S 0385 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 0385
O
BUILDING PROJECT'IDENTIFICATION O
BUILDING ADDRESS:I. SANITARY NO. APPLICATION SUBMITTAL DATI
/a23S BY I?h1 Z Vr r
OWNER'SNAME: PHONE: CONTRACTOR'S NAME: LIC NO:
S H d C H O N/C CONTROL.a
P:RCP LICNO: ADDRESS: 1:1 O
I 1Vf�[BE
C 13-6
CONTACT. .f•� PHONE.: 7
BUILDING PERMIT INFO
Consultant Fees Paid by Applicant(Iridal) BLDG ELECT PLUMB MIiCH
J LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE �(
1hereby0nod that ma licensed under Cmvisinn.x of Chapter 9lcnmmencing JOB DESCRIPTION
{s�]IZ with SmllcemailB)nf DivisionJof the Business end Pmfcssions Gde,and mylicensc is
F W O in full force and eRmt. - PERMIT ISSUANCE APIDE
� SE WI D KITCHEN REMODEL F-UZf License Class - Con
WQ� Date-Contractor APPLIANCES-RESIUF,NTIA1. ❑ADDITION ❑PLUMBING RE-PIPE
Fah
ARCHITECTS DECLARATION PANELS
❑MULTI-UNIT C1 STRUCTURAL
OZ-a I understand my plans shall he used as public records a MODIFICATION
UP102WAMPS El INTERIOR ❑CHIMNEY REPAIR
H�.F,W Ltcenud Nofeastanal 201-Iqp AMPS IMPROVEMENT
n+X -aJ OWNER-BUILDER D[CLARATION ❑SWIMMING I'OOIS
y❑y�G?PGG 1 hereby air,.that I um exempt tram the Contract nrt License Utw for Tho OVER nl(I(1 AMPS ❑BATH RE DELIREPAIR El DEMOLITION
xOSU following mason(Section 7031.5,Business and Professions Code:Any city or county DO'T R
W 3 LL SIGNS ELECTRICAL
f O which its kam a permit re cores the alter improve,demolish m repair any stmcturc
CC w that he slimuamcgalemreyuiree provisions
for such ContrarmiuLrile aicense Law(Chapter
SPECIAL CIRCUIT/MISC.
2;!(}
that he is licensed punuam 1.the provisions of the Contractor's license Ww(Chuptur9
(commencing with Section 7")of Division)ofthe Business and Professions Care)nr
TEMP.METER OR POLE INST.W
i�y m K that io is exempt tmrcrmm and the basis for the alleged exemption.Any violation of El NEW BLDG/ADDITION ❑DEMOLITION
4th Section]03 LS by any applicant fora permit subjects the opplicum macivit pewlty of POWER DEVICES
F Z Y not mom than five hundred dollars($500). 0 T17NANT D FOOD SERVICE
ACO 01,as owner of the properly,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT. f
y
will dothe work.and the structure isnot intendodoroffered forsule(See.91004,Boston,, DOI'HER a�71'T1r7'�-
and Rofessions CMB:Th,Contractures License Trow docs nm apply to an owner of OUTLETS-SWITCHES-FIXTURES
a'3 property who builds or improves thereon,and who does such work himself or through
his awn employees,provided that.such imprnvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sole.If,however,the building to improvement issold within enc year afnuuPierson.'he SQ.F $/SQ.FT.
ownervbuilder will have the burden of proving the he did not build or improve for Aur- �� �x/T-
pown.1"aleJ, t 7
0 1,as owner of the property,am exclusively contracting with licensed contractors to 1 Uf cur�kr/�
construct the pmjmt(Sec.7(WBusiness and Pmfessioms CM J The Commctores Li-
cense
i-c se Law does not apply to an owner of propcny who builds or improves thereon,and QTY. PLUMBING PERMIT FEE p
wba urmmets for such pti with o commetous)licensed pursuant to the Commet u's
License law. PERMIT ISSUANCE
0m
laeseerptunder Sec. ,B&PCfimmismuson bz
Owner ALTER-DRAIN&VENT-WATER(EA) v
Dote - VALUATION
W.underSCOM of peemION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby will
mai under penalty of perjury one d the imse,fm declarations mkx,' :
'0lhuve and will for
maintainCertificate7M of the sent Labor
sod.forte performance
of Conifer- DRAINS-FLOOR.ROOF ARRA,COND.
ration,as provided far by Section d. of the Inbar CMe.for the pertormance of the STORIES TYPE CONS'THUCTION
work for which this permit is issued. FIXTURES-PER TRAP
0 1 have and will maintain Worker's Compcn flue n Insurance,as required by Section 'V
My Worker's
Compensation
tInIthe uMormmcer and Policy
(number am:
is issued. GAS-EA.SYSTEM.]INC.4 OUTLETS
OCC GROUP CPN
My Wnrkerea Compematinn Insurance carrier and Policy numiscr ate:
Carrier: Page,FROM
GAS-EA.SYS'fEM-(lVER4(BA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRF.ASFlINOUSTRL WASTE INTERCEPTOR
IT section need not he completed ifthe permit is income hundred dollms(SBE) BU1.9110PIVISION FEES
or less.) GR17ASE TRAP PLANCHECK FAV/ r
Toy any perhatm the performaanymannce ro a sI work for whichNis perthe W isissued,'Comen- SEWER-SANITARY-STORM F.A.200 Ff.
not when
ploy any Canon i any Bronner no as m become subject m the Workers'Compcn- ENERGY FE'
Oz xution Laws of California.eData WATER HEATER WNENT/ELIiCfR
z Applicant - GRADING FV
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSI Idlil 'RExTING
become subject to the Worker's Compensation previsions of the labor Code,you must SOILS FEE
w r forthwith comply withmch provisions or this Permuted]M deemed revoked. WATER SERVICE
G
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIALPLMB. SQ.F1', PAID
U I hereby aRnn that here iso construction lending agency for the performance of Dole Rmeiptn
fire H thLender's Name e work for which this permit is issued(Sec.3W7,Civ.C.)
Lender a Address A TOTAL:
0. I certify that I have read this application end ntute that the above information is BUILDING FIA: /",
W correct.I agree to comply with all city a ad county oNinnnces and em¢Ivws rdatingm QTY. MECHANICAL PERMIT FEE Q
V building construction.end herebyvmhmi,m reprcsenmtive,ii to enterupoa the SEISMIC FET?
above-mentioned property for inspection purposes.
PERMIT ISSUANCE
. (We)agrec msave,indemnify and keep hannlcsa the City of Cupertino against ELECTRIC TLE
Iiabilities,judgmems,costs and expenses which may in any way accrue against said City' ALTF.RORADDTOMECH.
in cmeequemce ufthe granting of this per mit. - PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.080 CFM)
SOURCE REGULATIONS. MECHANICAL.FEE
AIR HANDLING UNIT(OVER 10,003 CIM7 CONSTEUCI'ION TAX
Signature of ApplicmilContructor Data EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Willtheapplicanterr future building necupemsmm orhandle Wooden,mamnal HEATING UNIT TO 100.000 BTTB
as defined by the Ca,minm Municipal CMe,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? HEATING UNIT(OVER I00,00()BTU)
❑Yes L]No
VENTILATION FAN(SINGLE RESID) PAID
Will the npplicvm or future building ttccupanl use eyuipmem or devices which IJmc Re ipt p
out hnwdous Bir contaminants as JefinM by Ne eery Area Air Quality Management BOILER-COMP(3HPOR 100,000BTU)
District? TOTAL:
O Yes No BOILER-COMP(OVER I W,000 RTU)
-� I have mad the hazmdmus nut7als AIR CONDITIONER ISSUANCE DATE
mqu"emems under Chapter h95 of rite Cnli
fomia Health&Safety CMe,Sections 25505,25533 and 25534.1 understand that if the NIiW RES1DIiNT1AI.MECH. SQ.PI'.
building does not currently have a mount.that it is my responsibility to notify the occupant
of the requirttrcms which must M ten prior m issuance of a Certificate of Occupancy.
Owner or euthonred age.. Date 1
ISSUED BY:
OFFICE
Inspection Query for a Specfic Permit 12/30/97
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Inspection Query for a Specfic Permit 12/30/97
PERMIT#, ITUSJSX SITUSTST,REET,O WINSDESCRIKTAM IaT`"" D'ATEDESIREI D'ateDone
SO428 10235 BYRNE UNDRFLR 12/18/97 12/18/97
$0428 10235 BYRNE PLBG 12/18/97 12/18/ 7
10235 BYRNE 12/18/97 12/18/97
SO428 10235 BYRNE FRAMING 12/18/97 12/18/97
SO428 10235 BYRNE UNDRFLR INSUL. 12/22/97 12/22/97
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