31091 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI'T'Y OF
CUPERTINO BUILDING-ELECTRICAL - � PF,RMITNO.
BUILDING DI VISION APPLICATIONIPERMIT PLUMBwc-mecxANICAL - 3.1091
BUILDING PROJECT IDI NTIFICATION
BUILDINGADDRESS: T SANITARY NO. APPLICATION SUBMITTAL DAM
U0-62,
PHONE: CONTRACTOR'S NAME: LICNO:
IA`Il "l4cl N/C CONTROL p
SRCHITECT/ENGINEER: LIC NO: ADDRESS: - ❑
CONTACT: - PHONE: BUILDING PERMIT INFO
93 Camadtant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
- . .
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE -
I hereby affirm
that thm 1 ma licensed under provisions of Chapter 9(commencing � � JOB DESCRIPTION �
'Oax with Section?")of Division 3 of the Business and Professions Code,and mylicensels RESIDENTIAL:
00 in full foreeand effect. PERMIT ISSUANCE
�BIF ❑SFDWL KITCHEN REMODEL
<U Done I Lic.N APPLIANCES—RESIDENTIAL []ADDITION - ❑ MBING RE-PIPE
LI... Dote Comracmr
ARCHITECTS DECLARATION I PANELS ❑MULTLGNIT ❑STRUCTURAL
Oz 1/14 I mm1.g&d my dums shall be used public records MODIFICATION
::4! '-�-11 O _ UP TO 2M AMPS
try ty Licensed Prof I �DE _ El INTERIOR [I CHIMNEY REPAIR s
45` 'OWNFiR-HUILDF.R DECLARATION 2061(NN)AMI'S IMPROVEMENT '
1 hereby efflrm thm 1 nm exempt from the Contmnars License Luw for the OVER 1000 AMPS - ❑BATH REMODEL/REPAIR ❑DEMOLITION I.
O y U following reason.(Section 7031.5,Business and Professions Code:Any city or county - []OTHER
3 tL which require a permit to construct.alter,improve,demoma
lish,or repair any srcm SIGNS ELECTRIC L
I:'�-y prior to its issuane"Iso requires the applicant for such perma to file a signed statement 2 SPECIAL CI IT/MISC.
y that he is licensed pursuant to the provisions of the Conumbts Lt...Lan,(Chapter 9
• 00 (oommeremg with Section]00B.17 Division 3 of the Business and Professions Code)or 6 TEMP.MF%RO LE INST. COMMERCIAL:that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
$y
IIx Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of - POWER TIEVIC
m []TENANT ❑FOOD SERVICE
rn more than five hundred Jallms($500). .IMPROVEMENT
Cl ❑ 4o the work,airline
my employeedin o wages asthei(Ses.aanpenunov„ 9WIMMIN O .LE - t t
will do the work.sod the swcwrc is notimendeJ or offered forsele(Sec.]f144,Rosiness []OTHER
and Professions Code:The Conuscmts License law does not apply m in owner of OUTLETS— IPCC S XTURES 07.0y
.. property who builds or improves thereoou end who data such work himself or through 14
his own employees,provided that such improvement are not intrnded or offered for NEW RESIDENTIAL EL15;1' SQ FT. -
sale.ILhowever,the building or improvement is sold within one ycarodcompletion,the •SQ.FT.FLOORAlkq S,SQ
.FT.
owner-builder will have the burden of proving that he did not build or improve for par-
potentiate.).
ar- •-
01 of eaten s ft?
❑ Lesow rofthepmpeny,am,Business
contracting with licensed cdnuumeam +' /Pry
cnnswct the project(Sec.]044,Business and Prnl'csxion Code)The Commcnrra hi- r o
censel.uw does not apply loan owncrof property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE 'oil yr (/
who contracts for such projects with a con=togs)licensed pursuant to the Conwetuex
License Law. PERMIT ISSUANCE �'�rcnl/ O
❑I am exempt unreas
der Sec. ,B&P C far this on
Owner Date ALTER—DRAIN&VENT—WATER IEA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
SO
m
I hereby affirunder penrju
alty of pery mi the following declarations: -J
Ihnve and will mrinwim CmiOcate of Cnnsenun self-inure for Workers Cnmpen- DRAINS—FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
ration,as provided for by Section 37W of the Labor Code,far,tm Nofornance of the
work for which Nis permit is issued. FIXTURES—PER TRAP
❑ I have and will maintain Worker's Compensation Insurance,as required by Section -
37W of the Labor Code,for the Performance of the wink for which this permit is issued. GAS—EA.SYSTEM-I INCA OUTLETS OCC.GROUP APN
My Work g� 1.y.ioyj�ssureyyce carrier end Policy n r
/ Carrie¢C. �/L..I Policy No.: GAS—EA.SYSTEM OVER 4(EA)
CERTIFICATE,OF EXWOREMP ION FROM KERS'
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR
BUILDING LJVk1ON 'ES
„ (This section need not be completed if permit is for one hundred dollars(Sla) GREASETRAP
or Few) I PLANCHCCK PCE
(certify that in the performance ofthe work for which this permit is issued,ishelf r SEWER-SANITARY—STORM EA.200 PT..
not employ any Person in any manner so as to become subject m the Workers'Compen- ENERGY FEE _
,zsectionlawsof California,Date WATER HEATER WNENT/EL[CTR
pplicird, - - GRADING FEE
fq NOTICE TO APPLICANT,If,after making this Cenif te of Exemption,you should WATER SYSTEMRREATING
CFei 5 become subject to the Workers Compensation provision of the Labor Cade,you must SOILS FEE
{Ta forthwith comply with such provisions orthis permit shall be deemed revoked. WATER SERVICE
Q
'Uz CONSem is ac ON LENDING AGENCY NEW RESIDENTIAL FUME. SQ.PT. PAID - Date ReeeiIN -
1hereby affirm thuuhcrcisawn es.30 lending agency for the performance of P
U�
Wire work for which thin Permit is issued(Sw.J09],Crv.CJ -
L7r Lenders Name ' TOTAL:
'yO U V LmJetI Address T -
I y 1 mnify that 1 have with
this application and nate(het IM drove information is BUILDING FE
!^S•1 correct.l agrx m comply with all cityend county ordinances erW score laws relating to QTry, MECHANICAL PERMIT FEE
V abase-mentioned
iropert hereby authorizereprcsenatives of Nis citymenmr upon th< SEISMIC FE
above-mentioned property for inspection puryoses. 1 PERMIT ISSUANCEIQF
(We)agree m save,indemnify and keep hamJers the City of Cupertino against ELECTRIC E O I
hahilities,judgments,ooit+and expenses which may in any way uccme against said City ALTER OR ADD TO MECH.
in consequence of the gnmting of this permit. - PLUMBING
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT ,AIR HANDLING UNIT CFO 10,000 CFM)
MECHANICAL FE
SOURCE REGULATION$. - '
C 1 �AAQ J 31 I '1 AIR HANDLING UNIT(OVER 10,"CF M) CONSTRUCf10NTA
Signature eof Applicam/Conuacmr a7 Date 'C- EXHAUST FOOD(W/DUC) HOUSING MITIGATION E
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupunt scam or handle hazardous material HEATING UNIT(TO 100,000 BTU)
to defined by she Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)'1''. HEATING UNIT(OVER 100,000 BTU)
❑Yea ❑Nu VENTILATION FAN(SINGLE RESID) PAID --
Will the applicant or future building occupant use equipment or devices which Dam R opt q
mit hazardous air consnminna as defined by the Boy Area Air Quality Management BOILER—COMP(3HP OR 100,00)BTU)
TOTAL:
rcmot] BOILCR—COM P/OVER 100.000 BTU)
❑Yes ❑No
I have read the horeadm s materials mr,docments under Chapter 6.95 of the Cali- AIR CONDITIONER . ISSUANCE DATE
forma Health&Safety Cale,Sections 25505,25533 and 25534.1 undersand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have a tenant,that it is my responsibility to antify the occupant /1
ofthe mluirenems which nun be met prior to issuance of a Certificate of Occupancy. S J/
Owner m vutharieed agent ' Date TOTAL: ISSUED BY:
OFFICE
194
99
=-=----------------- -------
WOR 141997
0 8 G.
nc-floN DEPARIMtNT
CUPERTINO
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COPY C- upe9-T I t4 0
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RESIDENTIAL PROJECT COVER SHEET
guy ar
Cupertino
Assessors Parcel Number:
Name of owner. N A-N C Y VZCMC-�---�
Project address. CAiy.YO0 k U5riA --DVe-
Contact person. Phone. 4'3(o -
Fax.
Net square footage of lot.
Existing Proposed
Square footage: First floor: 1l¢« e
Second floor: LI-1,
Garage: 4Mho z
Are there at least two 10 foot by 20 foot clear spaces inside the garage? N
• On what floor(s) is work being done?
Brief description of work. IF-leg-flMl fAl �rA—\C-� C-AcG I NL 7,5 0 LWzWFI;V�1&
k.t-t'c tF 4 C-12c_ u� lJ�Jc>0-o -T, xste� Cs -VzsTee T-op
Code editions: 1994 UBC (Y -N)1994 UFC (Y -N)1994 UMC (Y-N)
1994 UPC (Y-N)1993 NEC (Y -N)
•
Plan Review Process Work Book Page-7-