30451 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PF.RMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 3 0 4 51
BUILDING PROJECT MEMO "ATION
LDINGADDRESS: , SANITARY NO. APPLICATION SUBMITTAL DATE
� `•�' v � �-2.1.96
16�1• YT b PHUNE: NT iit%litT T6•COLIC �`
` NIC CONTROLM
ARCHITECT/ENGINEER: LICNO:' q ❑
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECTPL� MCPH
LICENSED. nsCONTRACTOR'SDECLARATION QTy ELECTRIC PERMIT FEE �l
I hereby affirm Nm I am liceed under provisions of Chapter 9(commncin
eg JOB DESCRIPTION
,�,•0Z70t))O with Section KKI)ofDivision 3 of the Business and Professions Cade,and my license is PERMIT ISSUANCE RESIDENTIAL-.
�
C W 5 full force enJ)Bret. [ISFDWL [I KITCHEN REMODEL
aU License Class Lic.# APPLIANCES-RESIOLNTIAL
rn ❑ADDITION C)PLUMBING RFPIPE
F� L Date Contractor
� ARCHITECT'S DECLARAT ❑
ION PANELS MULTI-UNIT [3 STRUCTURAL
ZOvZ 1mailmsmnd my Atom shall he users public,)caths MODIFICATION
OZ
.".1 UPTO200AMPS ❑INTERIOR (2CHIMNEY REPAIR
IME, Licensed Professional 201.1000AMPS IMPROVEMENT
6�k4 OWNER-BUILDER DECLARATION OVER Itgq AMPS []BATH REMODEUREPAIR ❑DEMOLITION
C sz I hereby affirm that 1 am exempt from the Comnnofx License Law for the
x a 6 U following reason.(Section"/031.5,Business and Professions Code:Any city or county SIGNS fit
RIC ❑OTHER
til LL LLO which requires.permit to consuva,ulmr,improve,demolish,or rep.is any swcmre
prior to its issuance,also requires the applicant for such permit to file u signed summer, SPECIAL CIRCUIT' SC.
pa0tbnamenccensed putstion 70th)previsions 3 the Cantmcnrz a License a4.m,Capter9
(commencing with SeaionT(Xp)af Divisinn3 of Ne Business and Professions C.de)or TEMP.MEIER L NST. COMMERCIAL A. K than he is exempt Ihcmfrem and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
•„y Smile.7031.5 by any applicant fora permit sabjecuthe apraicanno.civil penalty of POWER DEVICES ❑TENANT ❑FOODSERVICE
FZQt mom than five hundred dollars(4500).
01asowneroftheproperty,or my employees with wages as their sole compensation, SWIMMING POOL HLECTRIC IMPROVEMENT
will do the work,.nd the amcmm isnot imm�deJ.ro(fered for sole,Seco 7044,Business []OTHER
m end Professions Cale:The Contract.x License Law does not apply to as owner of OUTLETS-SWD'CHFS-FIXTURES
.. property who builds or improves thereon,and who does such moat inwortendk hirarelf or Nraugh
his awn employers,provided that such improveems am ed aofferer'for NEW RESIOCNTIAL F.LECfR S
cale.ILhowm or,the building.,improvement issold wilunane year of completion.the SQ.IT.FLOOR AREA 5/SQ.FT.
owner-builder will have the burden of proving Nat he did not build nr improve for pury _ a
poor infinite.).
h as owner of the prnpeny,um exclusively contracting with licensed contractors to TOTAL: A
arnmet the projmt(Ser.TBW,Business and Professions—.1 The Cammctnr's Li-
cense Law does not apply 70 an owner of Property who builds or improves themon,and QTY, PLUMBING PERMIT FEE AUG 21
who contracts for such projects with a cantmetor(s)licensed pursuant I) f(]�the Contractor's /J
I License law. 6
Imnexeptemader Sec. ,B&PCfordmsm"on PERMIT ISSUANCE
!
Owner - Mute ALTER-DRAIN&VENT-WATER EA) -' 1161VALUATION
•u,k/
WORKER'S COMPENSATION DECLARATION
I hereby afimtuatim a .lry of Perjurynne of Ne following declarations: BACK FLOW PROTECT.DEVICE
�•O l have and will maintain a Certificate of Consenuo self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
section,as provided for by Section 37M of the father Code,for the perfoanance of the T -
11,for which this permit is issueal. FIXTURES-PER TRAP
I have and will maintain Worker's Compensation Insurance,ns required by Section
W of the Labor Code,for the performance of the work for which Nis Permit is issued. GAS INC.4 OUfLIUS OCC.GROUP APN
My WarYpc��,�B�p ti�n��Jpp ryryuucc p{'rr��qq end Policy
Carrier./'CIg/htlA.Tsu(C7/`1JNnlic,No.: m `0 GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSTRL WASTE INTERCEPTOR
(This section ne14 nntM mmPl<tW il'Ne Permit Is Tatar)huodreJ dollars(SI IHl)
- or less) GREASE TRAP BUILDING DIVISION FRMS
PLANCHECK FEE s
I ttVify Nat in Neperfcannameofthework far which this farmit is issued.I shall SEWER-SANITARY-STORM EA.200 IT. ^
not employ any Person in any manner so as to nomme subject to the Workers'Come - ENERGY FEE
z,Ze nation Laws of C.1ifomia.Data WATER HEATER WNENf/ELECTR
Q Applicant GRADING FEE
pa NOTICE TO APPLICANT,If,after making this Certificate of Exemption,you should WATER SYSTEMTREATING SOILS FEE
tibecome subject,o the Workers Compcnaation provisions of the Labor Cade,you must
forthwith comply with such Provisions or Nis permit shut]be deemed revoked. WATER SERVICE
0
z CONSTRUCT]iso as LENDINGAGENCY NEW RESIDENTIAL PLMB. SQ.PE PAID Date Receipt#
V � Ihercby affimt Otanhem isaamswction lending agency for Ne performance of
O F the work for which this Permit Is issued(Sm.3091,Cls,CJ
Modern Name TOTAL:
Lenders Address TOTAL:
I crafty that I have read this application and state that the above information is BUILDING FEE'
tt,t cared.l agree to comply with all city and county ordinances and sum laws relating to QTY. MECHANICAL PERMIT PEE
V z building construction.and hereby authorize representatives ofthis city m enter upon the SEISMIC FEE
alcove-mentioned prop)ay for inspection purposes. 1 PERMIT ISSUANCE
(We)agree to save,indemnify and keep heardess the City or Cupertino against ELECTRIC FEE
habil'itmijudgments.costs and expenses which may in any,way amme against said City ALTER OR ADD TO MECH. PLUMBING FEE
in can notice of the granting of Nis permit.
APPL ' NT UNDERSTND AND WILL COMPLY 'ITH ALL NON-POINT AIR HANDLING UNIT(TO MIMCFM)
SO' RFAULATIONS MECHANICAL FEEI. A2 ! AIR HANDLING UNIT(OVER 10.WO CFM) CONSTRUCTION TAX
are of Applicant/C oactor f/ Date 1O EXHAUST HOOD(W/DUCq HOUSING MITIGATION FEE
i HAZARDOUS MATERIALS W4CLOSTIRE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100,00)BTU)
as defined by the Cupertina Municipal Code,Chapter 9.12,end the Heubb end Safety
Code,Season 25532(.)? HEATING UNIT(OVER 101y"BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RFSID) PAID
Data Receipt#
Willthe n,n,connoor tations
a building iscby the int Bay Area
Air mnrdwicegement BOILER-COMP(3HP OR 100,000 BTU)
dt
emit hazardous air cunmminams as defined by the Pay Arta Air QualilY Management
Drsmd? BOILER-COMP(OVER 100.000 BTU)
❑Yes � ❑Nn
I have read the hazardous materials mquiremenu under Chapter 6.95 of the Cali. AIRCONDITIONER ISSUANCE DATE
bumia Health&Safety C,dq Seders 25505,25533 and 25534.I understand dot if the NEW RESIDENTIAL MECH. SQ.PT.
building does not ee,,Co e,S a tenant,that it is my responsibility,to amity the occupant
of the requimmm�u which mus,M met prior m issuance of a Cenificam of Occupancy. .
Osmroraathorizedagem Date TOTAL ISSUED BY:
OFFICE