S 0538 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO. BUILDING-ELECTRICAL PE51TNO. 0538
RUILDING DI VISION APPLICATION/PERMIT PLUMBING-MECHANICAL J
INIIAING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
/b 940P 8 - g -97
OWNER'S NAME. CONTR OR'SN ME: 1 LIC NO' N/C CONTROL#
r PNONE- 03 r S trnrs J
.'ARCHFWE GINEER: LIC NO: ADDRESS: h� IQ ❑
CONTACT,. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT Plum MECH
❑ ❑ IV ❑
LICENSED CONTRACTOR'S DECLARATIONQTY ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under previsions dChapter 9(commencing JOB DFSCRIPTION
�alZ with Section Bull ofDividon 3 ofthe Business and Nafessionscale,end my license is RESIDENTIAL;
.00_ PERMIT ISSUANCIi
in fulIforce and effect O? 1 ❑SFUWI. ❑KITCHIiN REMODEL
<U Y. License Cl Co,. woq APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING REwPIPE
Z`fp, Dam To DEC'
,D¢ ❑MULTI-UNIT ❑MODIFSTRUCTURAL
ATIO
F-Om ARCHITECTS DECLARATION PANELS
Z O I uodernvm my pions shall o used.,Public reands MODIFICATION
OZ�O UP TO 200AMP5 ❑INTERIOR El CHIMNEY REPAIR
r`�; Licensed Professional 201-110(3AMPS IMPROVEMENT QSWIMMINGPOOIS
pd OWNER BUILDER DECLARATION OVER IOOIIAMPS ❑BATH RENIODEVREPAIR 0DEMOLITION
yy 6' st I hereby affirm that 1 am exempt from the Contrecmr's License Law for the
'aCOtLU following mason.(Section 7011.5,Business and Prefessiom Cale:Any city or county SIGNS FLECfRICAI. ❑OTHER
44y11 O(� which requires a permit to construct,cher,improve,demolish,or repair uny swcmre
prior la it.,issuance,also requires the applicants for such Permit o Naild'oed statement SPECIAL CIRCUIT/MISC. _^
that he is licensed pursumn to the previsions of the Contractor's License Law(Chapter 9
eCO� (commencing with Section 7")of Division J of the Business and Professions Cale)or TEMP.MFT ER OR POLE INST. comm -
6tbut he is exempt therefrom and the heads for the alleged!exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W Section 7031.5 by any applicant for a permitsubjects the applicant to a civil Penalty of POWER DEVICES
m nor more then five hundred dollars Siflif. C)TENANT ❑FOODSERVICE
E�set ❑I.asowaerof Ne pmpeny,or or employees with wagesas.heirsolecompensmion, SWIMMING POOL.ELECTRIC ❑OTHER
IMPROVEMENT
will Bothework,and theswcturc is nm imm�drA nroRerod for sale(Sec.71 ,Business
1+y7 and Professions Code:9'be Carburetors License I.aw does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds he improves thereon,and who does such work himself or through
his own employees,pmvidod tin such improvements are not intended or affered far NEW RESIDENTIAL ELECTR SQ FT.
sale.IL however.the building or improvement is sold within one yearnfcompletion.ffic C FLOOR AREA USQ,FT.
moveolsolder will have to burden of proving met he did nm build or improve for Pur-
pose of sale.).
E]L,as owner of the Property,am exclusively contracting with licensed contractors to TOTAL:
construct the project(Sec.7014,Easiness end Prolessinns Cm.:)TW Convectors Li-
cerise Law does not apply to an owner odproKcry who builds or improves thercon,and QTY. PLUMBING PERMIT FEE L.1
wh a commets fir such projects with acontractor(s)licensed puauam us the Ctntractors 6
License Law. PERMIT ISSUANCE s,
❑1 am exempt under Sec. .B&P C for this remain
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby oRum under penalty of perjury one of the following declarations:
•� Iheve erM will maimein uCenihcme of ConsenumelGinsurt for Workers Compen- DRAINS-FLOOR,ROOF,AREA,GOND, STORIES TYPE CONSTRUCTION
section,as previded for by Section 3700 of the Labor Cad for the performance of the
work for which this permit is Word. FIXTURES-PER TRAP
❑I have and will maintain Workers Compensation Insurance,as required by Section '.
3700o1fthe Lob Cal,forthe perform: ce of to work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS MIN
My WorkeY C pe Minn I Sgrance amler and"ey x.07 9 7 p�
Carsier: 4C% Policy No.: GAS-liq.SYSTEM-OVEN 4IPA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR
fuLti DIVISION FEES
(This section need not W completed ifthe permit is forone hundreddollan(SI00) GREASETRAP
or lens.) P CHECK FfiF. I dvV
l certify chat in the Performance of,he work for which this permit is issued.!shall SEWER-SANITARY-SFORM EA.213 FT. sNB
not employ any person in say manner so ce m become subject to the Workers'Compere t l%
Z cation Lawsof Callfamia.Dace WATER HEATER WNENrVELECTN
0 Applicant t GRADING FIiE
'Z rj2 NOTICE TO APPLICANT:IL after making his Certificate of Fsxempoint.you should WATER SYSTEM/TRRATING
become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEB
Wforthwith comply with such provisions orchis pnmit,hull he deemed revoked. WATER SERVICE
Q
UO CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
Ne tptp
I hereby etTirm thin then isanstmnion lending agency for the performance of Uma
4s F the work for which this Permit is issued(Sec.3097,Co.C.) TOTAL:
O U Lenders Name L
Larder's Address
0. I certify that I have read this application and state thin the ehavoc Information is BUILDING FEL?
rA correct.l agree to comply wit all city and county ursinanms and state laws relating to QTY. MECHANICAL PERMIT' FEE
U building construction,and hereby radminixe mpresenmtors of this city In enter atropine SEISMIC FEE
move-metnioredd property for inspection purlmus. PERMIT ISSUANCE
(We)agree 1.sa ,indemnify and keep h Jr.the City of Cupertino against F.hECTRIC FEE
Iiabilittes,judgme e, stsan xpenuswhi y in any way accme against said City ALTER OR ADD TO MECH. PLUMBING FEE 0
in consryucnc grami al tis per
APPLICA RS .US AN COMPLY WITH AL1. N DINT AIR HANDLING UNIT(TO 10.000CFM)
SOU -ATI (� MECHANICAL PEE
b AIR HANDLING UNIT(OVER 10,003 CFM) CONSTRUCTION TAX
oat n ppl' Commctn Use EXHAUST HOOD(WNUCI} HOUSING MITIGATION FEE
HAZARIXYUS MATERIAO DISCLOSURE
Will the applicant orfunam Wilding circulator store or handle houudous material HEATING UNIT LTO 113,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Code,Section 25532(a)'I ��%�!!l! HEATING UNIT(OVER 100,1X3 BTU)
❑Yes )fNo PAID
1 VENTILATION PAN(SINGLE RESID) Data Rcec"a#
Will the applicant or full building weapons use equipment or devices which BOILER-COMP PHP OR 100,000 BTU)
emit haurdnas air contaminates as defined by the Bay Area Air Quality Management TOTAL: O
Tq
District? BOILER-COME(OVER 100,0001 TU)
❑Yes
IIs-mai and mamnals tents under Chapter 6.95 of the Cali- AIR CONDITIONER SSUANCE yDATE
fomite HeaIth Sections c SJ3 an, 5534.1 unJcrxmnd t m if the NEW RESIDENTIAL MIiCN. SQ.I'f. �'� ^ �,
built ngd' II a enc, a nsihility to noff+th capant
ofther, um s L fa Cc ,ter Oc
Ow raumoriuJ agent Date TOTAL' ISSUED BY: `J
OFFICE