30061 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT EN ONLY "
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 1
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL 3 O O V/y�� 1
BUILDING PROJECT IDENTIFICATION
BUILDINGADDR!VS: - SANITARY NO. APPLICATION SUBMITTAL DAN
l0 r Z.A- 4-✓Q 8 06— 7 tax �-,tg� ,
OWNE 'S AME: ✓✓ PHONE: CONTRACTOR'S ME: LIC NO:
r0 fit T7rJ0 £CLEC /7 . 637 NAC CONTROL#
ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
-2111 C .r/£ cl,) kuLf-
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG F.LP PLUMB MECH
❑ ❑ El
CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hen 70 affirm Net 1 am licensed under provisions of shaper 9(commencing JOE DESCRIPTION
a2 with Sectian]IXgprf Divi,Sinn Jot the lluninesn and F'ndessiom Cade,orad my license is RESIDENTIAL
0p full(Dice it if , PERMIT ISSUANCE. mss..
WU i Lice. i.ic.a-�-7 Y6 -� 6 ❑SFUWL [I KITCHEN REMODEL
"fid-ups Dep Commend APPLIANCES—RESIDENTIAL. C1 ADDITION ❑PLUMBING RF.-PIPE
py ARCHITECTS DECLARATIONPANE S ❑MULTI-UNIT El STRUCTURAL
F�
1,understand my plans shall be twed as PuM1lic records MODIFICATION
OZ-O UP TO 200 AMPS C1 INTERIOR ❑CHIMNEYREPAIR
=1� LicensedProfessional 301.10MAMPS IMPROVEMENT
k 3 oat lam exempt
D the Con9'ION OVER 10MAMPS �BATH REMODEUREPAIR [I DEMOLITION
y CG ti Q I hereby,(flee on 11. exempt Trans the fessions Code:
License Law for the
�!a 0 V following reason.(Section 703 1.3,Business bed Re,char Professions h.or Any city as county SIGNS ELECTRICAL ❑OTHER
LL1 LL O whim rats ire,a perms oo or conxwe6 peer,improve,h .its,or repair ed awment
hard he
osliensed pu sant to the
tmvlionicant for Cchpnmluofileae Law(chapt em SPECIAL CIRCUIT/MISC.
vWvW11>y. tem he is licensed pursnunuotha Emulsions of the Cnnvunnr'x License Law(Cbepmr9
21,
(commencing with Section 7000)of Division 3 of the Business and Profexsionx Code)it TEMP.METER OR POLE MST.
tY p, eC tem he is exempr themfmm and the basis for the sltegcJ exemption,Any violation m' ❑NE L /ADDRI ❑DEMOLITION
at 4y.
Section 1031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICI3 TENA El FOOD SERVICELLl T not mom had five hundred dollars(8501). IMP VEM
p ❑Laxowner of the pmpcny,(it my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC ❑
will do the work,and the structure is not intended or offered for sole(See.7044,Business
Ila and Professions Code:The Contractors License law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES /
property who builds or improves theram,and who does such work himself or through
his own employees,pmvided that such improvements om not intended or offered for NEW RESIDENTIAL ELECTR SQ FC
aide.If,however the building or improvement is sold within one year of completion,the SQ.FT,FLOOR AREA VSQ.FT.
ser-builderwill have the burden of proving that he did not build or impmve for pus B
❑ Lux owner of the SeeEeny,.min Business
convecting Cid licensed cammnom i- TOTAL: a
construct the es not (Sec.]nu,Rosiness mJ property
whbur Cadet The Contractors Li- JUL 1996
Li-
cause Law doeensuchplytaan with
offpropcns who licensed
Or mmurd to the barrComomvnd QTY. PLUMBING PERMIT FEE ��
who
mse Low.li#such pmjeetx with a eomracmr(s)Ilamxed pumuam to the Cumramnr's
Limnse Law. PERMIT ISSUANCE
0,l am exempt under gee. ,B&PCfonhis reason Gilt Ur 4#Urtn11N
Owner Dam ALTER—DRAIN&VENT—WATER HDO
VALUATION
WORKER'S COMPI NSAJ'ION DECLARATION BACK FLOW PROTECT.DEVICE
1 hertby affirm under penalty of perjurymm of the following declarations:
CO] lhaveandwillmaihtaina Cenificam of Consent to self-insure for Workers Compen- DRAINS—FLOOR,ROOF,AREA.COND. STORIES TYPE CONSTRUCTION
sedan.as provided for by Section 3]1M1.1 the Labor Coda,for the performance of Bra
k for which this Permit is named. FIXTURES—PER TRAP
1 have and will maintain Workers Compensation Insurance,as required by Section
RMl of the Labor Cade, the Performance of the work for which this Permit is issued. GAS—EA.SYSTEM-]INC.4 OUTLETS OCC.GROUP APN
My Workers Comps tion Insurance curler and Policy number are
Carrier It a'2=-^-� JIWFw JM,No.: "7—E?i 794 - GAS—EA.SYSTEM-OVER 4 EA)
CERTIFICATE.OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR
(This section need not be completed dime permit is torose hundred dollars pi Ha) BUILDING DIVISION FEES
or less) GREASE TRAP
PLANCHECK ME
I cenify that in the performance of the work for which tele permit is i>ecJ,Iehall SEWER—SANITARY—STORM EA.200 FT.
nm employ any parson i a any manner sn as m become subjm m Ne Worker'Compen- ENERGY FEE
Z Armon Laws of California Data
O Applicant WATER IIfiAT1iR WNENT/F.LECTR GRADING FEE
NOTICE TO APPLICANT.If.after making this Cenificam of Exemption,you should WATER SYSTEM/TREATING
tri become subject In the Worker's Compensation provisions of the Labor Calc,you must SOILS FEE
forthwith comply with such provisions or this Permit&hall be deemed revoked, WATER SERVICE
Q
D CONSTRUCTION LENDINGAGENCY NEW RESNEMIALI'LMB. SQ.FT. PAID
V Q hereby whicfimUhmthcrti Tmrd(Site 3 leading agency for the perfonnence of Data 'Raeiptp
F thewark for which thix permit is ixsucA(Sec.3MJ,Civ.Cr
Q U Lenders Name TOTAL: '
ps
Leader's A TOTAL:
ps mryd
I cenify that 1 hove read this upplicntion end.vom tem the ansae information is BUILDING FEE
riZi norrtcLlugrt<mcomply with all city and rnumy nNinances end nam laws relating to QTY, MECHANICAL PERMIT FEE
U 4 building comanution,unit hereby amhori,m representatives of this city to enter upon the SEISMIC FEE
shove-mentioned pmpeny for inspertam purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupenio n4gaimt ELECTRIC FEE
liabilitievjudgmcnm,costs som expenxeswhich may many way Occnte against said City ALTER OR ADD TO MITCH. PLUMBING PEE
in consequence of the granting of this Permit.
APPLICANT UNDERSTANDS AID WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT('rO to,"CFM)
' S R 'E REGULA'rLONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION*TAX
rWBSI rebfAppimanlContractor EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEB
HAZARDOUS MATERIALS DISCLOS P.
Will the applicant or future building occupant store or handle baaardous material I1EATING UNIT(TO 100,001 BTU)
as defined by the Cupertino Municipal Cade,Chap¢r 9.12,and the Health and Safety
Codc,Snation 255320u)'! HEATING UNIT(OVER 100,000 BTU)
❑Yes rANo VENTILATION BAN(SINGLE RESID) PAID
Will the applicant or Imore hu i:din g occupant use e i Uam Racipt M
FF 6 pun yu#meuality,agement BOILER—COMP QHP OR 100,000 BTU)
Emir hirallous dr cnnmminams as define)by due Bay Area Air Quality Management TOTAL: L'
Dirtrin9 7
❑Yee //{`9'1 IlO1LER—CDMP(GVER IIMI,IMMI BTU) ,
d have read Nc huamd`1us materials myuirenmms under Chapter 695 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma IRuth&Safety Cade,Sectio s 8505,23533 wd 25534.1 understand that if the NEW RESIDENTIAL.MECH. SQ.Fr.
'ng does not currently have o re am,tom it ie my responsibility to notify Ne Occupant
x of th on comments which must et to suunce of nm of cupmay.
r rauthOri aga m TOTAL: ISSUED BY:
OFFICE