28652 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES=USE BALL POINT PEN ONLY '
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO; �.
BUILDING'DIVISION APPLICATION/PEBMIT PLUMBING.MECHANICAL
BUILDING PROJECT IDENTIFICATION '
BUILDING ADDRESS, - - SANITARY NU. APPLICATION SUBMITTAL DATE
IOL4-76 d e r. algid( al-AI7
OW ER'S ME: P BE CO ACTOR'S NAMEi nr. NIC CONTRQI_N
Ca un' cJ C v r a N 1 1 88
A 1' CT NGINIHHI LIC NO;. A It
IAA S OCt II - ( . I vVt (q 4I,e ❑ ��
CONI •' PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MCCH
Kik VIAw 9zY-eaO ❑ '' ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE '
I hereby affirm That I um licensed under provisions of Chapter 9(commencing 'JOE DESCRIPTION
C0O with Section]000)of Division 3 of the Business and Professions Code.and my license is PERMIT ISSUANCE
Is70 TQ \ RESIDENTIAL:
FW nfullf"C and effect. �pQ I// I �SFDWL ❑KITCHEN REMODEL
�U License Cl ss Lic.Y 2Ec7-b 'APPLIANCES-RESIDEN'f1A1. ❑ADDITION ❑PLUMBING RE-PIPE
�+ Date Cnnlm 4�JL1,—
ARCHITEA DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
N
PANELS
Z E2 Z I understand my plans shill be used as public records MODIFICATION
OZ-1 UP TO 200 AMPS ❑INTERIOR [I CHIMNEY RI?PAIR
1-I W Licensed Professional - 201-1000AMPS -IMPROVEMENT
Jq Ia-) OWNER-BUILDER DECLARATION OVER IIIIMIAMPS ❑BATH REMODEUREPAIR ElDEMOLITION'
O I hereby afford that 1 am exempt from the Counselors License Law for the
3 U following...(Sectiun7031.fl.Business and ProfessionsCWe:Any city mcounty SIGNS ELECTRICAL [I OTHER
which requires a permit m cnnawd site,,improve,demolish,or repair any oundure
prior 1.its iowance,also requires theapplicant nonsuch permitto file a signed statement SPECIAL CIRCUFUMISC.
that he is licensed pursuant u,the provisions of the Contractor's License Law(Chapter 9
Y� p0 (commencing with Section 7000)ofDivision 3 ofthe artiness and Professions Code)or TEMP.ME'I HR OR POLE INST. COMMERCIAL'
6yx
N
c,Y az he is exempt therefrom and the basis fom
r the alleged exeption.Any Amanda,of C1NEW BLDG/ADDITION [IDEMOLITION
_IoW' Section IBILI by any,,licull for a permitsubj«ta the application,a civil penalty of POWER DEVICCS
W rn , mote than five hundred dollars HINT ❑FOOD SERVICE
FZOtot
IMPROVEMENT
[ 1,as ownerofthe pottery,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
will do rhe work,and the xtmcwre is nut intended proffered I'nr sale(Sea 7044,Business ❑OTHER
and Pntlessors Code:The Contractor's Lianas law does not apply to rat.,a,,ft OUTLETS-SWITCHES-FIXTURES
property who builds pr improves thereon,and who does such work decd or
r offered f M1'
his own however,
me provided That such improvements are not intended«offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.ILhpwevcallhave the burden
issoldhewithin one
uiyearldor ao..se ipn,the - SQ.Fr.FLOOR AREA LSQ.Ff.
wne.fmader will have the harden of proving that he did nor build or intpmve for par-
pose of sola). )
❑ 1,as owner of the pottery,amsie exclusively and amtmctins with licensed cnmmdprs m
construct the protect(Sec.o an owner
and Professions Code:i The Comrasaon,Li-+ Gb p
whocerise
co.awdceor suapply recon hat aonproperty who
sedpmimproves thereon,and QTY. PLUMBING PERMIT FEE 4 ®�
who contracts for such projects with a contractors)licensed pursuant to the Contractor's
License Lowexempt
PERMIT ISSUANCE J- A
❑Iran escmpr under Sea ,B&PCfor this rcae.n ^
Owner Date - ALTER-DRAIN&VENT-WATER THATUN
9 UN
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
If
I hereby affirm under penalty of perjury one of rhe following Jedsratipns `
/❑ I have and will maintain a Certificate of Coram to self-insum for Worker's Compen- DRAINS-FLOOR,ROOF.AREA,COND.
sation,as provided for by Section 370H)of the Lb.r Code,I'or the IS.m'-nance of the STORI&, ..oego TYPE CONSTRUCTION
IIIwork for which this pewit is issued. FIXTURES-PER T
N) I have and will maintain Workee,Compen.amion Infinit ce,as required by Seen.
37 of the Labor Code,for the performance of the work for which This permit is issued. GAS-FA.SYS -IINC.4OUTL S- OCC GROUP APN
My Work e sCom $ah.a lnsumnctt//carrier nnJ Policy nu
Cartier, rVu( 'U',CAA Policy No.:� ra�`1S9obG,l GAS-E STEM-OVIik4(EAT
CER'TIPICAT OFEXEMPTIONFROM OkKERS' -
COMPENSATION INSURANCE G I%INDUSTRL WASTE IN UH CB Bllll G"UIV ION THEN
section need not be completed Fare pours is for one hundred dollars($100) GREASE TRAP
or less) PLANCHECK FE
I rectify that in the perfmmnnce ofthr work for whichthis pernit is is sued.d shall SEWER-SANITARY-STO 200 FT.
act employ any person in any manner so as m become subject to the Workers''Compen'. . ENERGY FE
,z satin Laws of California.hate
O WATER HEATER WN ECTR
Z Applicant GRADIN E
to NOTICE TO APPLICANT.If,rare making an,Certificate of Esemptl.my.0 should ATERSYSTE G
E, become subject .!he Workers Compensation provisions of rhe Labor Cale,you mum. SOILS F'EE
4ai.) forthwith comply with such provisions or permit shall bedecmcdrevoked. TERSE -
Q
z' - CONSTRUCTION LENDINGAGENCY' NEV)iIIEMA11VNPUxflL SQ.PT. PAID
V QI hereby amrtn that hem is a construction lending agency for theperfmmame of m xeiptp
F+ the work for which this permit is issued(Sec.3NO.Civ.C.)
tenders Name - TOTAL:
{U Lender's Address TOTAL:
1 eerily that I have read this application and amid that the above Inlirmad.r is BUILD EE
h correct.1 agree to comply with all city and county ordinances and state laws relating to Q-TY. M HANI ERM FEE.
U z building construction,and hereby authonze representatives of this city to enter span the SEISMIC FEE `
r above-mentioned property for inspection purposes. PERMIT ISSUANCE
We)agree to save,indemnify and keep humorless the City of Cupertino against ELECTRIC FEE
Iiabilitax,judgments,cosI and ex eases which may in any way acerae against said City ALTER OR ADI MHCH,
in coT4,1 :
uence of the gar a th spermit. - PhUMBING FEE
APPANT UND ANDS AND WILL COMPLY WITH ALL NON-POINT AIR HAN .NG D'(TO 10,000 F
SOUnH 1011 MECHANICAL FEE
V b r�� AIR NGL G \(OVER I0,0(hIk CONSTRUCTION TAX
Si,.bh.df Applicant/Cont or Date EXHAUSTIi( /DU HOUSING MITIGATION
HXRDOUS MATERIALS DISCLOSURE
Will the applicam or future building occupant stored,handle hazardous metcnalEAT T 1V, U)
as fined by the Cup,mim Municipal Calc,Chapter 9.12,and the Health and Safety
C ,Section 25532(m? GUN OV If1QfHta TTI)
❑Yes Fl No ,. VG LATION NN(SING .RESID) PAID
Date 1611
e 1 N
Will the air costa in ntum building tc me B use Area
Air error devices which OIL R-COMP DH 100,000 BTU)
mit District?.
us air contaminants as defined by the Bay Arco Aic Quality Management
Disci<t?, - - TOTAL:
[I Yes ❑N. - B LER-COMP F.R IW,1100 BTU) -
AIR
Ialth Safetyail the h odMrusrdats 25505,2553emsl nder T55. .I pter 6.95 understand
(beThai Celle NEW I ER>- ISSUAN DATE
folia Health no Safety Code,e a tions 2.5511 it 25533 and 25534.1 understand that Fare NEW RPSIDENIIAL MIiCH. SQ.FT. \`�r�'yv^'//
' building does not currently heveeterunt,tMrit is my responsibility mnotify the«copant
of the requirements which most be met prions iz ran«oft Certificate of Occupaind,
Owner or uulhnnzed agent Dat. + TOTAL: ISSUED BY: VV�\ F
OFFICE