29962APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINTPEN ORLY�
CITY OF CUPERTINO BUILDING - ELECTRICAL
PERMIT NO. 2 9 9 6 2
BUILDINGDIVISION APPLICATION/PERMIT PLUMBING- MECHANICAL
L J o G
BUILDING PROJECT IDENTIFICATION
BUI INGADDRESS:
X1317 Rai
SANITARY NO.
APPLICATION SUBMITTAL DATE
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OW R'S NAMrE - PHONE:- C NTRACTOR'
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ARCHITECf/ENGINEER:, LIC NO: ADDRESS:
CONTACT: PHONE:
BUILDING PERMIT INFO
' ❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT - UM MECH
❑ ❑ YZ ❑
0eeZ00
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LICENSED CONTRA unOR'SDEOLARATWN QTY ELECTRIC PERMIT FEE
1 hereby affirm Nut 1 con licensed under provisions of sCoder 9 (commencing
with Sectionof Division 3 ofthe Businosand Professions Cade,ends license is
inf.'aclass eR�it y PERMIT ISSUANCE
and
License Class �L- Lic.a 51st
Dore -/a In!'a 1�Contrvcmr APPLIANCES-RESIDIiNT1AL
JOB DESCRIPTION
EISFDWRESIDENTIAL,
D SFDWL ❑KITCHEN REMODEL
DADDITIONUMBING RE -PIPE
NQ
p.Drn
Z Ov� 7�.
ARCHITECTS DECLA 1 PANELS
I tmdentand my plans shell he uuJ us public records
DMULTI-UNIT STRUCTURAL
MODIFICATION
OZ�i�
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Oyx 0 �
W 3ta.0
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fsW�
.. UP TO 200 AMPS
[I INTERIOR ED CHIMNEY REPAIR
IMPROVEMENT
D BATH REMODEL/REPAIR [I DEMOLITION
❑OTHER
Licensed Professional 201-10WAMPS - -
Om I mr, exempt f DECLARATION OVER ]"AMPS
I hereby affirm Nat 1 am tempt from the Cessions o License law for the
following.sawn.(Section]OILS, Nosiness end Professions Cade: Any city or county SIGNSELECTRICAL.
which requires a permit to construct, alma improve, demolish, or mpur any structure
prion. its issuance also requires theapplic.rtt fmmch permit In file. signed.tmeram SPECIAL CIRCUIT/MISC.
that he is licensed punuanno the provisions of the Counselors License Law (Chapter9
COMMERCIAL:
D NEW BLDG/ADDITION D DEMOLITION
6^'O�
C. o C
(commencing with Section]000) of Division 3 of the Business mal Profusions Coda)or TEMP. METER OR POLE IN
that he is cmmpt therefrom and the basis for the alleged exemption. Any violation of
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»,
SRODL.dievv
I.
Seldom7o3L5hy any applicant for a pcomilsubjects the applicant o acivil penalty of POWER DEVICES
bmm.re thanfive hundred dollars ($SW),
rofthe propeny,onnyemplended with wren astheir sere 044, Hismion,' SWIMMING POOL ELECTRIC Is
ix not intended or offered
wiland drthewons
[]TENANT ❑FOODSERVICE
IMPROVEMENT
MOTHER
The Cure
Code: owner of OUTLETS -SWITCIiliS-FIXTURES
and Profusions Code: The Contractor's does not apply to an caner of
Law does not apply
who builds or improve themr's'License
rod who does such work himself or through -
s if
hispoulperty
t such improvement,, as non intended or "(fared for NEW RESIDENTIAL ELECfR SQ PT.
his awn employeese provided Net pooh
SQ. PL FLOOR AREA
5/SQ. ff.
If, however the building entisolw
is sold did n one yld
etfor
comer -sale.
will have the burden of proving Ihet M did not build m improve for pur-
burdmprov Incising or improve put -
From
From o .]a.)r
El 1, as owner of the pmperty� exclusively
contracting with licensed contnno.. to TOTAL:construct
704 , B
the projem (Sec. ]044, Business and Professions Code:) The Comrvnurs Li -
nd
c does not apply to ao owner of property who build or improves therson,aml QTY, PLUMBING PERMIT FEE
ram
whoconuactsfarsuch projects with ao.ntmmons)Rcemodp.rsunat lu Ne Conwcmr's
3
License Lim.
D I um exempt under Sec. , B& P C for this reason PERMIT ISSUANCE
:JUN 1996
Owner - Dam ALTER - DRAIN & VENT -WATER (EA) r
I T ur Vurs; II VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT. DEVICE -
1 hereby affiminnder penalty of perjury one of the fallowing declarations:
D (have and will maimain eCenificem of Consenuo ulGinsure for Workers Compen- DRAINS- FLOOR. ROOF. AREA, COND.
patio, as provided for by Section 37W of the Labor Code, for the performance of the
STORIES
TYPECONSTRUCTION
work for which Nis permit is issued. FIXTURES-PERTRAP
D 1 have and will maintain Workers Compensation Instance, ss squired by Section
37W of the labor Code, for the performance of the work for which this permit is issued, GAS- EA. SYSTEM. I INC. S OUTLETS
OCC. GROUP
APN
My Worker l nest Insum a carrier and Policy
Crmcr: T{ U%l( Policy No.: GAS - EA. SYSTGM-OVER4(EA)
CERTIFICATE OF EXEMPTION FRO WORKERS'
' I COMPENSATION INSURANCE GREASFANDUSTRL WASTE INTERCEPTOR
(This secsiotneed not be completed if the permit is ounce hundred doll ...($10n)
to less) GREASETRAP
BUILDING DIVISION FEES
PIANCHECK FEE
I cenify that in the performance all the work for which this permit is isxtied,I shall SEWER -SANITARY -STORM EA. 200 FT.
natemployanypersonin.ny sonars' to*u o Ne Wmken'C.mpem
ENERGY FEE
O,Z
z O^
cation Laws of Cali( —/ WATER HEATER WNHNT/ELECR
APPlicant s1 j`
GRADING FEE
NOTICE TO APPLICAN . Traliker making this ll7oifiiam of Exemption, you should WATER SYSTEM/TREATING
become subject to the Worke . Compensation provisions of the labor Coil must
fanhwinhcomply with such provisions nr this permit shall be deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ. FT
I hereby affirmconstructionrt
thhem is a construction lending agency foe performance of
the work for which Nis permit is issued (Sec. 3191, Civ. C.) _
y
a ;
Q
SOILS FEE
PAID
DamR eipto
Q
Lenders Nome
TOTAL:
_
Lenders Address
M
BUILDING
I cenify that 1 have rood this application and prate that the above information is
N
V 7
cocoon. r agree to comply with all city and county ordinances and sats laws mlaling to QTY. MECHANICAL PERMIT FEE
building construction, and hereby authorrepmunlalisn of Nis city m enter upon the
SEISMIC FEE
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep hamdess the City of Cupertino against PERMIT ISSUANCE
ELECTRIC FEE
liabilitin,jrdgmenns,cmns and expenses which m.y in any xmyattme... insttaid City ALTER OR ADD TO MECH.
in consequence of the grunting of this permit.
PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT AIR HANDLING UNIT (TO 10,000 CFM)
SOURCE REGAL S. / /
MECHANICAL 'E
/ 2f//Gj—I _ AIR HANDLING UNIT (OVER It1,fIW CFM/
LO `'Donee is
/
CONSTRUCfI TAX
SignamrCof ApplicanUConwmor EXHAUST HOOD(W/DUCE)
HAZARDOUS MATERIALS DISCLOSURE
HOUSING M[AcMihlu FEE
Will the applicant or future building occupant store unbundle hasrdous mmedH HEATING UNIT (TO I W,(HR) BTU)
es defined by the Cupertino Municip.l Code, Chapter 9.12, and the Health and Safely
Code, Section 25532(x)?�� HEATING UNIT (OVER I 00.00y) BTU)
Dyes j]No
i ` VENTILATION FAN (SINGLERESID)
Will Ne applicant or future building oocuinu t use equipment or devices which BOILER -COMP CHIP OR 100,000 BTU)
emit hazvdous air contaminants as defined by the Bay Area Air Quality Management
District? /�
D Yea BOILER— COMP (OVER IW.BWBTU)
PAID
Ome Receipt
TOTAL:
I have read the Intimations materials mquitemenn under Chapter 695 of the Cali- AIR CONDITIONER
ISSUANCE DATE
fomia Health & Safety Code, Sections 25315, 25533 and 25534.1 understand that if the . NEW RESIDENTIAL MECH. SQ. FT.
building Nes nm curently haveatenun4 that it isnry responsibility ..'it thamcupant
of the rim nb which�muusst�be tprtonoissuance nf(a/�Ce�ni///((Ujj((CWWWs of cupancy.
ISSUED BY: • ✓es- • '
OT a nt —/ 1 TOTAL:
OFFICE