S 3058APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO nun.DING- ELEcrRICAL
BUILDING DIVISION APPLICATIONMERMIT PLUMBING -MECHANICAL
6UILDING PROJEM' IDENTF'ICATION
PE IT No
{� 3058
BUILDING ADDRESS:
L-IFY Ave
SANI'IARYNO.
APPLICA'1'[ON SUBMITTAL DATE
( D -2 f 91
^OWWNNER'SNAME: ` PHONE,
1 ✓ Lx. a5 L (-,� J LiS L• -O I
CONTRACTOH;SNAME: LIC NO:
1- /1 Q
C,
N/C
❑
CONTROL It
f AKCHITECUENGINFER: 1,11 N,'.
ADDRESS'.
CONTACT: PHONE:
t
2-5. Z O (^
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
d' d ❑ ❑
LICENSED CONTRACTOR DECLARATION
I hereby 0) rl that I am licensed Bu under al Proops of Chapter v (commencing
7 with Scotian ] d cff rllivision 3 of the Business nnJ Pml'exeion. Ede, send lay llcenseis
in full force end effect.
� Licence Class Lic.p
Dam Contractor
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
R . IDFN
� % TIAL
❑SFDWL E'ICrCHF.N REMODEL
❑ADDITION ❑PLUMBING RE -PIPIT
❑MULTbUNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT ❑ SWIMMING POOLS
(] BATH REMODEfJRIiPAIR (] DEMOLITION
❑ OTHER
PERMIT ISSUANCE •f'
/
APPLIANCES-HESIDIiNTIA1.
ARCHITECTS DECLARATION
G I undersonl my plansshall he used as publicnamods
PANELS
UP TO 200 AMPS
Licensed Pmfesstanal
OWNER -BUILDER DECLARATION
1 hereby a01nn that I can esenyn from the Cnnoacmr's License Law lin the
fallowing reason. (Section 7031.5. Business and Professions Code: Any city or county
which requires a permit to concent, alter, improve, demolish, or repair any structure
Prior Yo its i1mm-, oleo requires the applwam Air saci,morm, to tileasigned.mtement
that he is licensed pur.uanna the provisions of the Cannanore. License law (Cli
(commencing with Section YOIXOof Division 3 of the Business and Pmfev.ions Cralc) or
g that he is exempt therefrom and the half, far ❑ e alleged exemption. Any violation of
n Section 7031.5 by any applicant for a Permit subjects the applicant m a civil penally of
not more than five hundred dollars ($50p,
I, as owner of the pmpeny,or my employees with wages as their sole compensation,
w Idothe work, and the structum is not intended oroffemd rorsale(Sm.]OW, Bu.inexs
The Contractor's License law does not apply ns an owner o
own employees, provided that such improvemenne are not intended or offered for
the building or improvement is veld within one year ofaompletiom the
ownerbuilder will have the huNen ofposving that hedid not build or improve for Fur-
ofsoled.
ror the Property, nm exdu.vively commeting with licensnl cnmoemra toT
theLproject (Sea AWa, Basin... and Profession. Cade:) The Commdnr. Ll-
seLawdoe.notapplymanowneraf mpenywhobuildsorimpmvesmemon.and
whonontrrs mtritium Projects rust licensed pu�utat nnhe Commerce,
License Law./ —
❑Iam exemptrind Se l .II&PCfarthiannom
2014"AMPS
OVER IIXq AM1t I'S
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
'TEMP. METER OR POLE DIST.
'
W BLDG/AUUI'I'ION EI DEMOLITION
NT ❑FOODSERVICE
0 CPROVEMFNT
POWER DGVICIS
TRIC
T'RandPmfession.eCsde:
VNIXI URES ('workhimselfmthrough
CTR SQ ET.sale.If.however.
n
-his
S Fb'fOQR 2pt .199
1.1L1 (.rse
By
FT.
AI aonstruct
QTY.G PERMIT FEE
�/ PERMIT ISSUANCE
ALTER- DRAIN &VF.NI'-WATER (EA)
Own R
VALUATION
( ��
W K CO I',NSATION DECLARATION
1 hereby affirm a penalty of Perjury one of the following declarations:
❑ I have and will maintain a CenifcaleofCmaml to self-imrirc far Worker's Camper'.-
sation, as provided for by Section 370() of the Labor Code, for the performance of the
work for which this permit is issued
❑ 1 have and will maintain Worker's Compensation Insurance, as rryuimd by Section
37M of the latrorCode, for rhe performance of the work for which this pmtit is issued.
Workers Compensn0on Innurance carrier tinct Polity nnmhcr aro.
Co
Cartiee Policy Nn:
CERTIFICATEOF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
fiis section newt not be completed ifthe permit is forme hundred
d Jollan ($IW1
or loss')
far subjectch to Ectthe WascrZ'Co shall
eofes to become
Loy my per in the any manner
not employ any person in any manner so as m Mcome object m the Workeee' Cnmpcn-
Lucas of California. Dam
Aliplicum
pp
BACK FLOW PROTECT. DEVICE
BRAINS- FLUOR. ROOF AREA. COND.
STORIPS
OCC. GROUP
TYPE CONSTRUCTION
APN
FIXTURES - PER TRAP
GAS - EA. SYSTEM -1 INC. J OUTLETS
-
OAS - GA. SYSTEM -OVER A (EA)
GRFASPINDUSTRL WASTE INTERCEPTOR
GREASETRAP
BUILDING DIVISION PETSCOMP
PLANCHECK FEE
SEWER - SANITARY - STORM IIA. 2W FT.
ENERGY PEG
WATER HEATER WNEMf/F.LECfR
GRADING FEE
Exemption, io re, y should
NOTICE TO APPLICANT: IL after Compensation of the
ti this provisions
n provision. of rbc labor Code, you must
become. comply
y the Wnrkero Comp or this
lonhwilh comply with.wch Provisions or this permit shall MJcemeJ revoked.
CONSTRUCTION LENDING AGENCY
I hereby aR'hi that there isanmgmc3lending agency for the performance of
the work for which this permit is issued (Sec..30G119], Civ, C.)
Lender', Name
WATER SYSTEM/TREATING
SOILS 143F.
WATER SERVICE
PAID
Date RecciPtk
NEW RESIDENTIAL PLMB. SQ. Cr
TOTAL:
'
Lemm's Address
TOTAL:
I certify that I have read this application and .man that the above information is
correct. l agree to comply with all city end county ordinances and vote laws relating to
building em suuction, tied hereby amhonm repreor a kr', of this city m enter upon he
above-ammionell property far inspection prPs.es.
(we) a to mor, indenoil p y o p b
Cit fCu Inst samoron
( gree yandhic bay in any
incoiniequnce of firets, focusicosts ng es pensesmit. may in any way uccme against said City
consequence of the grunting of thie permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1, NON.POINT
SOURC sUl.AT IONS.
- �-
BUILDING FEE
e
QTY MECHANICAL PERMIT FEF.
SEISMIC [ZEE
PERMIT ISSUANCE
ELECTRIC FEE
ALTER OR ADD TO MECH.
PLUMBING FEE
AIR HANDLING UNIT ('101(1,00X1 CEM)
MECHANICAL FEE
AIR HANDLING UNIT (OVER 10,003 CPM)
CONSTRUCTION TAX
ore Of Appociandruopirgan Dam
IIA IOUS MATERIALS DISCLOSURE
Will lheapplicunt minor, haddingaecapunlonsiahandle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12. end the Health and Safety
Code, Section 8532(x)?
❑Yes 0 N
Will thea applicant or future building
pp gby the B ace equipment or devices which
IlDcanazardou.v�ircnmaminamsenJefnodbytheBxyAreaAirQualityManugemetn
Di.bicY!
❑Yes ON.
( have read the h ode. Se mans 255 5, 255 3 an under 1 mor6.95 nimad that Cali-
folia does & Scurry Crile, have ba ro ,than 25533 and 255311 t onorsmnd that if the
ismy uace Ora bilityornmifythe ccipa,nt
holdingmapammrncurtelich must to met poor to
of the rrquirenrna which must be met pilar to ivvu:mce oro Cenifwm of Occupancy.
FATALIST HOOD(W/DUCT)
HOUSING MITIGATION PEE
HEATING UNI'I'fTO 100,000 B' I'll)
HEATING UNIT (OVER 101001 BTU)
PAID
Date Receipt fl
VENTILA9'ION PAN (SINGLE RESID)
BOILER-COMP OHP OR INLOW) BTU)
T(3T L:
BOILER - COM P(OVER It]p,IXXI BTU)
AIR CONDITIONER
ISSUANCE DATE
/ /r5� 2-
V T % 0
ISSUED BY,
NEW RESIDENTIAL MECH. SQ. FI'.
Owner or amhnnzed agent Dam
TOTAL:
OFFicL