30469 nn APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
r CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 30
46 w^y
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MI?CUANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMITTAL DA
10996 '�So)( . 2('
OWNER'SNAM-aE�: PHONE: CO RACTOR'. ME: T - LIC NO:
INy\ G S -` ��j.�- `,(�� /I 1(�� NIC CONTROL#
RCHITCCr/ENGINEER: LIC NO. AD RI�S� � �-`� v \�� �, ❑
CONTACT: PHONE: U+ BUILDING PERMIT INFO
k ❑ Consultant Fees Paid by Applicant(Initial) RLDG ELECT' MUMS MUCH
Zi'''t IT)X6 ❑ 'b-e ❑ ❑
LICENSED CONTRACTOR S DECLARAI]ON QTY ELECTRIC PERMIT FEE
1 hereby affirm Nmnt u
I acen.ad ander prawkions or Chaim,9(commencing JOB DESCRIPTION.
HOZwith section]IXro)u[Division3arnc�Nosiness and Professions Cale.and,.,llecrtsc is RESIDENTIAL:
I-W 2 in full force and eRat. PERMIT ISSUANCE:
C E C ❑SFDWL ❑KITCHEN REMODEL
Q U U Li't ac lass Lia.N
inQL Date Cnntre�m. GCSt�. APPLIANCES-RESIUIiNT1AL ❑ADDITION ❑PLUMBING RE-PIPE
ern ARCHITPANELSECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
F
Z p y Z I understand my plans shall he used as public records MODIFICATION
O Z— UP TO 21x1 AMPS
F C W Licensed Professional ❑INTERIOR ❑CHIMNEY REPAIR
Qy� '4 201-I
OWNER-BUILDER DECLARATION f1a1AMP5 IMPROVEMENT
r C Q I hereby affirm that 1 am exempt from the Contractors License Law for the OVER UW AMPS ❑BATH REMODEIIREPAIR ❑DEMOLITION
x 3 L FU fallowing runsao.1Senion]8315.Bovines,and Professions Gale:Any city no story SIGNS ELBCfRICAL ❑OTHER
LLl LL y which requires a permit to construct,alar,improve,demolish,or repair any nmeture
Og prior to its issuance,also requires the applicant for such Temti to file a signed statement SPECIAL CIRCUII'/MISC.
S y u
that he is licensed Pursuant the provisions of the Cononcerts License Law(Chapter 9
LL�00 (co'nrnencing with Section 7")of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMf•_RCIAi
LL d cC
X
Thai he is exempt iteration and the basis for the alleged exeimi
on.Any nfima of ❑NEW BLDG/ADDITION
^LL Section 9031.5 6 any applicant for a permit sub'ms the applicant to o civil ❑DEMOLITION
y) y Y J penalty of POWI3R DEVICPS
FZr not more Than five hundred dollars($500). ❑TENANT ❑FOOD SERVICE
TSG Ol,asownnofthcprnpcny.ormyemployen with wagesnsncairsolccnmpcnstoon. SWIMMING POOLELECfRIC IMPROVEMENT
an
p, willdothe work,atWthe.gmctureisnot intended or offered forsite(See.Jal4,Business - ❑OTHER
L3 m and Prolcs.ions Code:the Contractors License Law docs not apply m an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who docs such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR S FT
sale.IL howeventhe buildingur improvement is sold within one year ofmmpletion.the SQ.FE FLOOR AREA 5/SQ.ET.
,'-builder will base the burden of proving that he did not build or improve for pur- d
pre
❑1,m r of the property,am exclusively commeons wird licensed contmaors m
matma thees not(Sec.o an Business and ny%ho nm Code:)The Contractors nd Q -AUG2 n 1996
.costctxenaapply roan ithaofpropens wcense builds
ursunpnrves thereon,andTY. PLUMBING PERMIT PI(Ju a
whocontractsaw.for sato pmjecu wirdarommcmrt.)licenced pursuant in Ne Commcmrs
License law. PERMIT ISSUANCE
❑lam exempt under Sen. B&PChx this reason
Owner Data ALTER-DRAIN&VENT-W'ATERW VALUATION
WORKER'S COM PENSATION DECLARATION RACK FLOW PROTECT.DEVICE
1 hereby affirm under penally of perjury one of The following declarations:
,]l have and will maintain a Campeau,of Consent to self-insure for Worker's Compen- DRAINS-FLOOR,ROOF AREA,COND.
suunn,as provided for by Section 3700 of Ne Labor Came,for fileperformmce of the STORIES TYPE.CONSTRUCTIO
work for which thk perpon is issued, FIXTURES-PER TRAP
I have and will maintain Worker's Compensation Insurance,as required by Nation
3900 ofthe lnbnr Cale,for performance ofthe work for which this perndt is issued. GAS-EA.SYSTEM-1 INC.S OUTLETS OCG GROUP APN
My Worker's Compensation Insurance carrier and Policy number arc:
Carie': Policy No.: GAS-G.SYSTEM-OVER J(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRGSUINDUSfRL WASTE INTERCEPTOR
(This seenon need not he enmpletal tithe permit is forms,hundred dollars(SI W) BUILDING DIVISION FEES
or less.) GREASETRAP
PGNCHECK FEL
icertify chat in N,any
on Iworkforwhichthisper Waker,ued,lshall
notemployany Person in any mann t ro hecomes Je oath,WnrkecC Com SEWER-SANITARY-STORM EA.2a)F1'.
yy �_ 9u1r c pen. ENERGY FF.0
,0 sm;onlnws of Gry'lomia.Date 77 4a
O Applicant -atl�'�+C -N WATER HEATER W/VENT/ELECTR
Z 'r GRADING FEE
.5
NOTICE
subject
APPLICANT.The Worker's
IL after Compensate this Cerins of Th E Labor
inn,you u mull WATER SYSTEMRREATING
a M1easmn subject to it Worker's Com..or
on permit
hol of The Who'Code,you must SOILS FEE
� foMwiN comply with such provisions onhis permit shall he JeemcJ revoked. WATER SERVICE
ca
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.ET PAID
L)Q I hereby affirms that Ncre is a construction lending agency for the performance of Data Receipt#
CL f'-r tom work far which his permit is noural Sce.3099,Ci,C.)
Lenders Name
Lenders Address TOTAL TOTAL:
ky I seri fy that 1 have'rad his applicaion and state that the above information is IMECHANICAL
F.E
h correct.I agree to comply whh all city and county ordinances and state laws relating nes QTY. MECHANICAL PERMIT FEE
U Z building cmnswcdon,and hereby authorize representative.of Nis city to enter upon the
abrvc-mcmim ed property for inspe,ion purposes, PERMIT ISSUANCE
(We)agree to save indemnify and keep hamnkss the City of Cupertino against EE
Iisbilities,jmgmeme coo,mul expense.which may iarmy way aceims,prolvaid City ALT ER OR ADD'TO MECH.
in consequcnce mf the gmming of Nis pc.I" EE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'T(TO 10.(x)8 CFM)
SO RCF-REGULATIONS. FEE
AIR HANDLING UNIT(OVER Z10,000 CPM)� CONSTRUCTION TAX
Srgnawm of ApplteaHAZARDO Data IiXHAUS'T HOOD IW/DUCT)
HAZARDOUS fultuUS MATERIALS ,lone DISCLOSURE HOUSING MITIGATION PER
Willy(be Crisman
sur fmurei,.l act Chapter 9nnr handle Health and
HEATING UNIT(TO IW.aMI BTU)
os defined by the Cupertino Municipal Cods.Chapter 9.12,and the Hcalrh and Safety '
Calc,Nation 25532(a)9 HEATING UNIT(OVER 1 W,a)(I BTU)
❑Ym nNo
VENTILATION FAN(SINGLE RESIDE PAID
Will the applicant(it antra Funding occupant use equipment or devices eData Receipt p
mit hazardous air contaminancontaminantsnmmcontaminantsas definer by the Bay Area Air Quality Management BOILER-COMP CHP OR 100,01(p BTU)
Disoict9 TOTAL:
❑Yes (D No BOILER-COMP(OVER 100,0(xI BTU)
I have mad the hamrdous nationalsrcquirencra,under Chapter 6.05 mute Cali- AIR CONDITIONER
forma Heald&Safety Code.Sections 25505.25533 and 25534.1 undersand Na if the ISSUANCE DA
building docs nor currently have a tenant.that it is my responsibility to notify Nerreupaat NEW RESIDBNTIALMECH. SQ.ET.
of fle requirements which mold be met prior m issuance of a Centrale of U,.F,ncy.
Owner nr aurM1nrrred agnu Da¢ TOTAL:
:ISSUE:DBY.
OFFICE