rcquiremena under Chapter 6.95 of the Cvli- - ISSUANCE.DATE
hands Health&Safely Cule,S ons 505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT. 3 -
hmildimgd 1 as amount, at it ism stansibany to notify t eve,
ofthe In Imus Rome primmissuane ofa Ceni pa'
nelmilethorized ant Date r TOTAL: ISSUED BY:
OFFICE