30616APPLICANT.TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING - MECHANICAL
PERMIT NO. O
BUILDING PROJECT IDENTIFICATION
'
B616
UILDING AD 5:
SANITARY NO
APPLICATION SUBMITTAL DATE
OWNERNAME: �PN 2
CO CTONC'A^ME:� IC NO. O
NIC
CONTROL#
.RCHITECENGINMR: LIC NO,
U
ADDRESS:EDi� �o . 7— ST, S e
CONTACT - PHONE:
-
//%� l 41 C l�/���a
7
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
/ -r /% f' / /
/S
❑ V ❑ ❑-
L EN SED CONTRACTOR'S DECLARATION
I hereby n rpt Nm I am licensed under pmvi en, of chapter 9 (.mnmeneing
with Section 7") of 3 of the Business and Professions Code, and license is
Y
in full Promised eff.V
(,,: / D ���� V N/
License CClJtj
Dem /—fir=• Connector
QTY. ELECTRIC PERMIT FEE
O"Z
400
EF�.0
t�A+6a
ZO�N
'/5 Z
OZ—Q
gij—inlqq—�j
3.
Ot ped
°'�a�
a
JOB DESCRIPTION
1.
RESIDENTIAL
❑ SFDWL [I KITCHEN REMODEL
[]ADDITION ❑PLUMBWG RE -PIPE
❑MULTLUNIT []STRUCTURAL
MODIFICATION ,
El INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT
C1 BATH REMODE PAIR [I DEMOLITION
❑OTHER
PERMIT ISSUANCE J ��
APPLIANCES - RESIDENTIAL
- ARCHITECTS DECLARATION
I understand m tans shall be used public records
YP as Pu
PANELS
UPT02MAMPS
Licensed Professional -
' - OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Commences License Law for th<
following reason.(Section]031.5, Business and Pmfessiom Code: Any city or county
201;1000AMPS -
OVER IM) AMPS
SIGNS ELLCfRICAL
IL on
��0-1
Nthat
`'at00
S 11 m y
taXl 0.
^'m
Cno,
which requires a permit to construct, alter, improve, demolish, or repair any structure
pricrtoity issuance.alsoreeNures theapplicvm fx,mb Penni, m fleasigned scatenont
he is licensed pursuant m the provisions of the Comrannr's License Law (Chapter 9"
(commencing with Section 7100)of Division 3of the Businessend Professions Coimm'
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 byany applicant for.immot subjects theappliwnnoo civil penahyof
mom as wne five hundred dollar wripl.
❑Lottie work, the peshoctarmy emntended with wages astheir (role c0m, Business
do the work, and mmmurc is not intended or offered Business
SPECIAL CIRCUITNISC.
THNIP. METER OR POLE INST. S
COMMERCIAL,
❑ NEW BLDGIADDRIO' O ON
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
tl m
awillnd Code: s not a(Sec. o an
and property ax he b The th rota license law dna not apply toll owner of
properly who ?vies, or improves thereon, and who Jms mch work himself or through
OUTLETS -SWITCHES -FIXTURES
,
his own ctnployecs, provided t m such impms s are urn intendedurpletio offered for
NEW RESIDENTIAL ELECTS SQ Pf,
sale.If, hnweveall r sold completion.theSQ.
.
noneildori
en
FT. FLOOR AREA
LSQ. FT.
have
owner-bu u.). will have the burden of proving that he did nm build or improve for Pur-
bur offementismlhedid prove
'
❑E] 1 of sows.
Las owner of the exclusively contracting with licensed summers i-
Cf A t n
/i
'
TOTAL:
41 00
Business and Professions Code:) The
cense a the Sm. 70ci , B Li-
not (Sec. non,
es o an es the rid
cense mar soesnmapply man ith.ewner fpmpenywho tiedpads orormt.t ,cwtoammes
who contrecb for such projects with n conuacmr(a) licensed pursmm to the Conwc,oes
QTY. PLUMBING PERMIT FEE
OCT 91996
PERMIT ISSUANCE
License Law.
❑ I mneaeilowider Sec. ,B&PC for this sworn
ALTER -DRAW &VENT_ER(EA)
Owner Date
111 V, vupAHOAT
DECLARATION
O
Wm under Penalty
I hereby affirm utdtt penalty of perjury one of the following declinations:
BACK FLOW PROTECT. DEVICE
DRAINS-FLOOR,ROOP,AREA,COND.
ave and will maintain a CenificateofConsentto self -insure for Worker's Compen.
un, as provided for by Section 37M of the Labor Cade, for dee performance of the
or rwhichdinis akisissued.
STORIES
TYPE CONSTRUCTION
FIXTURES-PERTRAP
have and will maintain Worker's Compensation Insurance, as required by Section
01
Z
Q
7 O
G y
a'�^
W G
Q
V'O
Lks tti
O
39 "Ise labor Code, for thepperfarmance of the work for which this permit is issued.
Cuymeo*�nl fzN Ye Policy No.Y num 1���Ccv
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is fnrone hundreddollafs ($ Bq)
or leas)
Icertif that in the Performance of the work for which this
y anrf the
not employ any parson in any manner so as to become subject to the Workers' Compen-
rkers Compact,
-
A,,Iicawa of Cvlifomia. Data
Applicant
GAS - EA. SYSTEM -i INC. 4 OUTLETS
C. GROUP
L
G
APN
GAS - EA. SYSTEM-OVER4(EA)
GREASEONDUSTRLWASTH INTERCEPTOR
BUILDING DIVISI(3N FEf+S
GRPASETRAP r
PLANCHECK ME
-
SEWER-SANITA BY -STORM EA. 2W FT.
ENERGY FEE
WATER HEATER WNENT/ELECIR
GRADING FEE -
NOTICE. TO APPLICANT: IL niter making this Certificate ol'Exemp,ion, you ,hauls
become subject to the Worker's Compensation provisions of she labor Code, you must
forthwith comply with such previsions or this Penni, shall be dames revokW.
,
CONSTRUCTION LENDING AGENCY
ing agency for the performance of
I hereby affirm that there is v construction [ending an
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
WATER SYSTEMITREATING
SOILS FEE
WATER SERVICE
PAID
Dam Rmeipt0
NEWRESIDENTIALPI,MB. SQ. FT.
_
TOTAL:
Address -
TOTAL:
U
WLender's
a
1 cenify that 1 have read Nis application and state that the ehuve information is
BUILDING FEE
IA
+U7
corral l agree to comply with all city and county oNimences andsmm laws relafngm
building construction, and hereby authonte representatives of this city to enter upon the
QTY. MECHANICAL PERMIT FEE
SEISMIC PER
oNve-mentioned properly for inspection purposes.
(We) agree ,o save, indemnify and keep harmless the City of Cupertino against
liabilities,judgments, costs and expenses which may in any way seems against said City
in comenaence of the granting of this permit.
PERMIT ISSUANCE
ELECTRIC FEE
�
gL3'F.R OR ADD TO MECH.
PLUMBING ME -
AIR HANDLING UNIT (TO 10,000 CFM)
MECHANICAL FEE
APP UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
F RCE RIGULATIONS.
AIR HANDLING UNIT (OVER IO,W(I CFM)
CONSTRUCTIONTAX
�ia ?
Sig,phrimuCorourar me
MATERIALS DISCLOSURE
EXHAUST HOOD OVIDUCT)
HOUSING MITIGATION FEE
HEATING UNIT 00100,0011 BTU)
Will the applicant or future building occupmn store or handle hazardous material
sues by the CuPeninn Municipal Code, Chapter 9.12, and the Health and Safety
s
Cade. Section 5532hdl -
[3 Yes E] No
Will the applicam or future buildingt use equipmemlity Management[
by me
mi�h,zardous air ronmminanm as defined by the Bay Arca Air Quality Monagemcnt
❑Ya No
HEATING UNIT (OVER 100,000 BTU)
PAID
VENTILATIONFAN'(SINGLERESID) -
Dam Receipt #
BOILER- COMP (311P OR. 100,0110 BTU)
TOTAL
� D
_
BOILER- COMP (OVER 100.000 BTU),
AIR CONDITIONER
I have read the hevrdous materials requirements under Chaprerb.95 of the Cali-
ISSUANCE DATE
NEW RESIDENTIAL MECH. SU� FE
forma Health & Safety Code, Sedum 25505, 25533 and 25534. 1 unJersmrd Net if the
M1adJ'at
mntly have a tenant. that it is my responsibility to notify the mcupuntof
which must be rust porno issance ofn Cenifr
/ (/
o J agent Dam
TOTAL:
ISSUED BY:
f1FFICF