30191 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: _ SANITARY NO. APPLICATION SUBMITTAL DATE
O z"E Avc .
OWNER'S NAMEPHONECONTRA O 'S NA E: LIC NO, '
N/C CONTROL M
ARCHIIECf/ENGIN ER: - LIC NO: ADDRESS
-T.w:. IFv ctz. 1L_ ' .
CONTACT: PHONe. - BUILDING PERMIT INFO�SKH12- 1. x Z33--7 -pb - Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUM ME
' LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencingMAPPLIANCES-RESIDEWIAL
ELECTRIC PERMIT FEE JOB DESCRIPTION
Woo with Settidn7000)of Division Sof the Business and Professions Code,milmy licensees -
FWp in full force and effect„ ANCE. RESIDENTIAL
�U License Class Lic.It ElSTOWE, ❑KITCHEN REMODEL,
RE W0. Date - _ Commemr - S-RESIDENTIAL El ADDITION ❑PLUMBING RE-PIPE
[F-ppm ' " ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
Z O m 7�. 1undersand my planashall be used as public records MODIFICATION
NO'x'"'p MPSW Lsenxed Professmnal 'INTERIOR ❑CHIMNEY REPAIR
"`533 0.' PSOWNER-BUILDER DEthe Com TON tIMPROVEMENT
1 hereby affirm that Iam,temp[from the Crmrecturs License Law for theMPS ❑BATH REMODELREPAI E OLITION
following reason,(Section 703L5,Business and Professions Coda Any city or county L
3 0.F SIGNS ELECTRICAL El
y.]y¢ which coquinas a permit re eonawe,spec,improve,demolish,armful any tueare _
prm
ioriax issuance,also requires the applicant for such Permit ofile asigned statement SPECIAL CIRCUEDMISC. „I,
G$ [bathe is licensed pursuant the provisions oftbe Contramor's License Law(Chapter9 _
pC (commencing with Section 7000)of Division 3 ofthe Business and Professions Code)or TEMP.METER OR POLE INST. OMM R IA
that he is exempt Rercfmm and Ne basis for the alleged exemption.Any violation of ❑NEW,BLDG/AODITION DEMOLITION
it Yom. Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of POWERDEVICES
[more than five handled dollars($500). ,OPERANT -'❑FOODSERVICE
G ❑I,as ownerof[be property,or my employee,.with wages as their compensation, SWIMMING POOL ELECTRIC [IMPROVEMENT
will do the work,and the sanctions is am intended m-mffered for sole(Sea 744,Business ❑OTHER
and Profcselors Code:The Cortrecmr's License Low does or apply to son owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves Uterebn,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT, r
sale.If,however,the building or improvement is sold within one year of complexion,the SQ.PCFLOOR'AR6A
owner-builder will have the burden of proving that he did nor I'"met comP a far par Y, si-3 a I,/
oP eeleJ. - -
as owner of he property,am exclusively contracting with licensed comremors to - TOTAL:
Recife
pmjem(Sec.7044,Business and Professions Code:)The Contractor's Li- Q JUL 17..1996
ersn Law does nos upPly tat ar owner of properly who boil Its
or improves thereon,and 7•Y. PLUMBING PERMIT FEE
who comactsfor such Projects withatonuamorm0licemedpursuennothe Contractor's ,n V
' License Law. PERMIT ISSUANCE tr✓I�1 dfj
❑lam exempt nil rS' � — ,B&P C forrhis..,on VV�t�lf lf`
nen Date ALTER-DRAIN&VENT-WATER(EA), VALUATION
R'S COMPENSATION DECLARATION , `/-I — BACK FLOW PROTECE DEVICE '
1 herchy affirm under penalty of perjury one of[he following dedaratiane
❑I have and will maintain a Certificate ofCmvmt1.self-insure for Workers Camper- DRAINS-FLOOR,ROOF,AREA,COND.
sation,as provided for by Section 37M of the Labor Code,for the performance of the _ 'STORIES PE CONSTRUCTION
work for which this permit is issued: - FD7URES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Section I
37M ofthe Labor Code,for the Performance ofthe work for which this permit is issued. GAS-FA.SYSTEM-1 INC.40UTLETS ' -
My Walker,Compensation Insurance carrier and Policy nomber are OCC.GROUPAPN
Carrier. - 'I Policy No.: GAS-EA.SYSTEM-OVER 4(6A)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR
(T'his section nadnm be completed lfthe plain,is forma,handled fi lars($100) B DING IVISIONFEFS
orless.) , GREASETRAP
I certify that in the performance ofthe work forwhich this permit is issued,i shall PLA HECK
not employ any person many manner ,eo aur,become sabjat to the Wnrken'Compsn- SEWER-SANITARY-STORM EA.200 FT. ENERGY FE
Z Applicant
of California.Dae WATER HEATER WNENT/ELECTR'
Applicnnr '' - GRADING E
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should a WATER SYSTEM?REAPING _become object[o the Worker's Compensation provisions of he Labor Code,you must SOILS
forthwith comply with such provisions or this permit shall he deemed revoked
W Q WATERSERVICE
�
CONSTRUCTION LENDING AGENCY z Ihereb affirm that there is a construction lending NEW RESIDENTIAL PLMB'. SQ.FT. PND Dale Receipt Is
V the work for which,his pemtit is Issued(Sea 3(199,Civ C agency forth,performance of
QU Lender's Name - TOTAL:
{kl Lender's Address TOTAL:
y 1u . I certify aha[I have read this application and stare that the above information is rmBUILDING F
Fr N correct.I agree m comply with all city and county ordinances and sate laws relating to QTY, MECHANICAL PERMIT
U rZ+ building tamQa
im.and hereby muonze represenlarims idda,city h,emefuponthe BUILDING
FE
above-mentioned property for in purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cueni
prm against ELECTRIC E
liabilities,judgments;costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH,
in mcorlmoce of the granting of this pconal, PLUMBIN FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT Ig01f1 CFM)
SOURCE REGULATIONS, MECHA CALME
AIR HANDLING UNIT(OVER 10.009 CFM) CONST CTIONTAX
Signaam of APPlicantlConuactnr Date EXHAUST HOOD GODUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING IGATION FEE
Will the applicant r future building occupant stare mrhandle hazardous material HEATING UNIT(TO I00,003 BTU)
m defined by the Cupoom,Municipal Code.Chapter 9.12,and the Health end Safety
Code,Section 25532(x)? HEATING UNIT(OVER-I W hand BTU)
❑Yes F1 No _
VENTILATION FAN(SINGLE RESID), PAID
Will the applicant or future building occupant use equipment or devices which Date Raen,It
emit h teardods it contarninants as defined by the Ray Area Air Quality Management BOILER-COMP(3HPOR 1010,000 13117)
District? TOTAL:
❑Yes ❑No - BOILER-COME 4)VER 100.000 BTU) - se0 A9
AIR CONDITIONER L
I have read the h ore, a mans 215als 1,153 era under Chapter understand
of the Cali- ISSUA E DATE
fomia buildingHealth does ra Safety CWe,Sections 25505,25533 and 25534,1 undersand that if the NEW RESIDENTIAL MECH. SQ.FT.
" ofhediremarran aurhntlyich have amnetp that it is un,reofasCereymnotify Occupancy,
ofthe requiremenu which must be met poor issuance of a Cenifcaa of Occupancy.
Owneror authunud agent Dare :M:TA::L]=ISSUED BY:
,OFFICE