30231APPLICANTTO FILL IN INFORMATIONWITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL PERMIT NO, 30231 O 2 ^ 1
BUILDING DIVISION APPLICATION/PERMIT ,"vUM64llou"n MECHANICAL -J� L 3
. s•rt CHANICAL rvaN
/065— ES604,94
CONTACT:
ADDRESS:
❑ Consultant Pees Paid by Applicant (Initial)
Iii] Licensed Profwsimed
2, •� OWNER -BUILDER DECLARATION
P0. 1 hereby affirm that 1 am exempt from the Convectors License Law for the
dU following reason. (Section 7031.5. Business and Professions Code: Any city or county
Owhich requires a permit to commuck alcor, improve, demolish, or repair any stmcture
......111 prior to it, isimmur,alwmcniflee the applicant farmch permit to filevsigned statement
or,
that he is licensed pursuant to the provisions ofthe Contractor's License Law (Chapter 9
�p (commencing with Section 7") of Division 3 rfthe Buslaessand Professions Craft) or
rop� that he is exempt therefrom and the basis for the alleged exemption. Any violation of
an Section 7031.5 by any applimin for a furnat subjects the applicant to a civil penalty of
FSCZ not more than five hundred dollars (5500).
❑Las owner of the p.perty, or is employees with wages as .lei(See 044. Business Y
will do fee work, and the rte mrc wunnot i tendedskins Us,
net
apply 1. an, owner
of
y and Rofeshob Code: The was cancer,
License Law chine nm apply to if owner h
proerty, who builds or improves thereon, end who does such work himself or through
his own employees. e provide) that such improvements thin not intended of m offered for
owner
-,however,thebuildingor len of Wale. is sold within one yearn improve
the
owner -builder will have the burden of proving that he did not build or improve far pur-
pose of sale.),
/ ❑I.asowowerofthe Sm. 70c an .Bexclusively contracting with licensedThe
Ccommors to
renswp the project (Sec. ]Ban, Business and property
who
Code:) The es Contractors Li-
cenu Law does not apply to an owner of property who builds .improve thereon, ons QTY.
who . Law. for such pmjtta with a commuted a) licensed porsuam to the Contmanr's
Licenu Law.
C Iam,.Wt under Sec. .B&PCfonhis mown
SIGNS ELECTRICAL
SPECIAL' CIRCUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES - FIXTURES
NEW RESIDENTIAL ELECTS SQ FT.
1 hereby affirm under penalty of perjury one of Ne following deciarauons:
❑
water,
as and wie for by Seen..
37W of the L or Code, sure for eof.. re of ib -
workf rprovided forma Section 3]00 of the labor Cede, for the perfomance of the
work far which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Imvmne, as his required by Section
My ofthe Labor Code. per NeumsecPerformance r the work for which this permit is issued.
My Workers Compensation Insurance carritt and Policy number are:
Carrier: Polity FROM
CERTIFICATE OF COMPENSATION
NPROM WORKERS'
COMPENSATION INSURANCE
(This u<tionnced not be compleud ifthe permit is for one hundred dollars (SIM)
or less.)
1 certify Nat in the performance oldie work for which this permit is issued, I shall
not employ, any person in any manner w as to become subject to the Workers' Compen-
O z sation laws of California. Date
Z Applicant
r fA NOTICE TO APPLICANT: If. after making this Certificate of Exemption, you should
become subject o the Workers Compensation previsions of the Labor Code, you must'
tiforthwith comply with such previsions or this Permit shall be domed revoked.
Q
CONST LENDING AGENCY
U O (hereby off Nisacom
at there isconswaion lending agency (Doha performance of
!]. Fthe work for which this permit is issued {Sea 3097, Civ. C)
O Lender's Name
Lamers Address
C I certify that I have read this application and state that the above information is
N correct.) agree to comply with all city and county ordinances and state laws relating to QTY.
U z building construction, and herehy outhodon tepixuneoves of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of CLpenino ZZ
liabilities, judgment,, costs and expenses which may in any way acerae against mid City
in coraequence of Ne groaning of this pewit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
Sigetureof ApplicanVCommctor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the epplicunt or future building occupant nom or handle haurdous maetial
as defined by the Cupertino Municipal Code, Chapter 9.12, and the health and Safety
Code, Section 2553260?
❑Yes C] No
Will the applicant or future building oceupam use equipment or devices which
'emit haxaidous air comamirmnts as defined by the Bay Arca Air Quality Management
District?
❑Yes ❑No
I have read the houNous materials rcqu'uetents under Chapter 6.95 of Ne Cali-
fornia Health & Safety Code, Sectors 25505, 25533 and 25534.1 uMmand! that if the
building does now conically have a tenant, that it is my responsibility to notify the occupant
of the moulnmenns which must be met pier no issue.x of a Certificate of Occupancy.
Owner m i n lumm l age. Date
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER -DRAIN & VENT- WATER (EA
BACK FLOW PROTECT, DEVICE
DRAINS- FLOOR, ROOF, AREA, GOND.
FIXTURES - PER TRAP
GAS -EA. SYSTEM -I INC. n OUTLETS
GAS -EA. SYSTEM-OVER4 GEA)
GREASFANDUSTRL WASTE INTERCEPTOR
GREASETRAP
SEWER - SANITARY- STORM EA, 200 FT.
WATER HEATER W/VENT/ELECTR
WATER SYSTEMRREATING
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ. FT.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADDTO MECH.
AIR HANDLING UNIT ITO 10.000 CFM)
AIR HANDLING UNIT (OVER I0,00) CFM)
EXHAUST HOOD (WIDUC )
HEATING UNIT OYI 100,000 BTU)
HEATING UNIT (OVER 100,0110 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER -COMP (3HP OR 100,000 BTU)
BOILER - COME (OVER 100,000 BTU)
AIR CONDITIONER '
NEW RESIDENTIAL MECH. SQ. FT.
OFFICE
Ct
LLCBNMAI LONI KAL I UK NOLULAKAIIUN
QTY. ELECTRIC PERMIT
I hereby affirm that I an licensed under provisions of Chapter 9 (commencing
BLDG IELECT PLUMB MECH
❑❑ El
eE�
th Sedirn ]0007 of Division3ofthe Business and Professions Cale. and my license is
FEE
W 000
PERMIT ISSUANCE
in full force unit effect.
•`
=fW,)V
License Class Lic.p
APPLIANCGS- RESIDENTIAL
1+1
Date Contractor
GZ
�7y
ARCHITECTS DECLARATION
PANELS
)Z
I rnderstnnd my plans shall be used es puhlic records
=
UPT0200AMPS
Iii] Licensed Profwsimed
2, •� OWNER -BUILDER DECLARATION
P0. 1 hereby affirm that 1 am exempt from the Convectors License Law for the
dU following reason. (Section 7031.5. Business and Professions Code: Any city or county
Owhich requires a permit to commuck alcor, improve, demolish, or repair any stmcture
......111 prior to it, isimmur,alwmcniflee the applicant farmch permit to filevsigned statement
or,
that he is licensed pursuant to the provisions ofthe Contractor's License Law (Chapter 9
�p (commencing with Section 7") of Division 3 rfthe Buslaessand Professions Craft) or
rop� that he is exempt therefrom and the basis for the alleged exemption. Any violation of
an Section 7031.5 by any applimin for a furnat subjects the applicant to a civil penalty of
FSCZ not more than five hundred dollars (5500).
❑Las owner of the p.perty, or is employees with wages as .lei(See 044. Business Y
will do fee work, and the rte mrc wunnot i tendedskins Us,
net
apply 1. an, owner
of
y and Rofeshob Code: The was cancer,
License Law chine nm apply to if owner h
proerty, who builds or improves thereon, end who does such work himself or through
his own employees. e provide) that such improvements thin not intended of m offered for
owner
-,however,thebuildingor len of Wale. is sold within one yearn improve
the
owner -builder will have the burden of proving that he did not build or improve far pur-
pose of sale.),
/ ❑I.asowowerofthe Sm. 70c an .Bexclusively contracting with licensedThe
Ccommors to
renswp the project (Sec. ]Ban, Business and property
who
Code:) The es Contractors Li-
cenu Law does not apply to an owner of property who builds .improve thereon, ons QTY.
who . Law. for such pmjtta with a commuted a) licensed porsuam to the Contmanr's
Licenu Law.
C Iam,.Wt under Sec. .B&PCfonhis mown
SIGNS ELECTRICAL
SPECIAL' CIRCUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES - FIXTURES
NEW RESIDENTIAL ELECTS SQ FT.
1 hereby affirm under penalty of perjury one of Ne following deciarauons:
❑
water,
as and wie for by Seen..
37W of the L or Code, sure for eof.. re of ib -
workf rprovided forma Section 3]00 of the labor Cede, for the perfomance of the
work far which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Imvmne, as his required by Section
My ofthe Labor Code. per NeumsecPerformance r the work for which this permit is issued.
My Workers Compensation Insurance carritt and Policy number are:
Carrier: Polity FROM
CERTIFICATE OF COMPENSATION
NPROM WORKERS'
COMPENSATION INSURANCE
(This u<tionnced not be compleud ifthe permit is for one hundred dollars (SIM)
or less.)
1 certify Nat in the performance oldie work for which this permit is issued, I shall
not employ, any person in any manner w as to become subject to the Workers' Compen-
O z sation laws of California. Date
Z Applicant
r fA NOTICE TO APPLICANT: If. after making this Certificate of Exemption, you should
become subject o the Workers Compensation previsions of the Labor Code, you must'
tiforthwith comply with such previsions or this Permit shall be domed revoked.
Q
CONST LENDING AGENCY
U O (hereby off Nisacom
at there isconswaion lending agency (Doha performance of
!]. Fthe work for which this permit is issued {Sea 3097, Civ. C)
O Lender's Name
Lamers Address
C I certify that I have read this application and state that the above information is
N correct.) agree to comply with all city and county ordinances and state laws relating to QTY.
U z building construction, and herehy outhodon tepixuneoves of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of CLpenino ZZ
liabilities, judgment,, costs and expenses which may in any way acerae against mid City
in coraequence of Ne groaning of this pewit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
Sigetureof ApplicanVCommctor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the epplicunt or future building occupant nom or handle haurdous maetial
as defined by the Cupertino Municipal Code, Chapter 9.12, and the health and Safety
Code, Section 2553260?
❑Yes C] No
Will the applicant or future building oceupam use equipment or devices which
'emit haxaidous air comamirmnts as defined by the Bay Arca Air Quality Management
District?
❑Yes ❑No
I have read the houNous materials rcqu'uetents under Chapter 6.95 of Ne Cali-
fornia Health & Safety Code, Sectors 25505, 25533 and 25534.1 uMmand! that if the
building does now conically have a tenant, that it is my responsibility to notify the occupant
of the moulnmenns which must be met pier no issue.x of a Certificate of Occupancy.
Owner m i n lumm l age. Date
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER -DRAIN & VENT- WATER (EA
BACK FLOW PROTECT, DEVICE
DRAINS- FLOOR, ROOF, AREA, GOND.
FIXTURES - PER TRAP
GAS -EA. SYSTEM -I INC. n OUTLETS
GAS -EA. SYSTEM-OVER4 GEA)
GREASFANDUSTRL WASTE INTERCEPTOR
GREASETRAP
SEWER - SANITARY- STORM EA, 200 FT.
WATER HEATER W/VENT/ELECTR
WATER SYSTEMRREATING
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ. FT.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADDTO MECH.
AIR HANDLING UNIT ITO 10.000 CFM)
AIR HANDLING UNIT (OVER I0,00) CFM)
EXHAUST HOOD (WIDUC )
HEATING UNIT OYI 100,000 BTU)
HEATING UNIT (OVER 100,0110 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER -COMP (3HP OR 100,000 BTU)
BOILER - COME (OVER 100,000 BTU)
AIR CONDITIONER '
NEW RESIDENTIAL MECH. SQ. FT.
OFFICE
Ct
.SQ.. a..
JUL 191996
r
�MF t
y(v Uut-crtluvu
BUILDING DIVISION FEES
PLANCIIECK FEE
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
Dom Nectop'M
TOTAL:
BUILDING FEE
FEE SEISMICFEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTIONTAX
HOUSING MITIGATION FEE
PAID
Date Receipt#
DATE
BUILDING PERMIT INFO
BLDG IELECT PLUMB MECH
❑❑ El
eE�
FEE
JOB DESCRIPTION
RESIDENTIAL
C SFDWL C KITCHEN REMODEL
❑ADDITION El PLUMBING RE -PIPE
❑MULTI -UNIT [ISTRUCTURAL
MODIFICATION
❑INTERIOR C] CHIMNEY REPAIR
IMPROVEMENT "
C OATH REMODEUREPAIR D DEMOLITION
C OTHER/ 0-5
COMMERCIAL:
CNEWBLDOADDITION [I DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
C OTHER
.SQ.. a..
JUL 191996
r
�MF t
y(v Uut-crtluvu
BUILDING DIVISION FEES
PLANCIIECK FEE
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
Dom Nectop'M
TOTAL:
BUILDING FEE
FEE SEISMICFEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTIONTAX
HOUSING MITIGATION FEE
PAID
Date Receipt#
DATE