30373 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPFPTINO BUILDING-ELECTRICAL. PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL,. O 7
BUILDING PROJECT'IDENTIFICA'T'ION 1
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATI
G 3 �aLl iiE g-23-9
OWNE 'S NA E: OM4 CO CfOR'S NAME: LIC NO:
I Gyf� / _ NIC CONTROLp
CH ITECT/ENGINF.ER: LICNO: A RESS /
V 2-4e7 l✓<� Gv� r
CONTACT PHONE: BUILDING PERMIT INFO
<,T 4'7.x. �f�6Q ❑ Consultant Ems Paid by Applicant(Initiaq BLDG EI.ECf PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION CJ V ❑ ❑ ❑
QTY. ELECTRIC PERMIT FEE
I ion? affirm Net 1 am licensed under provisions of Chapter 9(commencing AL, DESCRIPTION
�0002 with Section]n00)oc DivisinnJofthe Business and Professions Code,and my license is RESIDENTIAL:
0 PERMIT ISSUANCE
W full effect. ❑SFDWL ❑KITCHEN REMODEL
UZ License Class Conor.IT APPLIANCES-RESIDENTIAL ❑ADDITION . MBING RE-PIPE
<� Date T$DECr
ARCHITECT'S DECLARATION PANE" [I MULTI-UNIT ❑STRUCTURAL
(O.H Z I understand my plans shall he used ss public records MODIFICATION
p z r+ UP TO 700 AMPS
❑
Licensed Professional - _ INTERIOR ❑CHIMNEY REPAIR
OWNER-BUILDER DECLARATION 201.1"AMPS IMPROVEMENT
OVER I N)AMPS ❑BATH REMODEUREPAIR'❑DEMOLITION
yy �6 I hereby.(firm that 1 um exempt from the fessionslCo License Law far she
Do
G.0 whichfollowing reason(Sermon7onstruRumness and Professions thions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
YYII O which reyuires o permit to construct,cher,improve,demolish,or repair any structure
3 prior o its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
That he is licensed pursuant o the provisions M the Contractor's License law(Chapter 9
(commencing with Section7000)of Division 3 of the Best.and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
from
h LL that he is exempt thereend Ne basis for she alleged exemption.Any violation of (Lid [INEW BLDGIADDITION ElDEMOLITION
Ir• Section 7031.5 by any applicant for.permit objects the applicennou civil penuby of POWER DEVICES
t mom than Eve hundred doll.P$5001. ❑TENANT ❑FOOD SERVICE
�•a� ❑I.ss�wner of ate property,or my employees wroth wages us their solecompensation S 1 G I IMPROVEMENT
Sec will do the work,and The structure is not intended or offered for sale(Sec.7000,Business ❑OTHER
la and Professions Calc:The Cnmover is License Law does not apply to an owner of O - 1 CHES FIXTU Fs
S 3 property who builds or improves thereon,and who does such work himself or Iq
his own employees,provided that such improvements are not intended or offered for NEW R (DENTIA L SQ FT
'ole.IL however,the building or improvement is sold within one year ofermpletion,the SQ.FT.FLOOR AREA &SQ.FT.
r will have the burden affirming That he did not build or remove for pur-
°"`er-huilde°``al`.'.
1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL: AUG 31996
onswr the Fro est(Sec.7044,Business and Profcuions Code:)The Commnor'a Li-
cense Law does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE
whoommets forsuchpmjerswith acontoror(s)licensed pursuant tothe Commcmr's �s ,-t u0�d
License law.m PERMIT ISSUANCE
e�O V Y s+r
❑l aexempt undo Sec. .B&P C for this reason Ll
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Data
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the following declarations: .
I have and will maintain a Certificate of Consenro self-insure for Worker's Cooper- DRAINS-FLOOR,ROOF.AREA,GOND. STORIES TYPE CONSTRUCTION
cation,as provided for by Section 37W of the Labor Code,for the performance of the
work for which This permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Workers Compensation Imamate,as required by Section _
37M of The Labor Code.for the performance of the work for which this pemout is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Work n p s Ins)mote arrierand Policy numblraM r.3
Cartier. Policy No.: ( !�V GAS-EA.SYSTEM-OVER 4(FA)
CERTIFICA OFFAEMP IONFROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR
(This section need not hecampleted if the permit is krone hundred dollars 0IN) BUILDING OI VISION FRCS
or less.) GREASE'(RAP - PLANCHECK FEE
I certify That in The Performance of the work for which this permit is issued,i shall SEWER-SANITARY-STORM PA.200 FT
not employ any person in any manner sn as to became subject to the Wnrkcrs'Cmmpcn- ENERGY FEE
Z
scion laws of California.Date WATER HEATER WNENTMLECTR
Applicant GRADING FEE
rA NOTICE TO APPLICANT:If,after m.king this Certificate of Exemption,you should WATER SYSTPREATING
a become subject to The Workers Compensation provisions of the Lahr Code,you must SOILS FEE
W forthwith comply with such provisions or this permit shallbo deemed revoked. WATER SERVICE
d Q
CONSTRUCTION NEW RESIDENTIAL PLMB. SQ.Fr.
U O Date Receipto
I herchy aRrtn Nat them is w
consction lending agency for the perlormance of
r the work for which this permit is issued
ued(Sec.3091,Civ.C.)
011�.U Lenders Name TOTAL:
{k1 LcndcrAddrcu
I TOTAL:
testify that I have read this application and trete that the above inRtwation is BUILDING FEE
rn coned.l agree to comply with all city and county nedmanccs and site laws relating to QTY. MECHANICAL PERMIT FEE
U FEE
building construction,and hereby authorize representatives of Nis city o enter upon the SEISMIC construction,
above-mendomed property for inspection proNses. PERMIT ISSUANCE.
(We)agree to ave,indemnify and keep hamlets the City of Cupertino against ELECTRIC HE
lubilhies,judgmems,costs and expenses whmchmay in any way name aImidu said City ALTERORADDTOMECIL
In en of th - PLUMBING FEE
granting of Chic ewit.
;OURC
LICANT U STAN W LL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000CPM) MECHANICAL.FEE,
E 0 S.
C AIR HANDLING UNIT(OVER 10,00)CFMI CONSTRUCPIONTAX
!
nawr Appltcant/Cm for Uet EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE r
Wllthe applicamorfumre building accupatxtore orhunNelazalloux moerihi HEATING UNIT TIO 100,000 BTU)
as defined by the Cupcdim,Municipal Code,Chapter 9.12,.ml the Health and Safety
Code,Section Z5532(a)7 HEATING UNIT(OVER 100,000 BTU)
C]Yes ❑No - VENTILATION FAN(SINGLE RESLLI) PAID
Doe ReaiptX
Will the applicant or building by the nt Bay
Air enure evice.which
Management
BOILER-COMP LIHP OR IN,"BTU)it hazardous air contaminants as defined by the Bay Area Air Quality Management TOTAL:
utncC -
Yes ❑No BOILER-COM P(OVER 100,0X0 RITH V i
Q
I have read the hazardous materials mluiremcm4 under Chapter 6.95 of We Cali. AIR COND91ONER - ISSUANCE DATE
form.Health&Safety Codes Scrions 25505,25533 mrd 25534.1 understand That if the NEW RESIDENTIAL MF,CH. SQ.EU
building does not currently have a tenant.that it is my responsibility to notify The occupant
of Ne requiremenu which must be met prior to issuantt ofe Certificate of Occupancy.
Owner or authmdud agent Date SUEDBY:
OFFICE