99090168APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
a610av1&9
Y OF CUPERTINO BUILDING - ELECTRICAL.
UILDING DIVISION APPIACATION/PERMIT PLUMBING -MECHANICAL
s. BUILDING PROJECTIDEN'I'IFICATION`
PERMIT NO.
DINGADDRISS:
buc
SANITARY NO.
APPLICATION SUBMITTAL DATH
Z� `�
'AMG' F&IPHONE: /
C R'S NAME: j�Y�^ Llf. �`jj �..-ver.
111u:4aV..���VV ✓4`/JI/l
NIC
❑
CONTROL#
.CHI — LICNO.
iner
All RESS, 3
CONTACT: PHONE:
❑ Consultant Fees Paid by Applicant (Initial)
- 'BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACfONS DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (eommcn g
with Section]OW)mf DivisionJof the Busines wd Professions Code, and mylimnse is
infull Clwo,nJefryy�� �� ���� y�rA3a9
Dionse Class_C,G/�L_Crum
ARCmllla, TS Dspu TION
1 understand my plans shnll he used as public records
'
QTY �� .) PLF.CTRIC fERMITs ' ) rFEE
' ,t ! '
s
]OB DESCRIPTION
RESIDENTIAL:
OSFDWL O KITCHEN REMODEL
El ADDITION C1 PLUMBING RE -PIPE
❑MULTI -UNIT STRUCTURAL
MODIFICATION
[_1 INTERIOR El CHIMNEY REPAIR
IMPROVEMENT I] SWIMMING POOLS
E) BATH REMODEUREPAIR El DEMOLITION
(_1 OTHER
PERMITISSUANCE
APPLIANCES- RESIDENTIAL
PANELS
UP TO 200 AMPS
Licensed Profcesionm -
ON
OWNER -BUILDER m Ce Contractor's
holI hereby affirm that I am exempt from the Cm ion, Cos License Law for the
ng remoo. (S iffit 1'103 L5, Business :uml improve.
which demolish. repair, any statement
h. m orny city or county erame
which us issu n permit ce. also re consweL aha. improve, demolish, file
that hesslicenedpursuarequites the
ovisiosofthecant for such Contrarmiuoicense ned ..(Cha mem
thatheislicensed#Section in the provisionsoftheW Bc,iaa,, nd Pom Law (Chapta9
(commomcing with Section 7001 of Division3nf the Business and Pndcssions Cnde)nr
that he is exempt therefrom and the fiaul 1'or he alleged exemption. Any violation of
Section 703 L.5 by any applicant for a permit suhiats the applicant to a civil penalty of
not more than five hundred dollars Sibiu,
El Las owncrofthe property, or my employees with wages as their wile compensation,
will do the work. and The shuctureis not intended orolfered for sale(See 7044, Business
and Professions Code : The Commcmzs r's License law Jsnot apply to an owner of
prapery, who builds tar improves thereon, and who does such work himself or through
hie own mnplmyea, provided that such improvements are not imeaded nr offered for
We. If. hvar co,thebuildimg in improvement i,odd withinnne yeronfcompletam. the
owncr-builder will have the burden of pving that he did not build or improve for put-
posenf rosale.l.
i, as owner of rho property, nm exelusivoly nmvacting with licensed anhnnors to
construct the project (Sec. 7044, Business and Profession, Code:) The Cmuma nr's Li-
rems,law does not apply to an owner of property who builds or improves thereon.and
who contracts for such projects with a communis) licensed pursuant o the Contractors
License[.aw.
❑ l am exempt under Sec. ,B& P C for This reason
2861000AMPS
OVER 1000 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEM['. M13T13R OR POLE [NST.
COMMERCIAL:
O NEW BLDG/ADDITION ❑ DEMOLITION
ANT ❑FOOD SERVICE
IMPROVEMENT
❑OTHER
POWER DEVICES
SWIMMING POOLELBCTRIC
OUTLETS -SWITCHES -FIXTURES
'TIA TR SQ f
NEW RESIDENil.RC
f I �1
1
FLOOARB
/ SEP -2-8 1993
V
��=.G......-.-,.._.-...._,
I�
�._.,�
OTIC L:
QTY. PLUMBING PBR T' T FEE
- r'
PERMIT ISSUANCE
AUTER-GRAIN & VENT - WATER (EA
rte i Date
VALUATION
�r l
/ x
WOR K ER:S COM PF.NSATION DECLARATION
I hereby afftra under penalty of perjury one mf the following declarations:
Lj I have and will maintain a Cenifvere of Consenuo self -insure for Winner's Compen-
sation, as provided for by Section 37W of the labor Code, for the perfntmance of the
work for which this permit is issued.
I have and will maintain Workcls Compcnmtion Insurance, as required by Section
3700 of the Labour Cole, for the performance of the work for which this permit is issued.
❑aria:'"-vI Policyolicy Y
Cm Worker' 'rt6 r. caricEah Policy glTOtytynrc� /rj
CERTIFICATE OF EXEMPTION FROM WORKEF sf�
COMPENSATION INSURANCE ',
(This section need not ba enmplemd lithe permit lx forme hundred UolWrs($100)
or less)
I comfy that in the pesfmparmarofthe work for whichthis permit is issued, [,hall
not employ any pe,an in any manner as as u, become s.hjcc, m the Workers' Council -ENERGY
soden Laws ofCalifinum. Data
Applicant
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF. AREA, GOND.
STORIES
TYPE CONSTRUCTION
FIXTURES - PCR TRAP
GAS -EA. SYSTEM -I INC. 4 OUTLETS
OCC. GROUP
Al.
GAS- EA, SYS' IT EM OVER 4(EA)
GREASUIN[IUSTRL WASTE INTERCEPTOR
v IIUII.dINO DIVISION FE
,3' y # t
GREASETRAI'
PLANCHF.CK FBI3
SEWER -SANITARY -STORM EA, 200 FT.
PEE
WAI'It It HHA'I'17R WIV17N'DELEC'IB
GRADING FEE
NOTICE TO APPLICANT: If. after making this Cenificate of Exemption, you should
become suhject to the Worker's Compensation previsions of the Labor Code, you must
Ihn n,ith comply with such provisions or Ihls permit such be deemed revoked,
CONSTRUCTION LENDING AGENCY
I hereby affirm that there isit construction lending agency for the performance of
the work for which this permit Is Issued (See. 3097, Civ. C.)
Lender s Name
WATER SYSTHWTREATING
SOILS FEE
WR'I'ER SERVICE
PAID
Date Receipt
NEW RESIDENTIAL PL IB. SQ, IT.
TOTAL:
Lender's Address
TOTAL:
I certify that I have teed this application and elate that the.Fane information is
correct. l agree m comply with all city andumnty a.houncesand,on, lowsrclming to
building construction. and hi amhmi representatives of chis city to enter upon the
above-mentioned pinpeny for inspection purposes,
(We) agree to save, indemnify and kap harmless the City of Cupcninm against
Iiabilhlq,judgments.consandexIsamea whichmay in any way nermcagalnsl paid City
in nscqucnce of the granting of this permit.
APPLIC UNDERSTAND. .D WILL COMPLY WITH ALL NON -POINT
SOUgJ' 1 NB. ////
I// /�' �-A%/A/
tgna re of Applicata ectnr Dam
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cuts nino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(.)]
❑Yes ONn
Will the applicant or future building by the Bt use equipment or denims Management
it hmarJous air contaminants as defined by the Bay Area Air Quality Munngement
Dialricl"
❑Yes ONo
1 have read the m4colaus materials requirements under Chapter of the Cali-
I p
that if the
forma Berlingdoes &t comty Gxh, Saunas 255115, 25533 and 25534. wNemf the
building does not curenpy have o tenant, that it is my responsibility m notify the oecupant
of the requitentents whicM1 must M me prim m issuance of a CenifcaR of Occupancy.
BUILDING FEE
QTY. MHCHANICAL''PERMIT FEE
SEISMIC FEG
PIiRMIT ISSUANCE
ELECTRIC FEE
ALTER OR ADD TO MEECH.
PLUMBING PELT
AIR HANDLING UNIT 01010,000 CFM)
MECHANICAL FE
AIR HANDLING UNIT (OVER I(I,INN)CFM)
CONSTRUCTION T/X
EXHAUST HOOD(WMUCI')
HOUSING MITIGAT NPEIi
HEATING UNI'r(TO I NEAT BTU)
HEATING UNIT (OVER 100,M) BTU)
PAID _.
Data Receipt#
VUNTILAq'ION FAN (SINGLE R0.511))
BOILER -COMP (THE OR 100,00f1 BTU)
TOTA -x6 41
ENTER - COMP (OVER IW,000 BTU)
AI R CONDI'T'IONER
y^ ISSUANCE DATA,.,,
/5(/
ISSUED BY:
N13W RESIDCN'I'IAL MliCfl. SQ. FT.
Owner or authorized a gem Date
'TOTAL:
OFFICE