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30579
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY - r CITYO CUPERTINO, BUILDING-ELECTRICAL. PERMIT NO. BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL. � 30579 O �7 9 BUILDING PROJECT IDENTIFICATION 1 9 BUILDING ADDRESS: ✓' F.� SANITARY NO. APPLICATION SUBMITTAL DATE 1©785, iSO-KWt5l Dr CuPe:!l2—Ttt•Xi CA RSO . ' OWN '5;AM; Y PHONE CONTRACTOR'S NAME: LIC NO: I ISM 2 NIC CONTROL N RCHITECT/ENGINEER: LICNO: ADDRESS: 1 ❑ CONTACT: PHONE: _ BUILDING PERMIT INFO 4 ConSURant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH - LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE ❑ I hereby add.that I am licensed under praviaions of Chapter 9(commencing JOB DESCRIPTION QOC with Section?000)of Division 3 ofthe Business end Professions Code,and my license is RESIDENTIAL, in full force and effect PERMIT ISSUANCE License 0-4 U•e° License Class Liu,# - ❑SFDWL 11 KITCHEN REMODEL gpp y 6 a Dae C APPLIANCES-RESIDENTIAL' ❑ADDITION ❑PLUMBING RE-PIPE > ARCHITECTS DECLARATION PANELS , El MULTI-UNIT El STRUCTURAL Z O m A 1 understand my plans shall be used as public records ' m MODIFICATION OZ�• uPT02W AMPS' ❑INTERIOR CHIMNEY REPAIR �� ul Licensed Professional 20710WAMPS IMPROVEMENT ��dd t•i!]]11 Oat I am exempt U mptfr DECLARATION Conti ON OVER I WOAMPS yy W Q I hereby.(tion that 1 am exempt from the Contractor's License Law for the ❑BATH REMODEIIREPAIR DEMOLITION Na d F following reason.(Sermon]031.5,Busincsx and Professions CWe:Any city or county SIGNS ELECTRICAL ❑OTHER 1i.�Ome which requires a permit to eouswch alter,improve,demolish,or repair any specum, - __ y.] prior to its issuance,also requites the applicant for such permit to file a signedsmremenl SPECIAL CIRCUIT/MISC. / that he is licensed primmeuo the provisions al Comracmrs License Law(Chapter9 aim (commencing with Section 7")mf Division 3 ofthe Business and Professions Cade)or TEMP.METER OR POLE INST. .COMMERCIAL: - Y y m ys IM1ar he is exempt therefrom and the basis for the alleged exemption.Any violation ofos) ❑NEW BLDG/ADDITION El DEMOLITION fid! W Se.tloo]03136y nay applic.m fora pernmit eubjecF the appllcar m vcivilpenaltyof POWER DEVICES p>, not more than five hundred dollars($510). - ❑TENANT ❑FOOD SERVICE T� ❑ 1,as owner of the property,or my employees wiNwages as their.ole compensation, SWIMMING POOL ELECTRIC •IMPROVEMENT 4E will do Ne work,and lM1e sticture is not intended or offered formic(Sec.]fW4,Business ❑OTHER d3 and Professions Code:The Committers License Law does not apply ro am owner of OUTLETS-, TCHE. FIXTUNFS . property who builds or improves thereon,and who does such work himself onhrough YO his own employees,provided that such improvements are not amended or offered for NEW RESIDE ECTR SQ IT. sale.If,however the building or improvement is sold withirim, ref cmmpletinn.rhe 1 SQ.IT.FLOOR AREA $/SQ.FT. ownwomilder will have the burden of proving that he did not build or improve for Cur- , 4 pose of sale'). `' 0,1,as owner of the property,.m exclusively contracting who licensedcnntmcmrs to TOTAL: A& % construct the project(Sec.7044,Business and Professions Cade:)The Commerce.LI- - - cense Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBI IT FEE SEP 251996 who continues for such projers with a contmror(s)licensed pursuant to the Connector's - LicIa Law. ❑lam exam under ec. ,B&PCfonhis reason PERMIT ISSUANCE — alt yr UUa LlullYk� ALTER-DRAIN&VENT-WATER(EA) weer Damm VAL�AT�ION� Wm under SCOMPENSATIQQ Qp CLARATION BACK FLOW PROTECT.DEVICE ✓4�•r I hereb tiimm under h f r u of the following declarations yet Penalty pej ry g ❑Ihave and willmaintain Certificate of solr WorkersComped- DRAINS-FLOOR,ROOF,AREA,COND. sation,as provided foby Section 37W of the Labor Code,for the performance of the TYPECONSTRUCTION work 01lrf rwhich this lmintain issued. FlXTURES'-PER TRAP ❑1 have and will mainwin Workers Compensation Insurance,as required by Serio. t - 37110 of the Labor Coda,for the peformance ofthe work for which this permit is issued. GAS-EA.SYSHSLI INC.4 OUTLETS iOCC GROUP APN My Workers Compensation Insurance carrier and Policy number are: Carrier: Pulley No.: GAS-EA.SYSTEM-OVER4(EA)' CERTIFICATE OF EXEMPTION FROM WORKERS',, GREASFJINDUSTRL WASTE INTERCEPTOR COMPENSATION INSURANCE BUILDING ONISION PEES (This section need net le,completed if the permit is fortune hundred driii.IS Uni GREASE TRAP . or less) PLANC IECK FEE Loy mythntinthe perfoanyannernce o the work as whichthisfire Wrkera'Concer .ssued,I shall SEWER-SANITARY-STORM EA.200 PT. not employ any person in any manner so as m become subject m Ne Workers'Compete ENERGY FEE OZ sation Laws of California.Date WATER HEATER W/VENT/ELECTR 77 O Applicant - GRADING FEE G y NOTICE TO APPLICANT.If,afar,making this Certificate of Exem inion,you should P WATER SYSTEM/I'REATING a become subject m the Worker's visions his provihal or the Labor Code,you must SOILS FEE ' Lki forthwith comply with such provisions nr this permit shall be deemed revoked WATER SERVICE - n. CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.PT. PAID V v I hereby stand that hem is a construction lending agency ferthe performance of Date Receipt# ' the work work far which Nis permit is is.sued(See.3097,Civ,C.) D, , Lender's Name TOTAL: yLender's Address TOTAL: 1 certify that 1 have read this application.nd site that Ne above information is O BUILDING FEE , b1 correct 1 agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE U building cntmmction,and herehy amhmrize repressmrivesofthis city m cnteroponthe, SEISMIC FEE above-mentioned property,for inspection purposesap PERMIT ISSUANCE (We)some to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER ON ADD TO MECH. nsequeneeof Negmntingoflhispermi[. PLUMBING FEE APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) SOURCE REGULATIONS. MECHANICAL FEE ' AIR HANDLING UNIT(OVER 10,1100 CFM) CONSTRUCTION TAX Signature of Applicant/Conmmcror ": Date EXHAUST HOOD(WMUCT) HAZARDOUS MATERIALS DISCLOSURE - HOUSING MITIGATION FEE Will the applies.[or future building cirearentsommr handle hazardous material HEATING UNIT ITO I00,00(1 BTU) as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety - CWe,S7Yes 5532(x)7 HEATING UNIT(OVER 100,000 BTU) �, � ✓s.� ❑Ye ❑No VENTILATION PAN(SINGLE RESID) PAID Y Will the applicant or(mum building by the p yuse A ea Air Qu or devices which Date Receipt# mat hazardous air contaminants as defined by the Bay Area Air QuslityManagemem BOILER-COMP(3HP OR IW,OOp BTU) Disvict] BOILER-COMP(OVER I W,000 BTU) r' TOTAL: 3 ❑Yes ON. I have read the hazmdous materialx ¢under Chapter b.95 of the Cali- AIR CONDITIONER meyuiremen ISSUANCE DATE forma Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT. building does mot currently have a anent than it is my responsibility m notify the occupant I offie requirements which must be me[prmar m issuance Of a Cemified,of Occupancy. Owner or authorized agent 'Dame TOTAL: ISSUED BY: a OFFICE . i l !__. ..... ... .. .. ._ 1 HALL _ J CARPET �t I I 'UNEN S CABINET I i ! I ENTF I o BATH BATHVKYL 0 Q O 0 a IN AC MRDANCE WITH THE CITY OF CUpVD TUEPER "INO CODES AND ORDINANCES SIGNED_ ELF E This set rf plans and specifications MUST be kept In the job at all times and it is un SEP 2 5 1996 lawful to make any changes or alteration, on same without written permission from the build ng Dept., City of Cupertino. BLDG. INSPECTION DEPARTMENT The start Ze g of this plan and specification; CITY OF CUPERTINO SHALL N A be held to pe.mit or to be an approval of the violation of any provisions 'if any C Ordinanre or State Law,