31007 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMII'NO, 1� OO7
1
BUILDING DIVISION APPLICATIONMERMIT PLUMBING-MECHANICAL 3
BUILDING PROIF.C1'IDENTIFICATION
BUILDING ADDRESS: J SANITARY NO. APPLICATION^S�URMITTAL DATE
$3 1 �h La/A e_v 1'v�J �-2
OWNtin'S NAME: PHONE: CON]RACTOR'S NAME: LIC NO:
r11 11,k1 -O NIC CONTROL%
dRCHITECP/ENG[ .1L jj LIC NO ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELE PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE F] El1 hereby affirm Nal 1 am license]under provisions of Chapter 9(commencing QTY
DESCRIPTION
OOZ with Section Division Business and Professions Cole,and my license is
F C in fall forecind effect. PERMIT ISSUANCE RESIDENTIAL'
yWH ❑SFDWI. CHEN REMODEL
6F Vy U Dole Clara ].is
ydii Dote Can DELL APPLIANCES-RESIDENTIAL []ADDITION '.UMBING RGPIPE
E.,ON ARCH]'1'LCI"g DECLARATION PANELS ❑MULTI-UNIT STRUCTURAL
Z p H Z 1 understand my plans shall rte used as public records MODIFICATION
ONFW UPTO 200AMPS El INTERIOR CI CHIMNEY REPAIR
F W L¢cnml Pmfesvonal
OWNER-BUILDER DECLARATION 301-I000AMP5 IMPROVEMENT
-y d'W Q I hereby affirm thin I am caving,from the Commnor's License Low forum OVER IOW AMPS ❑BATH REMODEDREPAIR ❑DEMOLITION
X a U following reason Igection]031.5.Business and Professions COJe:Any city or county
3 SIGNS ELECTRICAL ❑OTHER
Eli LL O y 1M1ich requires permit re conswn,aper,improve,demolish,or repair any swmurc
1 hat
itssliissuance,endpro requires the
ovisio so for mchperminoicensle ae signed(Chmment SPECIAL CIRCUIT/MISE.
dS ,hal osenciialiv Sectiomto n
Sof Comran.. nd PIne Luw(Chap¢v9
W..�O (enmmencing with Section]INNp nl Divininn3of the Business and Professions CoJe)or I EMP METER OR POLE INST. COMMERCIAL,
q m ff
(Nal he is exempt therefrom and the basis for the alleged exemption.Any violation of El DEMOLITION
W tectio n]031.5 by any applicant for a permit subjects the applicant m a cpenaty oPOWER DEVICES
ivil lf [:I NEW BLDG/ADDITION
F z n, t more than five hundred dollars(550X0).son
❑TENANT ElFOOD SERVICE
IS 1,a owner of the propeny,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
W1: will dorhe walk,andtneswnurc is net intended or offered for sale(Set.701 Business ❑OTHER
W m and Professions Cade:The Contractor's License law w aw
does no,apply n oneET
r of S-SWITCHES-FIXTURES
property,who builds or improves,hereon,amt who does such work himself or through
his own employees,provided that such improvements arc not intended or offered forE IAL ELECTR SQ FT.
sale.If.however for building to impravcmcan is tele wanton ane year of completion the SQ.FT.FLOOR AREA SJSQ.FT
ovorter-builder will have the burden of proving that he did not build or improve for par-
Ialseofsule.). IS[-1 p
A
❑ Las owner of the progeny,nm exclusively imcenaa,with licensed aontmmors m
construct the pmjem(Sec.70,14,Business and Professions Code:)The Contractor's Li- "E
sense law doesnot apply m un owner or property who builds or Improves themes.and QTY. INGPERMIT FEE 2Ey/ �C�
who contracts for such projects with a contracter(s)licensed pursuant to the Contractor's
License Law, PERMIT ISSUANCE
❑1 am exempt under Sec. ,B or P C for his reason - if Y Uf Loll-,
..
ALTIiR-DRAIN&VENT-WATEH(EAI
�)• herr Date L
)RATION
KER'SCOMPENSATI ECLARATION BACK FLOW PROTECT DEVICE w Iherebya under penalty of pclury one of the following declardions: r
❑ I hivumd will maimaina Cenllicmenf Cn twmi .elf-insarefnr Worker's Compen- DRAINS-FLOOR.ROOF.AREA,COND.
falian,as gavoided for by SoaLm 3700 o1h Labor Cold,far the pr loonnuncc of the STORIES TYPE CONSTRUCTION
work lin which this Permit is iswad Iq FIXTURES-PER TRAP
0 1 have and will maintain Worker's Compensation Insurance,as required by Secure
3710 ofthe Labor Cook,for the performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.-GROUP APN
My Worker's Compensation Insurance carrier and Policy number am:
Carrier: Policy Ne.: GAS-FA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR
or IcssJ
(' GREASE TRAP
Phis section need not be completed if the Permit is for one hundred dollars(SI W) BUILDING DIVISION FEES
I'LANCHECK FEE
Icenify thatin the gerformunccof,he work for which,htopee Wois rker.,.Counter-
Counter- SEWER-SANITARY-.
no,employ any person in any manner.at as n2 pjet to he Wnrkcn'Cnmpcn- STORM P.A.200 lap. ENERGY FEE
,z smionlowsofCalifs Disc ' `jd'T
z O Applinun WA'1'IiH IIEATER W/VENT/ELGCTR
z y GRADING FEE
NOTICE 1'O APPLIC P.If,after narking,his ertihcam of Exmnptinn,yon shout] WATER SYSTEMTREATING
a ; ismome subject to the rk vision,of the Labor Gyle,you must SOILS FEE
forthwith comply with such provisioru e deemeresident,or this permit shall he k
IA Q WATER SERVICE
q
7z CONSTRUCTIONetion tNGAGENCY NEW RESIDENTIAL PCMB. SQ.FT. PAID
1:_3 Ifor by which
that iso rd(See 0nlendis, agency for perfnnvnre of Dam Receipt or
[T. F tee work Tarr which this pcnnit is izmcd(sec.JW],civ.C.)
U Leaders Name tT)T'AL:
Ell landelI Address T TA
q 1 verify tate I htvc read Itis apglicminn and Hatt thin,he uMrvc information is
F BUILDING FEE
h bonen.I agree to comely hanhem all coyand aomty ordinances and same laws reaming m QTY. MECHANICAL PERMIT Egg
V nuilAingennamctiorpert fenny xuttionprposes.nm,ivec ofthincitymcutterupon the SEISMIC FEE
unnvcme e).9 1.1.1c for inspection[keener.
(We)agree to save,indemnify and keep harmless the City of Cu nits i City PERMIT'ISSUANCE.
pe B ELECTRIC FEE
in
of the cans and expenses mit. may in any way accmc against said City ALTER OR ADD TO MECH.
inconsequence of the gaming of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILT.COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000CF,M)
SOURCE REGULATIONS. 1 MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM)
�� 1 CONSTRUCTION TAX
Signature of Apprcan nonmetal D1 EXHAUST HOOD IWMUCq
H RDOUS MA'1 EHIALS DI. OSURC HOUSING MITIGATION FEG
Willlheupplicu or fuhlrc moldingcecupamstc or handle hu,norm,mneslal HEATING UNI'I(TO IW,000 BTU)
as]alined by the Capetian Municipal Code,Chapter 9.12,anJ the Heullh and Safety
Cole,Section 255J2(a)1 HP.A'I'INC,UNIT(OVER 100.E BTU)
.. ❑Yes ❑Nn
VENTILATION FAN(SINGLE RESID) PAID
W II Nc applicant or fuwre building«cupan,use equipmcm or devices which Date Receipt N
mi,hazardous air ememor manB a defincvl by,he Bay Arca Air Quality Management BOILER-COMP OHP OR 100.(10X1 BTU)
District?
❑Yes E]No BOILER-COMP(OVER 100.000 BTU) TOTAL:
I have Head the hazardous reasons rcyuimmentx under Clearer 695 ofthe Cali- AIR CONDITIONER
Pomiu Health do Su[ery Cole,genions 25505,25533 and 2,55]4.1 undersand thin if the ISSUANCE:IJATE
holdingdd,nm currently have amnan6thm it is my resgnnsihility tonality Nctxeugan, NEW RESIDENTIAL MECH. SQ.FT.
err the requirements which must rte me,prior m issuance of a Ccnifcme at Occupancy,
Owner or authnnurl agent
Date TOTAL:
ISSUED BY
OFFICE
n
i
9
I �
h �ro
cC'1
i
� 3
00
7
m
5 FE6 �,� 1991 I
' 0110NDEpAR�M�Nj __
I
B1.D0.1C�OF ONpER11N0
I