30160 APPLICANTTO FILL IN INFORMATION WITHIN REDLINES-USE BALL POINT PEN ONLY - 1 y^a
CITY OF CUPERTINO r BUILDING-ELECTRICAL PERMITNO. 30160
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILDTNGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
/ . L{ r o AVE ar`+
OWN"S NAME: PHONE: CONTRACTOR'S NAME: , LIC NO: r
Cri�� III
eo 6233 NIC CONTROL#
RCHITECVENGINEER: -LIC NO: ADDRESS: ❑
CONTACT. PHONE: _ BUILDING PERMIT INFO
OQ _ / ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB ME❑CH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE A
1 hertby n�,m Nm 1 am licensed under provisions of Clupmr 9(commencing JOB DESCRIPTION
D=z with Salton]gMBafDivisionJofthe Businessand Profusions Cwle,and mylicense is RESIDENTIAL;
i
PERMIT ISSUANCE
F fy� nfull force erW cR P ❑SFDWL ❑KITCHEN
IVU Licens lass Lica— APPLIANCES-RESIDENTIAL. ❑ADDITION C1 PLUMBING R&PIPE
u1 Dv¢ TS DECLARATION
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
z Orn 7 I understand my plana xhall4 used ns Public records. PANELS MODIFICATION
OZ—O UPI'02W AMPS ❑INTERIOR yaQHMNEY REPAIR
� ,�.W Licenmd Professional 201-IIgIf1AMPS IMPROVEMENT
J W$Ly+`a{ OWNER-BUILDER DECLARATION OVER IOIXIAMPS ❑BATH RBk�ODEVREPAIR �DEMOLITIUN
PJ a I hereby affirm that 1 tan exempt an the Communes License Law for the r
O V fallowing reason.(Salton]OJLS,Businessand Rafcssiom Code:Any city or county SIGNS ELECTRICAL ❑GINE
y O which rcqu a permit to conswcs,sites,improve,demolish,or¢pair any structure
pnor to its issuance,all requires Ne applicant for such permit to file a signed statement SPECIAL CIRCUITMISC.
Nat he ix licanscd personal m the provisions of the Conwctor'a license Law(Chapter9
OC (commencing with Section 700n)of Division 3 ofthe Business and Professions Cde)or TEMP.METER OR POLE INST. COMMERCIAL:
6 q p 2 that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDOIADDITION ❑DEMOLITION _
ad
�y Section 1031.5 by any applicant for a permit subjects the applicant a civil penalty of POWER DEVI ❑TENANT. ❑FOOD SERVICE
not more than five hundred dollars($500). - IMPROVEMENT
E] as owner claim property,or my employees with wages as their sole compensation, SWIMM LELECTRIC '
y wdldothework,and the swcmre is not intended orofferul for sale(Sec.70a4,Business ❑OTHER
al and Professions C lc.The Contractor's License Law does not apply to an owner of -5 ES-FIXTURES
ce'3 pmpeny who builds nr improvex thereon,and who does such work himself or through -
his own employees,provided that such improvements are not intended or offered for1DENTIAL SQ FT.
sale.If,however,the building or improvement is sold within one year ofcompletion,the Of
SQ.FI'.FLUOR AREA LSQ.ET..
wner-builder will have the burden of proving Nat he did not build or improve for put- YR9
poseofsale).
❑ I,as owner of the'roped,um exclusively commeting with licensed emitmctors m TOTAL:
instruct the project(Sec.7(W4,Business and Professions Cade)The Continuous Li- -JUL 15 1996
c s, Law does not apply to an owner of pre avy who builds or improves chanced,and QTY, PLUMBING PERMIT FEE -
who contracts for such projects with a conmacme(s)licenseal pursuant to the Commando a
Licene Low. PERMIT ISSUANCE -ry
❑I am exempt under Sec. ,B&P C farthis reason 's I I Ur LUrGrs I IIVU
Owner Dore ALTER-DRAIN&VENT-WATER(IDO VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE co(,-�'
1 hemby al5rm under Penalty of perjury one of the following declamation:
❑Ihave and will mwmaineCenilicete of ConsenuoxelGinsure for Worker's Cnmpcn- DRAINS-FLOOR,ROOK AREA,COND. STORIES TYPECONSTRUCTION
statin,on providad for by Section 37M of the Labor Code,for the performance of Ne
work(m which this Osamu is is mad. I FIXTURES-PER TRAP
❑1 have and will maintain Worker',Compensation Insurance,as repaired by Section '
37M offhe Labor Cade,for the Performance ofthe work for
width
this permit is iduel. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Workerjcf�nmtigpamice cv,rie Policy Nay to 'Ja 1 (7� GAS-EA.SYSTEM-OVER 4(EA)
/ Carries, hh dd
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASPJINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION f:EfiS
(This section need not he completed ifthe permit is foram hundred dollars 1$I W) GREASE TRAP
or loss.)(This
FEE
loyainy that in o the anymormunce serat Ne work for which this One Wores'Comper. SEWER-SANITARY-STURM EA.200 FT.
not employ any person in any manner so az m became subject m the Workers'Compen. ENERGY FEIi
OI shall
z ration Laws of California.Data WATER HEATER WNENDELECTR GRADING FEE
O Applicant
fry NOTICE TO APPLICANT,If,oftee making this CcrtiEcam Of Exemption,you should WATERSYSTEMMEATING
a become subject o the Workeh Com anvsion provisions of the Labor Cade,you must SOILS FEE
forthwiNcomplywiNsuchpmvisio..orthis lsummshObedecmcdrevoked. WATER SERVICE
�L Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.PL PAID
U Ih<rcby effimuhna Nero iia conswaian lerWing agency for the performance of eceaPrk
U. a-n Newark for which this permis is issued(gee.3097,Cie CJ
Fa W Lerider'shi Name TOTAL:Lendefs Address TOTAL: ..
1 certify lea I have read this application end sate Nanhe above information is BUILDIN 1Y
T0./] correct 1 opera to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
Uz Wilmagcorearction,and hereby outhorizerepmsentativesofthiscilymenmruNn the SEISMICFE
above-mentioned property for inspection proposes. PERMITISSUANCE
(We)"Sere d save,indemnify and kap hamdass she City of Cupertino against ELECTRIC TEP.
Iiabilities,judgmens,cosuand exparucs which may inany way same against said City ALTER OR ADD TO MECH.in consequence of Ne gtnnling of Nia permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT OD 10,000 CFM) MECHANICAL FEE
REGULATIONS.
F`7alf
AIR HANDLING UNIT(OVER 10,000 CPM) CONSTRUCTION TAX
camlcanaacmr D.'a EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will Ne applicant or future building OCcupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)7 HEATING UNIT(OVER IW,(M,D BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID
Data Receipt It
Will the applicant or future building occupant use equipment in devices which BOILER COMP(3HP OR 100.000 BTU)
emit hnvdous air -
deposal contaminants on desal by the Ila,Aro.Air Quality Management TOTAL:
Dismicap BOILER-COMP(OVER 100,0011 BTU)
❑Yes .ONo
1 have mM the hazardous mmerids mquimmcnm made,Chapter 6.95 of Na Cali- AIR CONDITIONER ISSUANCE DATE
(oris Health&Safety Cade,Saloons 25505.25533 and 25534.1 umlersand that if the NEW RESIDENTIAL MECH. SQ.En
Wilding does not currently have a mount,that it is my responsibility to notify the occupant
of the rerun rents which must ba met prior to issuance of a Certificate of Occupancy.
Owner or cautioned agent Data TOTAL ISSUED BY:
OFFICE