29450APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY '
CITY OF CUPERTINO I, T, 's `:'af'j,f BUILDING'- ELECTRICAL' -
BUILDING DIVISION APPLICATION/PERMIT u _ PLUMBING -MECHANICAL as
- PERMn'NO /� /1 q 4 O
L.V/
BUILDING PROJECT IDENTIFICATION
1 BUILDINGADDRESS
. ,. 10125 Coco 1' l.ee. �rwe a, �, '
SANITARY NO.
APPLICATION SUBMITTAL DATE
3-1q '
O$,IyER'$NAME: �' ��GPH(<6� �, -
IVt"1 Ne J s
CONT TO S E: LIC NO:
N/C
❑ '
CONTROL k
' . "
\RCHITE GINNER: ;, LIC NOn,
ADDRESS: , d
" CONTACT: - PHONE:' -
-
BUILDING PERMIT INFO
' f
W K¢ Ca 865 t 8'1
panic Paid•by Applicant (Initial)'
BLDG ,, PL ME H
; r.
„•. LICENSE O RACTORS DECLARATION
1 arehy effort that 1 ceased underD f Chapte 9 (commencing
witASection7") of Division 3 ofthe Busmcss and Professions Code, and my license is
m full force and effect. 1
LicenseClass Lic M "' '
4 Dat ContractorAPPLIANCES-RESIDENTIAL
QTY ELECTRIC PERMIT PEE
- JOB DESCRIPTION .%
"RESIDENTIAL:
❑ SFDWL [D KITCHEN REMODEL
f,�
/I/-,�a�t� DITION ❑PLUMBING RE -PIPE
VA
"LJMULTFUNIT ❑STRUCTURAL,
MODIFICATION
11 INTERIOR - El CHIMNEY REPAIR
,IMPROVEMENT ;
PERMITISSUANCE
''
-
g
ARCHITECTS DECLARATION,
" . 1 'nderstsnd my plans shall be used as publ'c - cords
PANELS
UPT02W AMPS
Lensed Professional .. - '.
' OWNER.BUILDMDECLARATIONs
201-1000AMP5 -
OVER IOW AMPS �
t Ihereby.affirm that 1 am exempt from the Contractor's License Law for the
following reason (Section 701 L1. Business and Professions Code: Any city or county
who bray s ne,.E.t wet alta p-ved 1'h- ore a signed
thio t T nepursuant
that he licensedpursu� tt theprevisions of the Contractors License Lew (Chaprer9
ursu .,.a. sh pili- beatentp rsit LBers,e Law (Chapter
(commencing wird Sectinn]WO)of Division3 of the Business and Professions Cnde)or
that he is exempt therefrom and Ne'basis for Has alleged exemption. Any violation of
Section 0031.5 by any applicant for a permit eubjuts the applioant m civil ull pcnehy of
not more than five hundred dollars ($500). -
❑_l, asowne�ofthe property, army employees with wages as theirsolecompensation,
will do the work, and the swcture is not intended or offered for sale (Sce. 7044, Business
3 and Professions Code: The Cantractor's License Law does Trot apply to an owner of
❑ BATH REMODEVREPAIR El DEMOLITION
❑ OTHER
SIGN$^ELECTRICAL
SPECIAL CIRCUIT/MISC.'
•.
'
TEMP. METER OR POLE INST
COMMERCIAL, '
❑ NEW BLDG/ADDITION El DEMOLITION
❑ TENANT ❑ FOOD SERVICE
IMPROVEMENT s
❑ OTHER
, 0
,. POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES'
property who builds or improves thereon, and who docs such work himself or through
his awn employers, provided Nei such improvements ere not intended or offered for
sale. If, however; the buildingbr improvement is sold within one year ofcompletion,the .
owner -builder adder will have the burden of proving that he did not build or improve for Pur-
pose of selene. d; ' p r ' „ -
❑ I, as ow r of the property, am exclusively contracting with licensed contractors to
I construct the project (Sec. 70,V1, Business and Professions Cade:) The Caotractor'x Li-
NEW RESIDENTIAL ELECTR r SQ FT
tA
SQ. FT, FLOOR AREA
1`Imirl�
p I 1
A FJ -
$/SQ. FT.
p
QTY. PL B RMIT FEE
cense Law docs not apply to an owner of property who builds or improves thereat, and
wM1e s -is each wiNacgntmctor(a,licensed pnrsn tmthe'ontmemre;
License -
t ❑.lam amp rSec. ,B&PCfor this reason
APR 9 1996.
`
^
MIT ISSUANCE•
HAULITER-DRAIN&VENT-WA IEA). a"
r BACK FLOW PROTECT. DEVICE -
wner '• - Data
W S COMPENSATION DECLARATION
• I h by our penalty of pe j ry f Ne following declarations:
❑Ihavc and will mmmem aCertificam oFConsentm self insorefor Worker. Compen
sation, as provided for by Section 37M of the Labor Cole, for Nperformance e perfoce of the
yy
11 Ur L; r 1IAE.IIATION
�I ��11JJ�� �.'
DRAINS -FLOOR, ROOF, AREA,'OND
STORIES TYPE CONSTRUCTION
,
FIXTURES-PERTRAP
work forwhich,this this is issued.'
El I have and will maintain Workers Compcnsamov Insurance, as required by Section
'I,
37M ofare Labor Coce, for the performance afthe work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy intrauterine.
Cartier:'' 1 Policy No.:"
''I! GAS -G: SYSTEM- INC. 4 OUTLETS
-
,
OCC: GROUP APN .
y'
GAS -EA. SYSTEM -OVER 4(EA)_
CERTIFICATE OF EXEMPHON FROM WORKERS'
GREASEIINDUSTRL WASTE INTERCEPTOR
` COMPENSATION INSURANCE i s"
section need oar be completed iftheprmit is for one hundred dollars 100)
BUIL r IV IO N.FEES
or leAsJ�is ($
I cenify that in the perfommnce of Ne aorkfor which this permit is issued, ( shall
not employ any person in any manner so as to become subject to Ne Worker, Compem
station Laws of California. Dam
Applicant -.
,. GREASE TRAP d
PLANCHECK FE
ENERGYFEE.
SEWER -SANITARY -STORM EA. 200 FE
_
WATER HEATER W/VHW(ELEC R
GRADING FEEg,' r
leer
of Exemption, yeti should
NOTICE TO APPLICANT: If. Co making this C Provisions
become u comp y' the Workers Compensation provisions of me Labor Code, you must
fotthwith comply'with such provisions or Nis permit shall he Deemed revoked.
WATER SYSTEMlIREATING
WATER SERVICE �
, , •
CONSTRUCIONLENDINGAGENCY '"
^ I hereby affirm that there s a construction lending agency the performance of
She work for which this permit is Issued (Sea 309], Civ. CJ
'PAID
"Date Receip
•. •. ,
t NEW RESIDENTIAL PLMB.. -SQ. FT.
•-
" --
TOTAL: -
BUILDING FEE -a'
SEISMIC EEE
ELECTRIC FE '
Lenders Name r •.'
LcirdersAddress r
I certify that I have read this application and state that the above information is
correct. l agree to comply wish all city and county ordinances and state laws relating to
building construction, and herebymativesf this city to enter, authorize represedupon the
above-rnantioaed property for inspection putposes.
-, (We) agree m save, indemnify and keep harmless me City of Cuperoao against
T
QTy, MECHANICAL PERMIT FEE
PERMIT ISSUANCE'
ALTERORADDTOMECU
liebi0ties.jud mems, costs end ex which me
g expenses yin any way accrue against said City
onof the Nis permit s
'ALL
PLUMBING E
AIR HANDLING UNIT(TOI(),OW CFM)
APPLICANT. RSTANof
ANDS AND WILL! COMPLY WITH NON.POINT
SOURCREGULATIONS
SOURCE REGULATIONS. '� 1
MECHANICAL PEEgooS
AIR HANDLING UNIT(OVER 10.000 CFM)
. -
CONSTRUCTION TAX
SignatureofApplicantiContracmr - Date
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(WMUCTI
HOUSING MITIGATION E -
HEATINO UNIT (TO IW,OW BTU)
Willthe applicainoifuture baildingoccu orh
Daat store endle hza
ardnn numnel
as defined by me Cupertino Municipal Code, Chapter 9:12, and Pc Health and Safety
Coda Section 25532(a)] (, . 11 -
-' HEATING UNIT (OVER'IW,000 BTU)
- -
PAID
Date Rceci a
❑Yes� LIN...
or furore adding occupant use equipment or davits which'
• Will Ne air contaminants
mit Y us air contaminants as defined by m. Rey Area Air Quality Management
VENTILATION PAN (SINGLE RESID)
-
- BOILER -COMP 3HP OR 100,000 BTU
( )
DisMdT
District'
❑Yes ,; a,' .[]No's s
TO L:
', BOILER -COMP (OVER IW,OW BTU) v,,
AIR CONDITIONER ,' - s -
- Ihave reed dic'moondous materials _p6.95 of the
ry25533 sunder Chapter understand
forma Heels no S rerc Cod S i . 25505 8533 and 25534 I d wad Nat if the
if
that I is ibilny m nnrty the occupant
ofthe g onesnotedmm0y havebe,
-
-a ISSUANCE DATE
, r ,
NEW RESIDENTIAL MECH. SQ. FT.
menL
ofinerequlmments which must be mut prior to issuance ofe Certificate of Occupancy.
ua ce ofa
ISSUED BY.
- Owner or authorized agent - Date
O'
OFFICE... r