31314 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT No. 3^ q 3,g JI
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL _ 1 31 L�
BUILDING.PROJEQ IDENTIF'ICA'TION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
1580 A Law.
OW NAP1 III Pf�� CO HAt- NAM)?: - LIC NO:
T1 S N/C CONTROI.M
FA
ARCHRECUENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) _ 'BLDG ELECT PLUMB MECH
® " ❑ . ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELEC9'RIC PERMIT FEE
q z L hereby affirm that I am licensed under provisions of chapter 9(commencing JOB DESCRIPTION
QWZ withSection700B. 11ivisiun 3 oftb,Business and Poidessions Code.and my license is PERMIT ISSUANCE RESIDENTIAL
�we- in tome and eHea' ❑SF'DWL [I KITCHEN REMODEL
<V1.. License Class Liao APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
nZ Aum C'S DECLARATION
< ARCf1ll beeaDECLARATION ❑MULTI-UNIT ❑STRUCTURAL. '
F�m PANELS .
I understanJ my plans shall he useJ ns Public rcmrds MODIFICATION
Pix,F.�W UP]'b 20o AMPS ❑INTERIOR ❑CHIMNEY REPAIR
GN�J Licensed Professional 201-I000AMPS IMPROVEMENT
Iy,YE, OWNER-BUILDER DIECLARATION OVER 1000AMPS ❑BATH REMOUEUREPAIR ❑DEMOLITION
C m Q I hereby affirm that I sm exempt from the Cort artors License law for the
X 3 6 V following reason.(Section 7031.5.Business and Professions Cole:Any city or county SIGNS ELECTRICAL. ❑OTHER
Ir,7 WO{'1 which rtquires a permit to comWe4 ulcer,improve,demolish,m repair any structure
. priormits iesunncq�lso.,mm,the applicanl fmsuch perming Bled signedsmtemern SPECIAL CIRCUI9'/MISC.
,1 P hot he is d unman Pimuoinrto the provisions c.f the Contractor's Lkens,Law(Chapter 9
W�G� (commencing with Section 9(1)()0(Dlkion3 ofthe Businmsuad Pr..e,.ima Code)on TEMP.METER Olt POLE INST. COMMERCIAL:
a q that he is exempt Amnith tit and the basis for the alleged exemption.Any viplmlon of [I NEW BLDG/ADDITION ❑DEMOLITION
44.• Section]OI LS by any epplicamfora pcnnit subjects the applicannnucivil penalty of POWER DEVICE$
'sH
not mom Brad five hundred dollars($5W). ❑TENANT ❑FOODSERVICE
F?6 Las ownerof the n,erm bees with woes as theirwle compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
winG ❑ the sa Y Yetm Y B Perna
'd do the work,and the he Con is no intended proffered s not apply
o tin Business ❑OTHER
3 and Professions Cole:The Convector's License law does not apply totinownerm' OUTLETS-SWITCHES-FIXTURES
property who builds pr lotal them
such i and who improvements
are
work himself or through
his own employees,provided that such impmvcments are not intnJ¢d or offered for NEW NESIUfiN'I IAL I?LECTR SQ PI'
sale,If.however the building or improvement is sold within one year ofcompletion,the SQ.ET.VO IED $ISQ.FT,
n
er-builder will have Nr. HH
e burden of proving that he did not build or improve for Au
tw• sale.). TOTAL:
1.m owner fine pmparty,amexelusively contracting with licensed contractors t OCT 181996
construct the rapso(Sec.70,14.Business and Professions Codc:)The Contractors Li. -
cerise Lawill not apply loan owner ofproperty who builds or improves thereon,and QE
TY. PLUMBING PERMIT F
who contracts for such projects wird a conowtur(s)licensed pursuantto the Commctgra
License Law. PERMIT ISSUANCE III Ur VUf1.:t'IIIIYL
ex
❑lam empt under Sec. .� ,B&I'Climhis relsnn
Owner Dam ALTER-DRAIN&VENT-WATER TA) VALUATION
w
WOR KER'S COMPENSATION DECLARATION B ACK FLOW PROTE(JT.DEVICE / �F/I (/✓
1 hereby nation under penalty of pc jury one of the following declarations: - V✓{I'�./
I have and will maintain a CertificatofConsent to self-insure for Workers Compen- DRAINS-FLOOR,R(%F.AREA.CONU, STORIES TYI'F:CONSTRUCTION
action,as provided for by Section 3000 of the Labor Code,for the perR)rmarm of the
Irk fur which this Permit is kacrd. III XTURES-PERI RAI'
❑ 1 have and will maintain Worker's Compon.wtion Insurance,is requimd by Section
3700 muse Labor Code,for the perl'onnance all the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Worker, ance's Compensation Insurcarie,nod Policy nmmher are:
Carie,.. Policy No.: GAS-EA.SYSTEM-OVER 4 BDO
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSTRLWASTE INTERCEPTOR
(ilik,ection need not becomplmed ifthe permit is forms,hundred dollars is I W) BUILDING DIVISION His
or Ices.) GRHASE TRAP
PLANCHECK HE
I cenify that in the performance uf Wu work for which this Permit lx lssucd,lshull SEWER-SANITARY-STORM EA.200 FC
not employ any person In uny manner so as m become subject t the Workers'Camper- (ENERGY FEE
O Z section laws of Culifnmia.Dam WATER NEATEN N'NI?NT/ELECTR
Z O Applicant GRADING FEF.
y NOTICE TO APPLICANT.If.after making this Ciminero,of Exemption.you should WATER SYSTEMA-REATING -
abecome subject top the Workers Compemation provisions of the Labra Cede,you must SOILS FEE
fSJ forthwith comply with such provisions or Permit shall be deemed revoked. WATER SERVICE
G
U0 CONSTRUCTION LENDINGAGENCYagency NEW RESIDENTIAi.)'LMB. SQ.IT. PAID
LJQ k hereby wick thipe themisued(Sectinn len ding agencyfnnhe perlinmance of Dom Receipt N
[Tw H Ih�e work for which this permit is issued(Sea 3117,Civ,CJ
Lenders Name TOTAL:
Landers Address TOTAL:' 3�
y I cenify that l have re ad this application and state Nat Or,abrve information is BUILDING FEE
t/) cored l agree to comply withitH city and county ordinances and state laws misting to QrY MECHANICAL PERMIT FEE
V z building construction,and hereby authorize repreacrainvesofthis city to enterupon the SEISMIC HE
uhove-mentioned nnto,for inspemiun pmt nsc,. PERMIT ISSUANCE
IWO p9m.lo'savc,indemnify and km,h.mdr,,the City of Co"-dino against ELECTRIC FEE
liabilities;judgments,costs and expenses which any in tiny way accrue again.a said City ALTER OR ADD TO MECH.
in cunsegmace of the gmming cif Nrs permit PLUMBING HE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. MECHANICAL FEF.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applicarca2moractor Date EXHAUST HOOD(W/DUC'T) HOUSING MITIM'HON FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle humidoua material I(EATING UNIT(TO IMOMB BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cole.Section 25532m)? DEALING UNIT(OVER 11111,0010 BTU)
El ye,, ❑No VEN'TH-VGON FANS INGLE RESID) PAID
Date Receipt Of
Will the applicant or antra building by the B use equipment or devices which BOILER-COMP(3111'OR 100,000 BTU)
emit hazardous air contaminants as defined by the Hay Area Air Quality Management
DtsatetTOTAL:
BOILER-COMP 100.000 BTU)
❑Yea ;QNu / / D
-
I have real the hnrardous materialsAIR CONDITIONIER
requirements under Chapter 6.95 of d®Call- ISSUANCE DATE
forma Bealth&Safety Col,Sections 25505,25533 end 21534.1 uWcratmd that if Ne NEW RESIDENTIAL MECH. SQ.Flt
building does not immorally have a tenant,that it is my mspant
onsibility to notify the occupant —
of the rcqubements which must be met prior to issuance of a Certificate of Occupancy.
1 Owner or authorized agent Dara TOTAL: ISSUED BY:
OFFICE