30938 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE.BALL POINT PEN ONLY
CITY OF CUPERTINO , BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL O 3
BUILDING PROJECT IDENTIFICATION
BUILDINGADD � SANITARY NO APPLICATION SUBMITTAL DATI
S '
OW $NAME: PHONE: - COMrJtACTOR'S NAA /f LIC NO:�
1A �, " C/+�' / }� NIC CONTROL I.
rl
RUTH CT/ENGINEFR: LIC NO: ADDRES. /� { ❑ -
/0.7-97 S,
CONTACT: PHONE: BUILDING PERMIT INFO
�� ❑ Consultant Fees Paid by Applicant(Initial) - BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRA R'S DECLARATIONler,orhap QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby affirm that I um licensed under and
Professions
of Chapter 9(commencing
�00OaZ with llforc mantefecDivision3nf the Business and Professions Code.and my license is
PERMIT ISSUANCE RESIDENTIAL: -
in full eeree and effect.
SWF ❑SFDWL" _ El KITCHEN REMODEL
m f„1U License Class Contractor
APPLIANCES-RESIDENTIAL - []ADDITION �IPLUMBING RE-PIPE
F<Z 47 Date' Cuntmcmr _
Z:)a, ARCHITECTS DECLARATION ❑MULTI-UNIT ' ❑STRUCTURAL
'z -TPANELS O SS I understand my plans shell be used as public records " MODIFICATION
OR ,UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
04-C' Licensed Professional 201-1000AMPS - IMPROVEMENT
OWNER-BUILDER DECLARATION OVER IOW AMPS O BATH REMODELBiEPAIR ODEMOLTTION�
I hereby affirm that 1 am exempt from the.Contractor's License Law for the
O0.0 following reason.(Section]0315,Business and Professions Code:Any city or countySIGNS ELECTRICAL OOTHER
Owhich requires a permit to consumer,alter,improve,demolish,or repair any structure _
prion,its issuance also requires the applicant forsech permit tofile aligned statement SPECIAL CIRCUIT/MISC.
ythat he is licensed pursuant to the provlsionsofthe C,ntremors License Law(Chapter 9
aOC (commencing with Section 7000)of Division 3 ofthe Business and Professions Code)or TEMP METER OR POLE INST. COMMERCIAL:
Is
c rG that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
0. Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of POWER DEVICES ❑TENANT ❑F000 SERVICE
Np, not more than five hundred dollars(8500). a IMPROVEMENT
6 01,es owner of the property,ce my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
Qo will do the wmk,vnd the streemfe isnot intendeimOffered forsele Part. Business OT R
�'3m ami Professions Code:The Conant License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
.. property who builds,r improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT
1 sale.If.however the building or improvement is sold within one year of completion.'he SQ.PT.FLOORAREA S/SQ.FT.
ncobeilder will have the burden of proving that he did not build or improve for pur-
pose of ve
❑1,as ow r of the property,for exclusively connecting with licensed contractors to TOTAL:
concoct the project(Sec.7044,Business and Professions Code:)The Ci ntmcmr's Li-
cense Law does not apply to an owner ofpmpeny who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a contractors)licensed pursuant to the Contractors
License Law. I
PERMIT ISSUANCE I ^ 3
0 lamexemptunder Sea. ,B&PCfordd,ocvson' ,
Owner
ALTER-DRAIN&VENT-WATER(G) VALUATION
Date ^
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE ,
(hereby affirm under,Penalty ofperjury one,Rite following declarations:
0 l have and will maintain a Certificate of Consent to self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,GOND.
satin,as provided for by Section 37W of the Labor Code,for the performance of the i STORIES TYPE CONSTRUCTION
work for which this Permit is issued. eFIXTURES-PER TRAP r
0 I have and will maintain Worker's Compensation Insurance,as required by Section
37Mofthe Labor Code,for the�performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP - APN
My Worket"s Cotttggqpensatio �Y c rtier and Policy no f 3f�iir GAS-EA.SYSTEM-OVER 4(EA)
Gamer:f�p� s• ea Policy No,:6
`CEgIpIFICATEOF XEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFJINDUSTRL WASTE INTERCEPPOR
BUILDING DIVISION PEES
(This ses,i,n need n tt be complemd lftho permit is forme hundred dollars($100)or less) GREASE TRAP '� PLANCHECK FEE
I certify that in the Performance ofthe work f,rwhich this permit is issued,I shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as m become subject to the Worked Common- ENERGY FEE
z smion Laws of California.Date
O Applicant WATER HEATER WNENTMLECfR GRADING FEE
y NOTICE TO APPLICANT:IL after making this Cenilicate of Exemption,you should
WATER SYSTEM/TREATING
H become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
w '.fnMwiN comply with such provisions of this permit shall be deemed revoked / WATER SERVICE' -
gy Q.
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL ELSE. SQ.FT. PAID
1 VO l herebywhich
thin there is issued(So.
agency for the performance of Date 'Real
the work for which this permit is issued(Sec.309],Civ.CJ - -
ULender's Name _ TA .
L>J Laurie,'',Address .TOTAL:
I certify that I have read this application and state that the above information is - BUILDING FEE
V0.1 correct.lagreeto comply with ell city and only ordinances and state laws relaing to QTY, MECHANICAL PERMIT FEE
V buddingconstmedov,and hereby mitten.represcramves ofthis city to enter upon Ne SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Copeman against ELECTRIC FEE
• liabilities,judgments,cask and expenses which may in any way accrue against said City ALTER ORADDTO MECH.
in consequence of the graining of tit' it PLUMBING FEE +
APPLICANT U' E TANG WI L COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO to."CFM)
SOURCE L ONS. MECHANICAL FEE
97 AIR HANDLING UNIT(OVER10,OWCFM) CONS TRUCTIONTAX
Signa ,fApplicvnUC n. r Date EXHAUST H06D(W/DUCT)
HA DOLS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Wlltheapplicaatorfuture building eccupant....car handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.E!,and the Health and Safety
Code.Section 25532(x)? ( - HEATING UNIT(OVER 100,000 BTU)
+� 0Yes ' ON. VENTILATION FAN(SINGLE RESID) - PAID ,
Will theapplicant or future building occupant equipment t use a ui t or devices which Date Receipts
it haaanious air contaminants as defined by theBvy Area Air Quality -COME OHP OR 100,000 BTU)
ty Management TOTAL:
dct?'.
O Yes ONo - BOILER-COMP(OVER 100,000 BTU)
I have mad the hazardous materials restatements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code,Sections 25505,25533 and 25534.I understand that if the
building does net cumendy have a tenant,that it is my responsibility to notify the occupant. NEW RESIDENTIAL MECH. SQ.FT.
of the requirements which must In met prior an issuance of a Certificate of Occupancy.
Owne m mthmized agem, Date s TOTAL: ISSUED BYi • L
OFFICE