S 1692APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF. CUPERTINO BUILDING - ELECTRICAL I'I?1j\�QIT NO
MN
BUILDING DIVISION APPLICKPION/PERMIT PLUBIG-MECHANICAL. \J 1692
CONTACT:
1 hereby union that I um licensed under pmvisiuns of Chapter 9 (commencing
with Seedim7(Xp)of Division 3efthe Business and Professions Gxi, umdmy license is
in full force and ec . C�
4 VZ U Licenx lacy Lic. g
F Q sal !jute Corona,
1 ANCHIT[CTS DECLARATION
b.z l understand my plans shall he used as public records
(: F W; Licensed 14dcssmad
Ca Q +OWNER-RUILDER DECLARATION
Q 1 hereby affirm that I am exempt from the Contmcas v License Law for the
LV following reason. (Section 7031.5, Business and Professions Codc Any city m county
0. O y which requires a permit m, mmswct, alter, improve, demolish, it repair any s..am
prior m its issuance. also requires the applicant for such perming rile a signed statement
Q�Shia he is licensed purau.n m the pmvUlons of the Contractor's Licensw
e Lu(Chapter9
�C (commencing with Section 7000) of Division 3of Ore Businessand Professions Code)or
y oy Ihm he is exempt therefrom and She basis for She alleged exemption. Any violation of
NSection 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
nos mom Nam livehundred doll., ($500)
SG❑ 1, as owner of She property, or my employees with wages as their tole couipanwitio i.
will JO She work, and the smrcmm is not intended or offered for sale (Sec. mW, Business
3 hod Professions Cole: The Contractors License Law does not apply uo an owner of
property who builds or improves Iherenn, and who does such work himmlf or through
his sewn employees, provided that ouch improvements arc not intended or offered for
sale. If, however. Ne building or improvement is sold withinunc ye.of eompledmi, the
owner -builder will have the Walen of proving that he did not build or improve for pur-
pose of sale).
❑ L. as owner or the property, am exclasively contracting with licensee) conneemns it,
mstram the projwt (Sec. 9044. Business and Professions Code:) The Contracher's Li.
cenna, law docs not apply to an owner of property who builds or improves thereon, and
who contmuns for such projects with a mntmmons) licensed pursuant o She Connector's
I.icc a Law.
C 1 um exempt under Sec. ,l4& P C for this reason
• Owner ITDs:
WORKER'S CGMNSA'fION DECLARATION N
m
1 hereby affirunder penalty of perjury one of the fNlowing declaration
_- ❑ I hsxand will rourmmria Cenificamof Cusum mself-mam,fmWolom'sCamper.
sation, as provided for by Section 3900 of the Ialxsr Code, for the performance of the
work for which this permit is issued,
W1 here and will mvinmin Worker's Compensation Insurance, as required by Second
3900 of the Inbar Cole, prattle perlimmxnce of She work for which this permit is issued.
My Werke'n,VgYun Insula ce denier and Policy pumbw= �f
Cameo YSEA Policy Nr.W'e1-( 1 I l
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
("is section need nun be completed (the permit is boron, hundred dollars ($1(X))
less)
deaity Ihmin Ilmliefforan any... cost oastworkfor whivh Ods per ms Is Issued,I,Noll
trot employ any person in any mm�ner w as to Mcnme subject to the WorkersContpen-
Z .Anon Laws ofCalifornia. Date
7 O Applicant
G NOTICE, TO APPLICANT If, anter making this Ceniim sal of Exemption, you should
rFNy 'N" become ,comp ms the Workers Compensation provisions of the ded Coxae, you durst
-Y�forthwith comply with such provisions gr this permit shall he Jcemed revoked.
CONSTRUCTION LENDING AGENCY
0 1 hereby ufnrmrhot lhme is s ennmucdmt 1,ho ng agency Scribe
pconnumace sal
Us the work for which his
permit os issued (Sec. 3097, Cie C)
ADDRESS:
�'�5Lb VkvVhg L,e,,, LIN. s-
❑ Consultant Fees Paid by Applicant (Initial)
QTY ELECTRIC PERMIT FEE
PERMIT ISSUANCE
APPLIANCES — RESIDENTIAL
PANELS
UP TO 200AMPS
201-1000AMPS
OVER IDWAMPS
SIGNS ELECT RICA].
u
BUILDING PERMIT INFO
ELECT PLUMB MECI
❑ ❑ ❑
JOB DESCRIPTION
RESIDENTIAL,
O SFDWL
C KITCHEN REMODEL.
❑ADDITION
❑PLUMBING RE -PIPE
❑MULTI -UNIT
❑STRUCTURAL
MODIFICATION
C INTERIOR
❑ CHIMNEY REPAIR
IMPROVEMENT
E3 SWIMMING POOLS
C BATH REMODF.IIREPAIR C DEMOLITION
El OTHER
SPECIAL CIRCUIT/MISC.
TEMP. MET FEE OR POI.li INST. COMMERCIAL
O NEW BLDG/ADDITION C DEMOLU'ION
MOWER DEVICES OTENANT CFOOD SERVICE
SWIMMING I'(HlL HL11C'IRIC IMPROVEMENT
❑ OTHER
OUD.ETS — S W ITCHES — FI:
NEWRESIDEN'FIAL ELECfR S 'f.
SQ. lel'. FLOUR AREA $ISQ. FT.
I QTY. PLUMBING PERMIT I FEE
Lender's Address
d Iceniry Nut l have read thisapplication and slate shun the above Information ix
nF. h conal. l agree to comply with all city and county ordinances and state laws relating,, QTY
Li building construction, and hereby amhome mpresentatives of this city in enter ups the
above-mentioned property for inspection purposes.
(Wc) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue tight ust said City
in consequence of the Imaging of his prooda.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POEM'
SOURCE REGULATIONS.
Signature im ApplicanVCoSnmelor Data
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant m furore building mvphnl score or handle hamrduos mmerial
as defined by She Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Cade, Section 25532(.)'
Cl Yes 0 N
Will the applicant or future building occupant use equipment or devices which
emit Weardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑Yes C1 No
I have read She haz.dous materials "moment, under Clause, 6V5 of Ne Cali-
fornia Health & Safety Cade, Sections 25505, 25533 and 25534. 1 understand Nat if the
building does not currcmly have a tenant, that it is my responsibility to unity the occupant
at She requirements which must Nt mer prior to issuance of u Certificate of Occupancy.
PERMIT ISSUANCE
ALTER — DRAIN & VENT— WATER (PA)
HACK FLOW PROTECT. DEVICE
DRAINS — FLOOR, ROOF AREA, CONS).
FIXTURES — PER TRAP
GAS — EA. SYSTEM -I INC.4 OUTLETS
GAS —EA. SYSTEM -OVER 4 (EA)
GREASUINDUSTRI. WASTE INTERCEPTOR
CREASE TRAP
SEWER — SANITARY — STORM EA. 21X)1.7'.
WATER HEATER WNHNI'/ELEC R
WATER SYST'EM/1'REAT[NG
WATER SERVICE
NEW RESIDENTIAL PLMB, SQ. LT.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECI(.
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING UNIT (OVER 10.000 CPM)
EXHAUST HOOD(W/DUCT)
HEATING UNIT (T) 1011,(X0 BTU(
GRATING UNIT (OVER 100,000 BTU)
VUM ILA'1'ION PAN (SINGLE RES][))
BOILER — COMP (31411 OR IMAX) O'N)
BOILER — COUP (OVER 100,000HTU)
AIR CONDITIONER
NEW RESIDERTLAL MECH. SQ. FT.
,3/ Do P
BUILDING DIVISION FEES
PLANCHECK FEE
HNERGY PEE
GRADING FEE
SOILS 171:17.
Date Receipt#
TOTAL:
BUILDING PEE
FEE SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE AlCH I r
LZI
MECHANICA 7./f'
CONSTRUCTION TAX ns�
HOUSING MITIGATIM P
V
PAID
Date Receipt M
TOTAL:
ISSUANCE DATE
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DATE: - 5/17/98
SCAIE
JOB NO.
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OF 3 SHEETS
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