31511 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY"OF COPE RTINO BUILDING•ELECTRICALPER1vll'T'N
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 1 .31511
BUILDING,PROJELT IDENTIFICATION
WILDING ADDRESS: - SANITARY NO. 7AEPL11'CA�T1N S UBMITT'AL DATE
Gaza Na
Ole- r L�� r�tb'
WNPp6 NAME: PHONE: C R'SN ME: O;tLI O: SIC CONTROhp
ARCHJTECT/ENGINEER: LIC NO: DRESS: x -
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT' PLUMB MECH
-LICENSEDCONTRACTOR DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby amrnt mal I am bnen.ed soda Pr is ons of chapter 9(commencing - TOB DESCRIPTION
�Z wim gceuon)(gp)of Divisinn3 of the Dusinesaand Ifessions Cede,and my license is
in full tome andeffect. PERMIT ISSUANCE RESIDENTIAL
❑SFDWL 1:1 KITCHEN REMODEL.
Dat
�U
License Class ' ' Lick APPLIANCES-RESIDENTIAL FF Date Convector - ❑ADDITION ❑PLUMBING Rli-PIPE
T',=tyy ARCHITECTS DECLARATION PANELS ❑MULTLUNF ❑STRUCTURAL.
Z O J� I undersuutd my founded]be used as public records
Oz qqqGsy UPT02MAMPS MODII'ICATION
E� Q Licenael Pmfcasinnal El INTERIOR ❑CHIMNEY REPAIR
OWNER- 201-1000AMPS IMPROVEMENT
BUILDER DECLARATION \c.,�w�ycmnty
OVL'R]"AMPS
y i hereby affirm that I am cm
from the Contractor's Licer the BATH REMODEVREPAIR ❑DEMOLITION
54 a 0.0 following reason.(Section]031.3,Business and Professions Code:A , unty SIGNS ELECTRICAL ❑OTHER
Owhich rcqui.a permitm convect,epee improve,demolish,or repmrcprior to its issuance.also requires the applicant for such Permiuo fileant SPECIAL CIRCUIT/MISC.
pnmot he is licensed pursuant to the provisums of the Conaucmr'a LicensteWYx (commencing with Section 7")ofDivision3 oftle Nosiness and Proe)or TEMP.METHROR POLE INST. COMMERCIAL
0.q m e' that he is exempt mm ertfmand me basis for the alleged exemption.Any violation of EW BLDG/ADDITION ElDEMOLITION
J� W Section 7031.5 by any applicant for a permit the applicant to a civil penalty of POWER DEVICES T ANT El FOOD SERVICE
F z} not more than five hundred dollars($LID).
6 Q hos ownerof the progeny,or my enployecs with wages an their sole compcnsution, WIMMING POOL OLF.CTRIC PROVEMENT
3$
will Jmhe work,and theswcture isnot internotimceffered for sale(SecJtvl.liusinees ❑OTHER
and Professions Code:The Cmemeam,License law does not apply to an owner of O LETS-SWITCHES-PI E
.. property who builds or improves thercon,and who does such work himself or through
his own employees,provided that such improvements are not intended c r offered for NF.W IDI NTIAL ELECTR Q FT.
We.If,however,the building or improvement is sold within one yearofcompletion,the Q.Ff.FL RARF.� D $/SQ.ET
ownerhuilder will have the burden of proving that he did not build or improve for pur- N�
Pau of sale,, -
❑I,as owner of Ne property,am exclusively contracting with licensed contractors to TOTAL: NO 26
- convect the project(Sec.](44,Business and Professions CndcJ The Comntemr's 1.1- 996
muse Law does not apply to an owner ofpropeny who builds or improves thereon,and QTY PL BING PERMIT ���
U
who commas for such projects wim a contmctur(s)licensed pursuanuo the Contractors /
License Law. r
PERMIT ISSUANCE LVrC A
❑I um exempt under Sec. ,B&PCforthismason • Nrllyv
Owner - UamRM1 2:ffyRfI@fflk WATER IEA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT D- ICE
Ihereby affirm under penalty ofperpry one ofthe following declarations: -tn,tintle ton
. ae pI(] I have and will muinmin a Cenifcate of Consent mself-imure for Worker's Compels UG DkkA ,A 'OIND.—,..
STORIES TYPE CONSTRUCTION
mut
sation,as provided for by Section 32M of the Labor Code,for the perfomance of n r
work for which this peis issued A
❑I have and will maintain Worker's Compensation Insumnc'm man and by Start --e�
3lMofthe labor Cade,for the Performance onhe work for which this"radnisissuet?' SD
My Workers Compensation Insurance caniatud Policy number-1. =15! st��xskky� a� OCC.GROUP APN
/ Carrier: Policy No.: A IS I=S'AI. ) '
CERTIFICATE OF EXEMPTION FROM WORKERS' akxke�k I�Aax&}n�
COMPENSATION INSURANCE . Ca 111 1� .MTERCEPfO
' MeTf
(This section need no completed ifthe dt is for one hundred dollars r BUILDING DIVISION FEES
or less.) ot hpemminy PLANCHECK FEE
"Toy mythat in the anymrnanceof the become subject
to the Wori.kers
rd.Ca ped SEWER , N4W FAp21
not employ any person in any manntt m at to become xubjccnn the Workers Compact' ENERGY FEE
O z Applicant
o(Cali(omia.Omc QAl - Ali ellel%Awdswiligi
z Applicant - ADING FEE -
,-, NOTICE TO APPLICANT.If,aper making this Cenifcate of Exemption,you should WATER SYSTEM? ATIN
F , become subject to the Workers Compensation provisions of the labor Code,you OILS FEE
forthwith comply with such provisions or this permit shall be deemed revokeds16121
z . - CONSTRUCTION LENDING AGENCY NE - M"Mr ,p AID
UO l hereby affirm that there is a construction lending agency for the Penn n o k Date Receipt If
{I4 r the work for which this Permit is issued(Sec.3097,Civ.C.)
Q U Lenders Name TOTAL'.
Lenders Address TOTAL:
y I certify,that 1 have read this application and state that the above information is B IMING FEE _
h correct.1 agreo to comply wim ell city and county oNinunees and stem Iowa relwing m QTY, MECHANICAL PERMIT FEE
U Z buildingconstruction,and hereby mumizerepresemativesofthis city b carterupon the SETS ICFM
above-mentioned progeny for inspection purposes. PERMIT ISSUANCE(We)agree m sive,indemnily and keep harmless the City of Cupertino against - ELECT C ITE
Iiebilities.juug ms.essrs end expenses which maymeny way accrue ugainsl veld City ALTER OR AUU TO MECH.
inconscqucnce fthe granting of this pcmtit. PLUMBIN FEE
APPLICANT NDERST S ANI WILL COMPLY 'ITH•ALL NON-POINT AIR HANDLING UNIT(TO 10,"CFM)
e159
5 URCER JULATIO' MECHANICA FEE '
,I^ AIR HANDLING UNIT(OVER 10,17CO CFM) CONSTRUCTIO TAX
Signawm of ApplicanVCommcmr Date EXHAUST HOOD(W/DUCT) HOUSING MITIGA ON FEB
HAZARDOUS MATERI S DISCLOSURE
Will theappliesm or future bulldingswcupantstereor handle hazardous material HEATING UNIT(TO 100,000 B'N)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)Y HEATING UNIT(OVER I00,000 BTIL
❑Yea ON.
' VENTILATION PAN SINGLE RESID) PAID
Will the applicant of future building occupmn use equipment nr devices which Date eeipt k
. emit hazai air contaminants as definedh the Be Area Air BOILER-COMP QHP OR Ifff"BTU
DistrictT y y Quelity'Manegemem )
TOTAL:
❑Yea ON. :. � - � BOILER-COME(OV P.R IW,q)O BTU)
I have read the buaNeas materialsAIR CONDITIONER ISSUANCE DATE
requirements under Chapter 6.95 of the Calm
twain Health&Safety Cod,Sections 2-5505.25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT. '
buildingdtes set currently have a tenant,that it is my responsibility W notify the oecupam
of the requirements which must be met prior to issuance ofa Certificate of Occupancy.
Owner or authorized agent Date .TOTAL: ISSUED BY:
OFFICE
Inspection Query for a Specfic Permit 4/7/97
),
r
Alli : �$ $S o UESG T ns -11 10201 DE ANZA FRAME 11/27/96 11/27/96CC 2 P
11 10201 DE ANZA ELEC 11/27/96 11/27/96 CC2P11 10201 DE ANZA SCREW 12/4/96 12/4/96 JB 3 P
_ Pa01
L •