30919 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF 3091 091I CUPERTINO BUILDING-ELECTRICAL PERMIT NO. ^ .a
6UILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. UVJ
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTTAAL.DATE
�2D l
OeogNE: _/? NTRAC7Yj 1.js'Ap7EO /�
1 a4,,7 Cts 61 NIC CUM RO n
WFARCHITECT/ENGINEER: LICNO. ADDRESS: C' ❑ T
CONTACT. w „ PHONE: BUILDING PERMIT INFO
N� 7 9-(0 3 EDConsultant Fees Paid by Applicant(Initial) BLDG ELECT. PLUMB MECH
JGI-N1] 1:1 ❑
LICENSED CONTRACfOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�Q=Z with Section]BW)ofO,mrn 3ofthe easiness and rn u' nsC e,a ylfeenu is RESIDENTIAL
CO in full force nil efftt (y/y PERMIT ISSUANCE
,ZH LO ❑SFDWL ❑KITCHEN
F<Ut,,) I.iccns Lic.M
NQ Dom Convenrn APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING R&PIPE
(..Dur, C rrECTB DECLARATION PANELS C1MULTI-UNIT C1 STRUCTURAL
Z p 2L' 1 undernwd my plain shall be used ss public rtcords MODIFICATION
OZ , UPTD200AMPS ❑INTERIOR C1 CHIMNEY REPAIR
5Licensed Pmorssiunal 201-I000AMP5 - IMPROVEMENT
OWNER-BUILDER DECLARATION OVER Food AMPS ❑BATH REMOD UREPAIR ❑DEMOLITION
o w Q I hereby arfvmand
m cnt 1 aexempt from the Conlncmrs License Law'for the
O y U following reason.(Section 7031.5,Business and Professions Code:Any city or county CIOTHER
3 V.�j which t to construct,alter,int rove,demolish,or minor an amour, SIGNS ELECfRICAI.
�w.QJ rtquitea a Permit p ppm y s
prior to its issuance. h.mi,aireadhe applicant basset,permit to file a signed statement SPECIAL CIRCUIT/MISC,
y that he is licensed purmantto the provisions of the Contractors License Law(Chapter 9
GAO (commencing with Section700did-Division 3ofthe Basineesand Professlon6Ca1C)or TRMB METER OR POLE INST. COMMERCI
asM C that he is exempt therefrom and the basis for the alleged exemption.Any violation of El NEW BLDG/ADDITION ❑DEMOLITION
Y' Section 9031.5 by any applicant fora permit subjectatheopplicant to.civil penaltyof POWER DEVICES ❑TENANT ❑FOOD SERVICE
'3a. not more Nan five hundred dollars($500). IMPROVEMENT
❑Las owner ofil,property.or my employees with wages as their wale compensation, SWIMMING POOL ELECTRIC
will do the work,and the svodare is not intended m offered radial,(Sec.7BU,Business ❑OTHER
L 3 and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTUR
,property who hands or improves Hereon,unit who does such work himself in through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTRJId SQ FT
sale.If,however,the building or improvement is sold within one yearofcompletion,the E/SQ.FT.
cowner-builder will have the burden of pmving that he did not build or improve for put-
Trueofsale.). OTA .
❑1.as owner of the pmp,ny,.m exclusively cantmeting with licensed conferences to
SEP 2 4 1997
consumes
the Proleet(Sec.7094,Business and Professions Code:?The Connector,Li-
ccenu Law does not apply to an owner of pmparty who builds or improves therrem.and QW.. PLUMBING PERM FEE "
who connects(orsuch projects wiH a cuntmem(s)licensed pursuant to the Convenors
License law,
E]I um exempt under-Ser. ,B&PCfmthixreasnPERMIT ISSUANCEn _ BY:
Owner Data ALTER-DRAIN&VENT-WATER(CA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby aflimm under Penalty of pedury one of the fallowing declamtio m:
❑I have and will maintain a Certificate of Consent toself-insure for Worker's Compete DRAINS-FLOOR,ROOK AREA,GOND.
sation,as provided for by Section 3707 of the Labor Code,for the performance of the STORIES TVPE CONSTRUCTION
work fm which this permit is issued. ' FIXTURES-PER TRAP
n I have and will maintain Worker's Compensation Insurance,as required by Section
3700afthe labor Code,for performance offl,work int which this permit is issued. GAS-L SA.SYSTEM-1 INC,4 OUTLETS OCC.GROUP APN
C ym orgpty ani Itsuran5e 5xrieP lily N'�acy um
GAS-EA.SYSTEM-OVER 4EA)
CERTIFICATEOP
COMPENSATION
NPROM WORKS
COMPENSSATION INSURANCE. GRLASFn NDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION WAS
(This section deed not he completed ifthe permit is for one hundred dollars PS l W) GRITSHTRAP.
m less.) PLANCHECK PEE
I certify that in the performance ofthe work forwhichihis permit isissuuLlshall SEWER-SANITARY-STORM FA.200 Fr.
n
non employ any pcon in any runner so as to became subject to the Workers'Compeer. ENERGY FEE
Z e.d.Lmwsof Califomia.Date z WATER HEATER W/VENT/ELF.CI'R Q Applicant GRADING FEE
tq NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/TREATING
atibecome subjectto the Workers Compensation provisions of the Labor Code,you must SOILS FEE
forthwith comply with such provisions or this permit shall be deemed invoked. WATER SERVICE
2 CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID y
V 2 l hereby affirm that hem is a construction lending agency for the perfomunce of Data Receipt#i
ry (,
T.work for which this permit is issued(Sec.ANI,Ci,C.)
O lenders Name AL:
WLender's Address TOTAL:
I cenify in.I have real this ep,li.ali.a and nate That above information is - BUILDING FEE
t�/3 comet.l agree to comply with all city and county audiences and state laws relating to QTY MECHANICAL PERMIT FEE
U z building consumed.,and hereby umhorive repmsematives of this ah,u.etnerupon the SEISMIC FEE
r above-mrntioned property for inspection pmpivies. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEB
Whilmeajudgmems,cmtsand expenses which may fnany wayaccme against said City ALTER OR ADD TO MECH. -
in consequence of the gmnling of lois emit. PLUMBING FEE
APPLI A UNDERSTANDS AN WILL .OMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
S 'GULATIONS. MECHANICAL FEE
aAIR HANDLING UNIT(OVER 10,010 CFM) CONSTRUCI'IONTAX
SnatumafAppliandCnnsurfor I Data EXHAUST HOOD OYMUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle lurardous tnmefial HEATING UNIT(TO 100,0100 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Stiction 25532(a)? ABATING UNIT(OVER 100."BTU)
❑Yes ❑Nn
• VENTILATION PAN(SINGLE RFSID) PAID rl
.WillHe applicanture or futbuilding occupant use thimpmenr or devices which I Date Reccipt 0
emit haaurdetaism,mmournmamsasdefined by the Bay Area Air Quality Management HOILER-COMP(3HPOR IYTTTIOBTU) TOTAL: 0
District?
E]Yes 7 N BOILER-COMP(OVER 100,000 BTU)
I have read the hadardous armarelsrequirements under Chapter 6.95 of use Cali- AIRCONDITIONER ISSUANCE DATE
forma Health is Safety Cada.Sections Z505,25533 and 25536.1 understand that if the NEW RESIDENTIAL MECH. SQ.'FT. (\ _/1 / �/
huioling reqdoes not currently have a tenant.that it is my responsibility m notify the occupant 1% 2 C f� /
of the requirements which must be met prior it)issuance of n Certificatepw
of Occocy.
OwnerorauNoracti.gari Ilse TOTAL: SSIJED BY:
OFFICE