29670h 'APPLICANT TO FILL IN
CITY OF CUPERTINO
q BUILDING DIVISION
ILDING ADDRESS: -
IRMATION WITHIN RED LINES
APPLICATION/PERMIT.r
BALL POINT, PEN ONLY
- BUILDING - ELECTRICAL
PLUMBING - MECHANICAL
BUILDING PROJECT IDENTIFIC
'TOR'S NAME.
a146.7 C0AFT p
: /JCBSSON /VlC[ Or AD
c ❑ Consultant Pees Paid by Applicant (Initial)
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby anion that 1 am licensed under provisions of Chapter 9 (commencing
IQI�11�Z with Section ]000)of Dwisian Softhe Business and Professions Code, and my license is.
in full force and effect. - PERMIT ISSUANCE
60Unee Class olr
ty-em APPLIANCES -RESIDENTIAL
-ComL
a ARCHITECT'S DECCLARATION PANELS
G I undeisiand m I h'll be d bl'
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Lsensed Prnfessional'•� .•
OWNER -BUILDER DECLARATION
1 hereby affirm days, 'r am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit io construct, .Iron improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such Permit o file a signed statement
that 11 11 licensed Immunity to the provision, of the Contractor's License Law (Chapter I
UPTD 2fNIAMPS .
201-1000AMPS"
OVER 1000 AMPS
SIGNS ELECTRICAL
'
SPECIAL CIRCUIT/MISC..
TEMP. METER OR POLE INST.
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L W eC
W'm'm
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(commencing with Section 7") Division3 of the Business a ad Profession, Code) or
Sec he is exempt Therefrom and the basis for the alleged exemptions Any l penalty of
not mn'ID31.5 byive any hundred lunars( 500).permitsubjects the applicanuoacivil penalty of
t more man owner of t hundred collate y Sop. -
theiraliScle compensation,
❑Lo the work, said
property, or myemployeesor offend
will do the work, acid the structure is not intended m offered s car a (Sec. ]flan, Business
and Professions illsCody: The Contractors Licence Law does net apply to if owner of
property who builds or improves thereon, and who does such work himself m through
his own employees, provided that such are not intended or offered for
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL. ELECTR
mentis olden
owns -aide If, howeveethebulldeburdeng or of pecten is he t[hinon build ri prove for the
owner -builder will have the burden of proving Lha[ he did not build or improve for par -
Post of si
INTERIOR
'.
IMPROVEMENT
❑ as owownI, s r of the property, commmins with licensed contractors to
`
cdnanved the project (Sec. ]044, Business and Professions Code:) The Qmtmemrs LY
, B sinessiand
QTY, PLUMBING PERMIT
cense Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contmctons) licensed pursuant o the Contractor's
PERMIT ISSUANCE
License Law.
❑ I am exempt under Sec. ; B & P C for this reason
ALTER - DRAIN & VENT- WATER (EA)
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF, AREA, COND.
O l have and will maintain a Certificate of Consent to set f -insure for Worker's Compen-
Indian, as provided for by Section 3700 of the Labor Code, for line performance of The
FIXTURES - PER TRAP
GAS -EA. SYSTEM -I INC. n OUTLETS
work for which this permit is issued.
C I have and will maintain Worker's Compensation Insurance, as required by Section
37M of the Labor Code, for performance of the work for which this permit is issued:
My Worker's Compensation Insurance carrier and Policy number are: '
GAS -EA SYSTEM-OVER4 (EA)
Carrier: Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASE/INDUSTRL WASTE INTF.RCEP
COMPENSATION INSURANCE
- Glyissection need not be complemd ifthe permit is fomite hundred dollars is Ifin
or less) 1.GREASE
TRAP
SEWER -SANITARY -STORM EA. 2001
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I certify that in the perfurmance of work for which this permit is issued, l shall
not employ any persmi In any manner sit as to become subject to the Workers' Compen-
solid. Laws of California. Dam'
.ri
Applicant -
NOTICE TO APPLICANT: If, afteumaking net Certificate of Exemption, you should
become subject w the Worker's Compensation provisions of the Labor Code, you must
faithwith comply with such provisions or this permit ,hull be deemed revoked. '
CONSTRUCTION LENDING AGENCY
•`. I hereby affirm that there is a construction lending agency for the Performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
WATER HEATER WNENT/ELECTR
WATER SYSTEMOBEATING
WATER SERVICE „
NEW RESIDENTIAL PLIR.
Q
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Lender's Address
I cenify that I have read this application and state that the above information is
-
QTY MECHANICAL PERMIT
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correct. l agree m comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of this city in enter upon the
above-mentioned property for inspection purposes.
(We) agree to smve, indemnify and keep harmless the City of Cupertino aga,.ml
liabilities.judgments, costs and expenses which may in any way accrue against said City
in coca, no.. of the granting of this permit.
PERMIT ISSUANCE "
ALTERORADDTOMECT
AIR HANDLING UNIT (TO 10,1X111 CFM)
ANT DERSTANDS AND WILL COMPLY WITH ALL NON -POINT
E REG ATI
AIR HANDLING UNIT(OVER 10,0(X) City
Stgeatu p¢anI/dn-......_...__.. _. [e
EXHAUST HOOD(W/DUCT).
Will the applicant by future building occupantxtore or hon hazardoanm enol
as defined by Ne Cupertino Municipal Code, Chapter 9.12, and the d fety
Cade, Section 25532m)?
❑Yes 7 N
Will the applicant or future building occupant use'eyuipment or devices which
emit haiardous air comami... Is as defined by the Bay Area Air Quality Management
District? - I
❑Yes - L] No ^
I have dead the ho,ird us materials requirements under Chapter 695 of the Culi-
probe Health & Safety Code, Sections 25505, 25533 and 25534. l understand that if the
building doieanot currently have a rearm, drat it is .,responsibility to notify the arupon'
of Ne requirements which most he met prior to issuanre of a Canormate of Occupancy. '
SQ FT
SQ. FT.
HEATING UNIT (TO 1M.", BTU) -
HEATING UNIT (OVER 100.000 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER -=COMP (3HP OR 100,000 BTU)
BOILER -COMP (OVER 100,00OBTU)'
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ. FT.
FEE
PERI
/
SANITARY NO. , AP
NIC
BUILDING PERMIT INFO
7
BLLD�DO ELECT
PL_U B MECH
JOB'DESCRIPTION
RESIDENTIAL
C SFDWL
C KITCHEN REMODEL
❑ADDITION.
El PLUMBING RE -PIPE
El MULTIUNIT
CSTRUCTURAL
MODIFICATION
INTERIOR
" C CHIMNEY REPAIR
IMPROVEMENT
ATH REMODEUREPAIR ❑ DEMOLITION
COMMERCIAL•
C NEW BLDG/ADDITION C DEMOLITION
❑TENANT [I FOOD SERVICE
IMPROVEMENT
- C OTHER
SQ. FT FLOOR AREA1 lace S/SQ. FT.
1217y �r 1 1996
VALUATION
STORIES
I .
PLANCHECK FEE
ENERGY FEE
GRADING FEE q.
SOILS FEE
PAID
Dam Receipt#
FEE
BUILDING FEE -
SEISMIC FEE '' I
ELECTRIC FEE Oc
PLUMBING FEE -
MECHANICAL FEE '
CONSTRUCTIONTAX '
HOUSING MITIGATION FEE
PAID
Data Receictie I - -
ISSUANCE DATE