S 1839 APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY.
CITY OF CUPERTINO BUILDING-ELEC'T'RICAL , PE ITNO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL 1839
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATA
b7 / �� �. Gil �a��C I
OWN 'S NAE, _fOHOZ SLS C RACTOR'S NAME: LIC NO:
[[LLJJ t NIC CONTROL#
RCMFECfIENGINEER: LIC NO: ADDRESS: ❑
C^ONTA'C-T�:� _ , /`'� - BUILDING PERMIT INFO
/ h `qll - ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB SOCIAL
44
❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby afB.nt that 1 ran licensed order prerlsirns of chapter 9(rnmindming JOB DESCRIPTION
�pZ with Section]0W)ofDivision 3offine Businessand Profession.Gude.add mylicen,eis RES NTI L
F in full farce and effect. - !/ PERMIT ISSUANCE
rrLap, `; (rD at DWL ❑KI'PCHEN REMODEL
UU License Clan [soca# APPLIANCES-RESIDENTIAL ❑ADDITION ` El PLUMBING RE-PIPE
o,'D rrZ4 Date Crntrvdnr
ARCHITECT'S DECLARATION L1 MULTI-UNIT El STRUCTURAL
PANELS
u'F"y z I under,tund my plans shall be used nimble records MODIFICATION
I^ UP TO 200 AMPS
F�.F.W Licensed Pmfeasional EXTERIOR CHIMNEY REPAIR
�W22 OWNER-BUILDER DECLARATION 2111-IINXIAMPS IMPROVEMENT SWIMMING POOLS
C 1 hcmby affirm that 1 am commit ifnm the Contractor's License Low for the OVER I WO AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
d U following reason.(Section 9031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL El OTHER
E. la,F which requires a permit te eone0un,altee Improve.demolish or repair any nhmemre _
F^�Oq prior to its issuance,also require the applicant for such permiuo file a signedstatem°°t SP ALCIRCUI'I'/MISC.
pipp`�p+ that he is liccnxed pursuant to the provisions°fthe Contractor's License Law(Cbuptcr9
aA� (commencing with Section 91101)of Division 3 ofmc Business add Donovvan, Cidej nr .TBR OR POLE INS'I'. COMMERCIAL:
F g,o y` that he is exempt therefrom and the M1usis for the alleged exemption.Any violation of [I NEW BLDG/ADDITION [I DEMOLITION
m Section 7031,5 by any applicant for a yO permit subjects the applicant to a civil penult f POWER 14
W^m ❑TENANT ❑FOOD SERVICE
F Z'T n'n tare than five hundred call aa($501). IMPROVEMENT
rs dO 01,asowner fihe property,or my employees with wages as their sole compensation, SWIMMING POOh . C
will dothe work,and the structureknit Intended..mmired Outside(See 704QBusiness n ❑OTHER
a and Professions Code The Contractor's License Law does not apply to en owner of y OUTLITS-SWITCHES-FIXTURES
prnpeny It.builds or improves demen,and who doessuch weak himself or through l
his ow°employcen,provided that suoh improvements ore not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If.however,the building or Improvement is sold within ane year of cottttoddon,the ir1-10.VTHLOORA �,4 $IS¢FT.
oil
-builder will have the burden of proving that he did not holdnr improve for Pur- 11�
pomade.) -
I,as owner of the property,am exclusively contracting with licensed commcmts 1. TOTAL:
..redact the proyeet(Sea 7044,Business and Professions Cod..)The Condacrors Li- JUL 14 1998
cand"Law does notapply to an owner of property who builds or improves maroon,and QTY, PLUMBING PERMIT FEE .
who contracts branch Project,with a wat..t oflicensedPur,iamto the Contractors
License Low. PERMIT ISSUANCE IG. INSrtCTIONDEPART ENT
O I am exempt under Seo. ,B&P C for mismaum
ALTER-DRAIN&VENq'-WATER(EA)
Once, Data t
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby i ffimt under penalty of perjury..car the nitw ing decl:onJons:
I haveand will maitnaina Cxniftcam mCcusont msdf-Insure far Workers Compert- DRAINS-FLOOR,RODE AREA,COND. STORIES TYPE CONSTRUCTION
cation,as provided for by Section 37W of the],,,bar Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
1 have and will Ommin Workers Compensation Insurance,a,acqu ed by Section — JUL 14 AMR
3700of the Labor Codd,for'he perfonnanm..title work for which this permit is Is sued. GAS-EA.SYSTEM-1 INC.4 DO]LETS OCCGROUP APN
My Worker's Compensation In umnm comer and Policy numbre are: TV
i
lard"
h,,�'�w A h 'I Policy No-1111i 1-1610.]76 GAS-EA.SYSTEM-OVER 4(EA) GII1 Ur t urCC11 Il
CERT ICATI� E Of EXEMPTION FROM WORKERS' L D l
COMPENSATION INSURANCE GREASEINDUSTEL WASTE INTERCEPTOR DELUDING DIVISION FlP.ES_
(Thissectirn need nit be compWedlfthe permit is Ounce hundred delta,,G IIID) GREASETRAP
ar lens) PLANCHECK FEE
I certify that in the performance ofine work for which this permit in issued[,hall SEW[R-SANITARY-STORM EA.200 FT
not employ any person in any mann'{�j te e t to the Workers'Compcn- ENERGY FEE
nation laws of Califomia Datp /ut, p�nlps�jw
7�� Applicant—90 ant /•r�a�trl/-E-pyI '�I a WATER HBA'1'[k W/VGMf/ELLCI'R GRADING FEE
q NOTICE TO APPLICAN IT, making this Cenillcam of Exemption,you should WATER SYSTEMC REA'TING
F-t lacerate aidectm the Wnrker'x Compensation.....sime,of the Labor Code,you must SOILS FEE
Wti forthwith comply with such provisions r1 this permit shell he deemed revoked WATER SERVICE
Q
CONSTRUCTION is a comm LENDING lNGngAOENCYagony NEW RESIDENTIAL PCMB. SQ.IT. PAID
0 for which
that t,sued(Seeti0lending agency[rano pot[ormvnce of Date ReceiptM
Lks `-I the work for which this permit is issued(See.309].Civ.C)
Q F'' Leader's Name TOTAL:
V Lenders Address TOTAL:
t� 1 certify that l have rend this application and state that the shove information is BUILDING FEE
rFih correct.l agree m comply with all city and county ordinances and state laws relating m QTY. MECHANICAL PERMIT FEE
V `& building construction,and hereby authorize representative,of this city to enter upon the SEISMIC PEE
abave-menti..nad property for inspection purposes
(We)°gree m levo,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE. ELECTRIC FEE
Iiabilities,judgments,costs and expenses which may many way accrue against said City ALTERORADDTOMECH.
in consequence of the granting ar this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. MECHANICAL HE
AIR HANDLING UNIT(OVER 10.001 CFM) CONSTRUCTION TAX
Signature mApplicanJCdntmetnr Dote EXHAUST HOOD(Will HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building weet,crawme..r handle hasuNor,material HEATING UNIT ITO I0fW0 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT
Codd,Section 25532( (OVER( ER 100,000 BTU)
El Yes %No VENTILATION FAN SINGLE RBSID) PAID Date Rececontaminants --
Will the applicantitfmade buildingoccupantuse equipmentitdeviceent BOILER-COMP QHP OR 100,000 BTU)mit hazardous air contaminants as defined by the Bay Area Air Quality Management TOTAL:
ieaicfP Yes Nu BOILER-COMP(OVER Icol n rd,)
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1 have read the hazardous materialsrequirements under Chapter 6.95 of the Cali- AIR CONDITIONER w ISSUANCE D
famia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that Lthe NEW RESIDENTIAL SUCH. SQ.IT.
building does not currently have a tenant,that it is my rcsficia iliry to notify the cou from
oFt eregmirut swhtchit bmmetpf...to issuance fa rid m DRsvpnncy.
GOn dor M 5119 fir
Hwa imdagem �� Date TOTAL: ISSUED BY:
OFFICE