30329 APPLICANT TO FIL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTIN BUILDING-ELI1,6'FRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT 'PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION 30329
BUILDINGADDRESS:- - SANITARY NO. APPLICATION SUBMITTAL DATE
10240 R6AO Q6
OWN,R'S NA .+� P ON • -.� - C pC 'S B: LIC NO: O NIC CO ROI:M
4 TELT/.NG EER LIC NO: ES,': ° I ❑
CONTACT PI BUILDING PERMIT INFO
sic-
` I�
El Consultant Fees Paid by Applicant(Initial)
`WaCONTRACTOR
HL E PLI1M - MF. H
,TIL
LICENSED CONTRACTO :S DECLARATION QTY ELECTRIC PERMIT PI?E
I hereby affirm that 1 am licensed under provisions of Chapter 9 mntetmmg JOB DESCRIPTION
�0C•.FUW Dv¢nsememal 0)ef Drv'nnJ ol'me C'^nexsnne�mtgssinns Cndo,pndm license lx RESIDENTIAL
Z6/{X.L�' 7C*✓� PERMITISSUANCE
I.fall force and effttc _ CSPOWI. E:1 KITCHEN REMODIjI,
R APPLIANCES-RESIDEN'T'IAL ❑ADDITION
2. mens, ❑PLUMBING RE-PIPE
�s a' CTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
zF8p Lunde my enss u da. PANELS ' „
oz ry 61s UP T0400 AMPSERIOR MODIFICATION
P(4. LL�i Licenwd ❑IMPROVE El REPAIR
rofcxaiomtl -4111-ICIMIAMPS IMPROVEMENT
OWNER-H UILDERnt the RATION OVER KXOAMPS C BATH REMODEUREPAIk ❑DEMOLITION
yy 1 M1ereby a um that 1 am exengn fnmt the Cnmm.yels Liwnvc Law tor the
X0 F following revsoa(Seeti..7031.5,Bmineseaml Rnfessiuns Cod;:Any city m emorYGNS IiLECTRICAI. - COTHER
which rc,mm,a permit to cmannao,Nmr,improve,demnlish,nr rery'it any nwdurc
��y6 pnonoits issuance,also rcyuites the appli[ant for such pemtino fleasigned stalemem SP tALCIRCUIT/MISC. -
that he is licensed pursuant to the,provisions ufthe Committers License law(Chapmr9
1+]`00 (commencing with Section 7W)of Division 3 mine Bushels and Professions Ctdehu 'TEMP ETER OR POLE INST. OMM R -IA L.
a M C that he is interior therefrom and the basis far the alleged exemption.Any violation of ❑ LDG/ADDITION ❑DEMOLITION
Section 101LI by mry applicant I'nr a permit enlivens the applicant to a civil pc defy of POWER I VICES
u1"tn EN IC GOOD SERVICE
I-, 8 no[:]'La,
mom than five hundred probe dollars($S.N I OVEMENT
6Q will
Lo the woroRhe pro peny,onnyemntended with wages r aei(Sm. (W.B linen. SWIMMING )OL ELECTRIC
wdl do the work.and the he Cont is not intended circulatedwdo for sale(Sm.
to an Nosiness ❑OTHER
W m and Professions Gvk:the Contractor's License Law docs not apply to an owner of OUTLETS-SW CHES-FIXTURES
•63•� his own who builds or improves thereon,and who ntws such work himself or through .
his own however
lin building that such mem is old within ere nm intended ar offcrcd for NEW kEi1DENTIA F.LEGTR SQ Fr.
aleJLhowevcill havtheIterim ofprosenl issnW ddtn buildyear oimpro letiunthe SQ,FT.FLOOR AREA $ISQ.I>I'.
paw. ,ander will have the burden.(proving Nat he did not build m improve for poo
C]1 of soled, w
❑1.as owner of the progeny,nm exclusively contracting wioh licensed mnactor, t. TO"fAL.
mineconsta the project(Sec.9(130,Business and properly
who ons Code:)The Cones Ther(un,Li- AII�
mine does not apply to an owner of pmpeny who huilda or improve thercoq and Q'1•Y. PLUMBINGP IT PEE U � ��
who contracts for such projects with a conoracoor(s)licensed pursuant to the Comracm �
rs /s1t 9
License law. - PERMIT ISSUANCE CI) Y
El1 am esempt under Sec. ,B&P C mr this reason Ur
Owner
ALTER-DRAIN&VENT-WA1FR( ) VALUA'f1UNV
- Dam
WORKER'SCOMPENSATION DECLARATION BACK Iq,OW
I hereby affirm under penalty of perjury one of the following declarations:
•C l havainl will maintain a Certificate of Cun.sen to self-insure forWorkds Coupon. DRAINS-FL n nm�RIES TYPECONSTRUCTION
,..,,an, spro it for by Section 3]00of the Lao MCode,for the performance of the M Q IVR
woAr rich Nis permit is issued. FIKTURIS-I" T T9♦ ♦
[ lave and will maintain Workers Compensation Insurance,as earned by SWumt ,.� Pipl Ci�mp'QlQ
J900 of t�g,1�barCodgfnr the edotrnsnmo he work for which Nis Permit is issued. GAS-PA.SY. M-1 N .i 1'S dd AiM('6.GROUP APN
Came'.. y�glJu n f1f t r 1, Pnlicyt �� UU lUJ�1lk VVI�IJJI
Carver. '[1L`LIS..� Y1 yNo.: Oj GAS-EA.SYSTEA OVUR4(L>A)
CERTIFICATE,OIs EXEMPTION FROM WORKERS
t oil
COMPENSATION INSURANCE OREASEJIND lil S' .IN' EPI'O bv BUILDING DIVISION FEES
(This section need not be completed ifohe comit is for one hundred dollars(sion) GRBASP,TRA
m less.) - NCHECK FEFi
Iccnifytha' cp una.ntt aft w kfor ht his permit is issued,i shall SEWER-SA - A.2
noengsloyu •rsnn it ry train, In, 1 10
Ore Winners Compmt- Eoull NERGYFER
Z, anionla r dC.Efo Dare /���
Z_ O Appiica WATEk HEAT 1'/ELF.CTR GRADING FEE
y NOT] TO APPL1 NC If,attar making this Certificate of Exemption,you should WATER SYSTIeM/IRFA
ahecom subject to Worker's Compensation ouskimisof the labor Code you must
W I,� fonhwit wioh such provisions nr this perntio shall he deemed revoked, WATERSERV
Ignalre
z CONSTRUCTION LENDING AGENCY NEW RESIDIiNT171,PLMB. SFT PAID
I hercbyaffitm rat
hthere ititimmuuak
ion ndingngency for the performance of a Date Receipt it
�� the work for which this permit is Issued(See.3099,Civ.C.) Da� -
O Leaders Name TOTAL:
Lenders Address TOTAL
L7r I cenify Nat]have read this application and state that the above information is BUILDING 1'
U) cancel.Ivgrecm comply with all city and county ordinance and state laws mImingm QTY. MECHANICAL PERMIT FEF,
V z buildim,ematruction,.nit herehy authorize npreentatives of Nis cioym cnmrupsmth; SEISMIC FEE
abnve-mentioned property for inspection purposes. PIiRMI'I'ISSUANCE
(We)agrees In save,Indemnify and keep hmmoss the City of Capetian,against ELECTRIC FEE
liabilioies,judgments,casts and expenses which may in any way seemmgainst said City ALTER OR ADD TO MECH. PLUMBING PEE
in consequence of the gran ting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 110.00D CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10.040 CFM) CONSTRUCTIONTAX
Signawreof Applicana'ContmcturDoc - EXHAUSTIfOOD OAMUC'D HOUSING MITIGATION FE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building III store or handle hazardous material I]EATING UNIT(TO 100.000 BI U)
as defined by the ,mint Municipal Cade,Chapter 9.13,and the Health and Safety
Code,Secoi 53401 ., HEATING UND'(OVER 1110,0011 BTU)
ca ❑No VENTILATION FAN(SINGLE RESID) PAID
Dam Receipt#
Will the epplmanl nr Tamm building ceche p use ea Air a of Marta ement BOILER-COMP JHP OR 100,000 BTU
•emit hazsvd.us air contaminants lodcBn the Bay Arca Air Quality Management ( )
District? TO'T'AL:
❑Yes BOILER-COMP(OVER 100,f(h)BTU)
•
Ihave reod the ha .us maoenais AIRCONDIUONER
regnder Chapter 6.95 of the Cali- ISSUANCE DATE
Rsmiu Hevhh uy C� ,Sections l 533 and 49534.1 uodecannit that if the NEW R17STDI?NTIAI.METH. SQ.lel'. '
buildin moo cutreit veam .than iiismy respomihi�ty to unity the reception
of quiremen w hmu met pnonnixxu.nce of C ri f cc lFunny.
Ow rnram nzed.gem TOTAL: ISSUED BY:
OFFICE
Inspection Query for a Speck Permit 4/7/97
032910260 BUBB RGH ELEC 8!1196 8/7/96 JB 2�P
0329 10260 BUBB PLBG_R 818196 8/8/96 AD 20
0329 110260 iBUBB I IROOF FRAMING 818/96 8/8/96AD 2P