30348 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY r.S( /a�1
CITY OF CUPE'RTINO BUILDING-ELECTRICAL PERMIT NO. 30348 O J T H
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL �;
BUILDING PROJECT IIIENTH ICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
ai / S7 C&-L C7 p'6-
OWNER'S NAM PHONE: (�,/ CONTRACTOR'S NAME: r� 1 LIC NO:
ISS= 377 �p SO USf+'Y 4�i t/I' •G C�O SS S/J N/C CONTNOLp
ARCHITECT/ENGINMR'. LIC NO: ADDRESS: TL - - ❑
10/ S CR hI'OY( TfY•rQ$� S4r� ✓4/ C4
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fens Paid by Applicant(Initial) .BLDG ELECT , PLUMB MUCH .
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE ❑ ❑
1 hereby affirm tbe,I..licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
000atz wird Sation 9000)of DivisianlofNc Business and Professions Cade,endm 1 nu is
00 i y sec PERMIT ISSUANCE
ty kende full rceGla and effect. _ ❑SFDWL ❑KITCHEN REMODEL
�FV Data Claw Contractor
APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
N<SData _ Contmcmr
❑v, ARCHITECT'S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL.
SCO 1 understand my plans shall be used as public records PANELS MODIFICATION
0z p�p OTTO 200 AMPS - [I INTERIOR ❑CHIMNEY REPAIR
a4-izl Licensed Professional 201-IIIOf1AMPS IMPROVEMENT
0 OWNER-BUILDER DECLARATION OVER I000 AMPS [I BATH REMODEVREPAIR E-)DEMOLITION
Q I hereby affluent but I am exempt form the Contme o's License Law for the 06 ❑OTHER V following«axon.(Section]011.5,Business and Professions Cale:Any city or.ommy SIGNS ELECTRICAL
which minutes a Permit to construct,alter.improve,demolish,or repair any sbunme
�N prior to its issuance,alm regtims no.pplieam for such permit to flea signed statement SPECIALCIRCUIT/MISC.
y thus he is licensed pursuant no theprovilmas ofthe Cunlmclo's License Law(Chepmr9
G£Oq (cummencingwiatScetiont0(111)of Divi,sion3ofthe Businessand Professions CWa)or TEMP.MITER OR POLE INST. COMMERCIAL:
6 e W that he is exempt thereabout and the by is for the alleged exemption.Any violalian of ITI
❑NEW BLDG/ADDON ❑ ITI
DEMOLON
Sx Y• Satins 9031.3 by nny applicant for a permit subjects the upplicam to o civil penahy of POWER DEVICES
al�y []TENANT C]FOOD SERVICE
of momthan❑f thundred e property,
or mye($50mployeesIMPROVEMENT
zQ ❑Lo lie work,Ne pro structmmyemployres with wagesends al ES le INFI.B since, SWIMMING POOL ELECTRIC
O will do fesiork,and the The mteisnot s License aw docs'rsale(Sec.to a4.Business ❑OTHER
and Professions Code:The oyes th mrd License Ines does not apply to if owner of )UTLETS S W S-FIX
hispropertyown who builds or improves thereon,and who does such tine himself m through t
his own employee,a provided r i such improv sold within are not intendeJ or oRcrcd for NIiW NESIDENTIAL ELECfR SQ Ff.
ownr-ower will hvethngmien of Muntithat heion build at improve
SQ.FT.FLOOR AREA SISQ.PT.
owner-builder will have the burden o(prvving that he did not build or improve for put. '; .(� ❑ it
pose o os LZ U it
❑ 1.as
owner ofijtheproperty,am exclusively contracting wordlicensed:)HimCconwcross U. ,.
construct d project apply
to an Business and premonitions tui Cade i Tho Comramols nd AUG
,1G 8 1996
cense Law does nmapply�oanowner ofprnpeny whahuildsor omantmilac Coteoq and QTY. PLUMBING PERMIT FEE ![lIU
who se Law.for such pmjau wird a contractogs)licensed#moment m the Cnmmcmrs
License Law' I
PERMIT ISSUANCE.
❑l am exempt ander see. ,a&P e for W,reaaan Ct I Y Vr 4Ut"Cn ulY(J
Owner Data ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE )
I hereby affum under pcnulty of perjury one of the following declarations: -
❑I have and will maintain aCenificate of Coment to self-insure for Worker's Camper- DRAINS-FLOOR,ROOK AREA,GOND. RIS TYPECONSTRUCHON
sation,as Provided for by Section 37W of the labor Code,for the Performance of the
work for which this Pewit is issued FIXTURES-PER TRAP
❑I have end will nminmin Wmker's Compensation Inmtance,as u im ad by Scrums
37W ofthe Labor Code.for the performance ofthe work forwhich this Permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROLIP APN
My Worker's Compensation Insurance carrier and Policy number art:
Comae Policy Nu: GAS-P.A.SYSTEM-OVER 4(EA) /
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASVANDUSTRL WASTE INTERCEPTOR FAV.DING DIVISION FEES
(This section need not becompletul ifthe pewit is Toronto moment dollars 0100) GREASE TRAP
or less.) PLANCHECK FEE
I rectify that in Ne performance of the work for which this Pewit is issued
,❑hell SF,WER-SANITARY-STORM 0A.Y00 FT..
not employ any person in any manna o as Altos,�e�object w the Workers'Compen- ENERGY FEE
OZ stow.Laws of I'omie.52
Jf Y WATER HEATER W/VENT/ELECTR
O ApPticam GRADING FEE
IA NOTICE TO APPLICANT.If,after making This Cenifcateof Exemption,you should WATER SYSTEM/TREATING
F' became subject to the Worker's Compensation provisions of the labor Cade,you must SOILS FEE
wr forthwith comply with such provisions or this Pewit shall be deemed revoked. WATER SERVICE
Q
�z CONSTRUCTION LENDING AGENCY - NEW RESIDENTIAL PUSH. SQ.FT. PAID Date Receipt#
L)O dhe1 llhwNat then issued Sec.30 len ding ngency for the perfnmunce of -
the work for which this pewit is issued(gee.309'1.Civ.CJ
u' F"
Leader.Name TOTAL:
O V Lendeb AOdress TOTAL:
?+ W� --- BUILDING FEE
ammuc�+ I racily that I have read this application and dime that the stove information babitinn is
y buildir.lagueto comply hereby miry and miany represntativsofthid state enter upon the
QTY. MECHANICAL PERMIT FEE
U x, building construction,and hereby auNoriu representatives oflhis city reenter upon the SEISMIC FEE
move-mentioned property far inspection p trpmes.
(We)ague motive,indemni( PERMIT ISSUANCE. ELECTRIC FEE
yandhich hayin on,
ywo of itiourwnd inn
incoitiaxma eof the coursingof this eswhich may in wy way aurae egvnst sail City ALTER ORADD70 MECH.
in consequence of the granting of this pewit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO Ig000 ChM)
MECHANICAL FEE
MS :REGULA 1 NS.
- -
Oft t?G-9` - AIR HANDLING UNIT(OVER If."CF1y7 CONSTRUCTION TAX
Signature of ApplicardConnaetor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building recupum stone orhandle hazardous material HEATING UNIT(TO 100,000 BTU)
as defend by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532(x)9 HEATING UNIT(OVER IM."BTU)
C Yes FIN. VENTILATION FAN(SINGLE RESID) PAID Uae-. Receipt#
Will the applicant or future building occupant vu equipment or devices which
`nit hazsrdmus air comanditios as defined by the Bay Arca Air Quality Management BOILER-COMP(3HP OR I00J00 BTU)
TOTAL
El
❑Yes ❑No BOILER-COMP(OVER 110,000 BTU)
1 have read the harmdaus materials requiutmmts under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
ramie Health&Safety Cede,Sections Z505,25533 and 25534.1 undetsmnJ not if the NEW RESIDENTIAL MECH.
buildingdoes not currently have a tenant,that it is my msPonsihility m notify the occupant
of the rcquircttmnu which most be met prior to issuunce of a Certifiesta of Occupancy.
Owraom idamized agent Dale TOTAL ISSU BY:
OFFICE '