3052 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO,
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 3� 5Z
DING PROJP,CI'ID
BUILDING ADDRESSBUILENTIFICATION
: SANITARY NO. R97
AT
2,1 7S6 loo//1 swr7 OW 'S NAME: YO 2, N C RACTOR'S NAM LICNsP U7� N/C O
RCHI I ECTMNGINEER: LIC NO: A.VKLSS:sr ❑ _
tfbllf,�,;�.mud
PHONE:
/ BUILDING PERMIT INFO
Z Z7-Z7 0 El Consultant Fees Paid by Applicant(Initial) BDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION V ❑ ❑ ❑
b affirm that I am licensed under provisions of Chapter9(commcoemg QTY ELECTRIC PERMIT FEE
CI ]Wp)o(Divisioblof the Businext gaJ Profloesiona Codc,and myliane is JOB DESCRIPTION
FWP t. // PERMIT ISSUANCE RESIDENTIAL:
�QZQe Ll # (4 ❑SFDWLhQy Curb.for APPLIANCES-RESIDENTIAL O PLUMBINREMODEI
H. . ARCHITECTS DECLA ON ❑ADDITION []PLUMBING PIPE
oz22Z Iunderstandmyplanshallbeused aspublicrtento, PANELS OMULT6UNIT []STRUCTURAL
UPTO NCAMPS MODIFICATION
F. I"IcIks� LsenseJ 1'mleseinnul INTERIOR 11 CHIMNEY REPAIR
Sy ,'4j OWNER�BUILDER DECLARATION 201-10D)AMPS IMPROVEMENT
pQQQ I hereby affirm that 1 em exempt from the Contractor's License Law for the OVER 10010AMPS 11RAM REMODEUREPAIR D DEMOLITION
F fallowing reason(Section 7031.5.Business and Professionx Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
I. C y¢ whicpoorh requites o permitxuare'did to construct,alter,improve,demolish,or repair atmy sweture
CmJ that buhBlaissaudIncoeadaresmosrhe applicant for such pc.it to file.signedsmtoment SPECIAL CIRCUIT/hIISC.
GF thatM is licensed pursuantmthe provisiovsoftbe Cmfldi License Cars,(Chapter 9
Iy�pp (commencing with Section]000)of Division 3 of Ne Business and Professions Code), TEMP.METER OR POLE INST COMM R fA
a q o y that he is exempt therefrom and Ne basis for the alleRN exemption.Any violation of
W m try, Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑NEW BLDG/ADDITION El DEMOLITION
F_ZT' not more than five hundred dollars($500), ❑TENANT ❑FOOD SERVICE
pI,as owner of tM1e property,or my empinyeea with wage as their xole compo ration. SWIMMING POOL ELECTRIC ROVEMENT
y^o will do the work,and the sweture is not intended orufundl'orxele(Sea]044,Business OTHER
Gaand Profcssionx Code The Convenors License Law docs not apply m an owner of OUTLETS-SWITCHES-FIR'TURES
property who mi Ids or improves thereon,and who dues mch work himself or through
his own employcm,provided that such improvements me our intended or offend fur NEW RESIDENTIAL ELECfR SQ FT.
sale.IL hoover will have the
burden
of prmcm is at he did n one ye or improve
fon the SQ.F`C FLOOR AREA ygQ.Pp
owderb alld)r will have the burden of proving that he did not buil)or impmve for pun
puu of sale.).
0 h as owner of the lumped,sm exclusively contracting with licensed contractors to TOTAL:
construct the pmjat(Sec.]044,Business and Profession Cade)The Comment's Li-
m - EP
clone law does napply to an owner of property who bulls or improves thereon,and QTY, PLUMBING PERMIT FEE 9 /996
whoaontmcts for such pmjeets with a rontractor(s)licensed punmnt to Ne Contractor's
License Law.
O l am exempt under Sec. ,B&P C for Nis reason PERMIT ISSUANCE j' � „ L•UI-,,,r(1 ,J
Owner Date ACrER DRAIN&VENT—WATER(EA) VALUA3'ION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty ofperjury one of the following declarations: SU U,
O l hmemd will maimaln a Certificate cf C-miml o xelfimxma for Worker's Comped- DRAINS-FLOOR,RODE AREA.COND.
sation,as provided for by Section 37W om
f the Labor Code,for the performance mom STORIES TYPE CONSTRUCTIOC
work for which this perdt is issued. FIXTURES-PER TRAP
0 1 have and will maintain Worker's Compensation Insurance,as required by Section
37M of the labor Craft,for the performance of the work for which this permit is issue. GAS-EA.SYSTEM-I INC.4 OUTLET'S
My Workp' CmpenylA�ttc.rtier and Policy nq��e�Ar� OCC.GROUP APN
Cartier. -H Policy Nu: 1x+"1�'}(eO GAS-EA.SYSTEM-OVER4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE.INTERCEPTOR
(This section need not be,completed Hum permit is forms hundred dollars($100) BUILDING DIVISION FEES
mless.) . GREASETRAP
1 certify that in the performance oldie work Pill which this PLANCI IECK FEE
the Workers sues6l sh 111
soli mLms no,personin any mannerm este hensmc suhjoct to the s'Comped- SEWER—SANITARY—STORM CIA.200 IT
p ',� 'Appli Laws of California.Dam ENERGY FL'C
z� Applicant WATER HEATER W/VENT/ELECI'R
W NOTICE TO APPLICANT:If,after making this Cenifmcale of Exemption,you should GRADING FEE
become 4ubi m the Worker's Com sation WATER SYSTEM?REATING
pen ersdau ions of We Labor Cade,you must SOILS FEE
LTJ foMwilh comply with such provisions or this permit shall he deemed revoke. WATER SERVICE '
4 Ca
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
L)0 1 lac',affirm that there is a construction loth",agency forthe perfomunm of ).m Receipt#
U. F' the work for which this permit is issued(Sec.3097,Civ.C.)
0 U lenders Name
Undoes Address TAL:
Hy I certify that i have read this application and state that he above information is TOTAL BUILDING
W correct.l agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT
building construction,and hereby authorize reprscntudles of this city to enter upon the FEE SL'ISMICf;E
above-dxntioned properly for inspection purposes PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City f Cupertino against ELECTRIC E
Rabilitieajudgment ostsandexpenseswhichmayina way c eegainrsaid City ALTER OR ADD TO MECH.
in ruination of g.d.g of Nis permit. PLUMBING FE
APPLICAN U ERSTANDS AND W C PLY IT ALL NO'POI T AIR HANDLING UNIT('TO U),IXp CPM)
SOURCER G .ATIONS. MECHANICAL
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TA
Signet is uUm, Dat EXHAUSTHOOD(WMUCT)
HA DEUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
�Willthea lican r form building occupant score or handle hazardous material HEATING UNIT(TO 100,tNp BTU)
e defined Cu no Municipal Cale,Chapter 9.12,and the Health add Safety
Code.Section 25532(x)? HEATING UNIT(OVER 100,000 BTU)
GYes ONo
-
VENTILATIONFAN(SINGLERCSIU) PAID
1 Will the applicant or future building occupant use equipment or devices which Dam Receipt p
District?
r Nounfous air conmmimax es defined by the Bay Area Air Quality Management BOILER-COMP(THP OR 100.000 BTU)
O Yes C]N. BOILER-COMP(OVER 100,000 BTU) TOTAL:
1 have hand the Indications materiels dopm its under Chapter 695 of she Cali. AIR CONDITIONER -
funds Health&Safety Code,Section 8505.25533 and 25534.I undersmnd dust if the ISSUANCE DATE
building xsnotcurrendybaveataunt,0utitismymspoosibilicyto=ify Nooccupadt NEW RESIDENTIAL MECH.
of the memarms which must be met primm iannceon Cenowam oftMupancy.
O rauthmied agent Dme TOTAL:
ISSUED BY:
OFFICE