S 1982 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUILDING-ELECfRICAI.
1'E I'I'NO,
BDILDING DIVISION APPLICATION/IaERMIT PLUMPING-MN,CIIANICAI. �J 1 9 8 2
BUILDING:PROJF,CF IDENTIFICATION
BUILDING ADDRESS, (�,l\ . SANITARY NO. APPLICATION SUBMITTAL DATE
I,f11'
OWN' A ,) I'IR) 3_ O 'I� �
eln AMN 13A �C LI„ yNIC
CA
ARCIIITECTIiNGINEHR: LIC NO I.R^JI'`SmYC Zl VSA-JIJD `ID C� N4 /NgS37
CONTACT: PHONE: BUILDING PEMITINFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY, ELECTRIC PERMIT FEE
I hereby affirm that I am license under pmvisions of Chapter 9(commencing JOB DESCRIPTION
O0Z with Section700)of Division 3 of the Business and Proessio s e,and my license is O RESIDENTIAL,
{{yyOO ,^� PERMIT ISSUANCE
Fm 1y .full tome and efts ❑SPDWI. [I KITCHEN REMODEL
aUV LirenscI X —1�Lie.M v gppuANCES—RESIDIiNTIAL ❑ADDITION El PLUMBING RE-PIPE
FZW Dam Cont. •f>E C !
'n ZU ❑MULTI-UNIT El STRUCTURAL
Dw ARCHITECTS DECLARATION PANEUS
ZO Z 1understand my plans shall bused.public records MODIFICATION
OZ—O UP TO 200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
Qom["., Licensed Puof,soom�l 2"I-PXXIAMPS IMPROVEMENT SWIMMING POOLS
{ O U 1 hereby affirm Nm Ilam exemptfrontContnmemr's License Law for the TION OVER 1 WO AMT'S ❑OTHER BATH 1-MO EIJREPAIR DEMOLITION
fiiLLS5 0. following reason.(Section 703 1.5.9usineas and Professions Cert Any city or county SIGNS Ii=RICAL
0 0q
which requires a permit to con>a.a,alter,improve,demolish,or repair any.trucwrc
F"�Oa prior to its issuance,also requires the optician for such Permit file a signed stammenl SPECIAL CIRCUIT/MISC.
Shy thm he is licensed pumuam to the provisions of the Cnmmctor's Litansc Law lCM1up¢,a
tY�� (commencing with Seen..9WU).rIo,oton3nf the Business and Profusions Code)or TEM('.METER OR POLI?(NST.
d y M C
,hot he is exempt Neo from and the basis far the alleged exemption.Any viol.ion of ❑NEW BLDG/ADDITION ❑DEMOLITION
lit Y• Semion70315 by any applicant for a crunit subject.the app,icam to a civil pemllyol POWE EVICES ❑TENANT ❑FOOD SERVICE
FZN too nm than five hundred dollanx($500). IMPROVEMENT
Mo C1 ,asowocrof,he pmpany,of myemployecs with wagcsas theirmleccapensalion. MMINGPO0LELECRIC 10 OTHER
willdothe work,and the strucuum is not intended(it offered for sale(Sea.]044.Itusme
and Noferxinn.a Code'.The C,,mraaor's license Law dues not apply to an owner - OUTLET'S-SWITCHES-FIXTURES
property who builds or improves,hemon,and wha does such work himself or Ihmug
his own employee.,provided that such imprommcnts are nm intended or offered( NEW RPSIDENTIAL ELECT SQ FT.
sale.IL however,the hnilding nr lmnpmvenmm is s,,lA within one year of cnmpletion,me SQ.IT.FLOOR AREA SISQ.FT.
woenhuildcr will have the burden of proving that lie did. ,build or impropar
ve for -
poseofsale.). AI
I es owner of the properly,...m exclusively comm�ning wish licensed Coal "I.,e to -
an,c La the project ftiec.to an
Bulinus and Professions Cee:)Toe C themon.and
cern,anono,snotupplytoan with
aofpmpen,I whosedporimpmves themon.and QTY PLUMBING PERMIT FEE
wha wnauc6 for xueh pmjedx with aennmemr(ni licensed pumuum to the Cnmramnr's
License Law. PERMIT ISSUANCE
I am exempt under Sec. ,B&P C for this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECE DEVICE
I hereby affirm under penalty Of perjury one of the following declarations:
❑I hiveand will mIranian.C,nifeme Of Co.sem to self-insure for Workers Compen- DRAINS-FLOOR,ROOP AREA,COND. STORIES 'TYPE CONSTRUCT ION
sation,as provided for by Section 390(1 Of Ne Labor Coda,for the perfmcnam a of the -
work for which this permit is issued. FIXTURES-PER TRA['
❑ 1 hive.,,it will maintain Workers Compenswlnn Insumnee,as rcgtdred by Section
3700.fthe labor Cee.for the performance of the work for which this permit is issued. GAS-FA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
CMy ur Wr ry Co Pnsa )nl a tum carver uGy No.: p¢r�`W �1
. �- WOl .�yA1 GAS—BA.SYSTEM-OVER 4(EA) Q y, a D
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASdINDUSTRL WASTE INTERCEPTORP'+
COMPENSATION INSURANCE, BUILDIN N FEES
(ThienemlOn need.,,,hca:mplemdlf the permit,,foams hundred dulls($100) GREASETRAP
or less) PLANCH-
Iccnifythminthepemurumm.f the w,,sfar wbichthis permit is issued.Isha11 SEWER—SANITARY—STORM EA.200 FT.
ENERG
nemploy any person in any manner so as m become m e subject the Workers'Compen- s s U•sJ
z,Z sation lows of California.Date WATER HEATER WNENOELI=R GRADING fIF.fiJC V
Q Applicant
NOTICETO APPLICANT:11;alto takingthis Cenifente M Exemption.you should WATER SYSI'EM/TREAGNO
a; SOILS PERbemnc subject to the Worker's Compensation provisions of NL
e bor Code,you must
LII roti tmb%ith comply with such previsions or this permit shall b deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL('LMB. SQ.Ff. PAID Data Heceipl M
UO 1hereny affirm that them is a construction lending agency for the ferfommmem of
w E-' the work for owhich this permit is issued(Sac.3099,Civ.C) TOTAL:
L7 Unders Name TOTAL'
kit Landers Address
y I certify that I have read this application and stun Ghat the ousts in!..,mon in BUILDING
0 vomit lu,reu. Imply withal]city and county ordinmaes and state laws relating in QTY. MECHANICAL PERMIT FEE SEISMIC PE
V Z building c,,namction,and hereby authorize representatives of this city to enter uponthe
ahovc-mentioned pmpeny for Inspection purposes. PERMIT ISSUANCE ELECTRIC FEE 3
(We)agree m save,indemnify and keep harmless the City of Cupenine again,,
Iiabilities,judgmentx,costs and expenses which may in any way aceme against said City ALTER OR ADD TO MECH, PLUMBING FEE
in c,umtn,nrvc of the granting ofthis permit.
APPLICANT UNDERSTANDS ANI)WILL COMPLY WITII ALL NON-POI N Alli IIANDLI NG UNI T(TO I0.0d0 CPM) MECHANICAL+E
SOURCE REGULATIONS.
AIR HANDLING UNIT OVER 10,0(10 CFM) CONSTRUCf10N X
Signamm of Applic..UC.nnicer Date EXHAUST I IOOD IW/DUCT) HOUSING MITIGAU! FEE
HAZARDOUS MATERIALS DISCLOSURE;
Will the applicant(it furore huildngoceupunt store or handle hazardous material HEAT]NG UNIT(To 110,000 BTU)
m defmcd by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 255320)? HEATING UNIT(OVER 100,000 BTU)
❑Yex ❑No VI;NTI LATION PANS INGLE RESIDE PAID
Data Receipt p
. Will the applwam or furore building occupant me equipment or devices which BOILER—COMP(311POR 10,0(0 BTU)
emit hazardous air contortas defined by the Buy Arca Air Quality Management TO i
D.emct? BOILER—COMP(OVER 1,,1100 BTU)
C]Yes No
I have read the brooms,m wrial,requirements under Chapter 6.95 of the Coli- At CONDI'T'IONER ISSUANCE DATE
Boom Health&Safety Cale,Sections 25505.25533 and 8534 1 understand Na,if the NEW RESIDENTIAL MECH, SQ.14.
holdingdoes am really have a enanithat it is my mspOntsihil'dOccupant y to notify the (O
of the reyuiremenu which must he at prior 1. users of a Cemfil te Of Occupancy.
Owner m authorized ager pare TOTAL: ISSUED BY:
OFFICE