30318 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NQ ^ 0
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. JK VX
NUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL GATT
as Dy y CZ e6JC3-_D (4- Oa
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,OWNER'$,yNAbyE:z2 ' ^ PHONB: is CO ORS NLAjf nLCNO: NAC - CONTROLM
AR HITECfIENGI R: 9JLIIC/L NO:
,/f- ��b ❑
CONTACT: PHOeTNE(:�,� BUILDING PERMIT INFO
/�/O 5 N0 et D P d7�U ❑ Consultant Fees Pnid by pppllcant(InRial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hertby affirm at I um licensed under previsions of Chapter 9(commencing JOB DESCRIPTION
CMZ with Section 7000)af Division 3 of[as Business and Professions Cade,and my license is - RFSIDFNTIA ,
Cwr , ^ �� I PERMIT ISSUANCE —�—�
❑ mfuma CIeand effee ❑SFDWL [I KITCHEN REMODEL
Uh License Class Lic.M
Can Cantmcmr APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
Ipy ARCHITECTS DECLARATION PANELS ❑MULTLUNIT [I STRUCTURAL
O z r0 M
4 I uerslarM my plans shall leased as Public remarks MODIFICATION
::J]Q UPTO200AMP5. ❑INTERIOR ❑CHIMNEY REPAIR
rr3 Licensed Professional 201-IOMAMPS IMPROVEMENT
1 .• OWNER-BUILDER DECLARATION OVER 1000 AMPS [D BATH REMODEUREPAIR DEMOLITION
Q I hereby affirm that I am exempt from the Comracro's License Law for the
3 3; following mason.(Session 7031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑DIRER
F which requires a permit to coolant.alter,improve,dentabob,or repair any structure
try prior to ire i.aoance, Is.acquires theapplicant fmsuch perdt 1.file a signedsmmmcnt SPECIAL CIRCUIT/MISC
t4asil p„ that he is licensed pursuvnl in the provisions of the Commcmre License Law(Chapter9
GD (commencing with Section 7f10I1)of Division 3 ofthe Business and Professions Cada or TEMP.METER OR POLE INST. COMMERCIAL:
p, eE that he is exempt Iherelrom and the basis for the alleged exemption.Any violation of ❑NEW BLDCJADDITION ❑DEMOLITION
iC LL Section 7031.5 by myappwturt fora permit subjects the applicant to a civil penalty M POWER DEVICES
{Y rn ❑TENANT ❑FOOD SERVICE
D• not mom than Eve hundred dollars($500). IMPROVEMENT
Q� Q.I,as owner o(Iheprajeny.or my employees with wages asthcumle compcnsaioa, SWIMMING POOLELECTRIC
will dmhe work,end the strucuoe is not intended or offered for sale(Sec.7044,Business 10 OTHER
and Profusions Cade:The Cons mfe License Law does not apply to an owner of OUTLETS-SW ITCHES-FIXTD ES
property,who builds or improves thereon,and who docs such..,it himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECT R . ' SQ PT
sule.IL however tha building orimprovemem is Bold within one year of compinion,the SQ.FT.FLOOR AREAT.
VSQ.F
owner-builder will have the burden of proving that he did not build or improve for pur- fi4 ll D
pose of vele.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
mummuct the project(See.7044,Business and Isme simu CmM:)no Conna 's Li- ii
cense Law does not apply to an ownerof pmpeny,who builds or improves thereon,and QTY, PLUMBING PERMIT FEE AUG 11996
who contracts for such pmjnns with a contwtogs)licensed pursumuo the Contractor's
License Lew. PERMIT ISSUANCE
El I ore exempt under Sec. ,B&P C for this mason CIIY Ur UIJren I INL
Owner Date -
ALTER-DRAIN&VENTWATER JQO VALUATION WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE 3 J r7
OD
I hereby affirm under Penalty of perjury one of the following declarations:
I have end will maimaina CenificamfConmm msclf-insdre for Workers Cooper. DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
.tion,as provided for by Section 37011 A
of the labor Code,far the penaro nce of the
work for which this pemdt is iasoed. FIXTURES-PER TRAP
❑ 1 have and will maintain Worke's Compensation Insurance,as required by Section -
37Mofthe Labor Code,for performance of the work for which this permit is issued. GAS-EA.SYSTEM.I INC.4 OUTLETS OCC.GROUP APN
My Worker's mpensadon umnceca 'rodYolicy m -R GAS-FA.SYSTEM-OVER4(EA)
Carrico tic Nn:
CER ATE OF 'ION FROM o ERS\
COMPENSATION INSURANCE GREASWINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(Ihisseclum neednot becompletdiftep nitisforonehundmldollms(810(1)
or less.) GREASE TRAP PLANCHECK FEE
I certify that in the pertonnaneeofthe work far which this permit is issued•I shall SF.WF.R-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as to become subjecrao the Workers'Compen- ENERGY FEE
0 z sation Lows of California,Dam WATER HEATER WNENTIELECTR
z O Applicant GRADING FEE
IA NOTICE TO APPLICANT If.after making this Cenificate of Exemption,you should WATER SYSTEMOREATING -
I"' become subject m rhe Worker's Compen satinn provisions of the Labor Code,you must SOILS FEE
{ail forthwith comply with such provisions or this Permit shall he deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID
f, Iherwhichvm drat Here iI...M(w.31007nding agencyfor the performarwe of Date Receipt If
ids, I-r thewod for which this permit is issued(Sec.3P9],Ci,CJ
U nds Name 'TOTAL:
Undoes Address TOTAL:
I certify that I have read this application and sum that the above information is BUILDING FEE
Ncared 1 agree to comply with all city and county ordinances and state laws relating to QTY MECHANICAL PERMIT FEE
7
U F7 building construction,and hereby authorize representatives ofthis city to enter upon the SEISMIC FEE
above-mentioned prat far inspection parposes. 'sa
(We)agree to save,indemnify and keep humorless the City of Cupenino against PERMIT ISSUANChumorlessD ELECTRIC FEE. 6.6d
liabilities,judgments.casts and expenses which may in any way accmc against said City ALTER ORADDTO MECH.
in consequence of the granting of this pemtit. PLUMBING FEE
APPLICANT U DERSTANDS AND\'ILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TO 10,000 CFM)
SOURCF,R .TIONS. MECf1ANICAI.FEE 2J
/! elf In3 AIR HANDLING UNIT(OVER 10.0110 CFM) CONSTRUCTION TAX
Signal ppr ucinnac r Date FXHAUSTHOOD(WMUCn HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building oecupam sure or handle hazardous material / HEATING UNIT(TO 101000 BTU) / •as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cade,Section 25532(x)? HEATING UNIT(OVER IM."BTU)
C]Yea No VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which Dam Rueipt a
'mit hazardous air contaminants as defned by the Bay Area Air Quality Management BOILER-COMP(311P OR 100,003 BTU)
District? TOTAL:
E)Yes E]No BOILER-COMP(OVER 100.000 BTU)
1 have read the heamdous monorails nquircments under Chapter 6.95 of the Culi- Alft CONDITIONER / ISSUANCE DATE
fomia Health&Safety Cade,Sections 25505,25533 end 25534.1 understvW tha if the NEW RESIDENTIAL MECH. SQ.Ff. -
building does not currently have a mnMt.Nat it is my meponsibility to redly the occupant
of use"aimments which must be met prior to issuance of a Certificate of Occupancy.
Owner or outhorized agent Data
TOTAL: a SSUED BY:
OFFICE