S 0341 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO II131L=11..ELECTKICAI. PERMIT NO.
APPLICATIONMERMIT DING PROJECT IDENTIFIC S 0341
BUILDING DIVISION - BUILDING PROJECTIDENTIF'tCAT10N
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER' NAM PHONE: CO OR'SNA C 0:
') NX CONTROL#
ON
CHI L13C1'/ENGINEER: LIC NO: ADORES. qlg:
L ❑
CONTACT PHONE: k 17
,J1•• BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG > PLUMB MECH
❑ ❑
LICPNSED CONTRACT'OR'S DECLARATION QTY ELECTRIC PERMIT FEE JOH DESCRIPTION
I hereby afna rho 1 am licensed under provisions of Chapter 9(commencing
C'MZ RFSIUFP_TIAL'
PERMI
TISSUANCE
CIs, a full forecast e0bct lo$Z9L6 ❑SFDWL ❑KITCHEN REMODELaULEEL�f License Cl sn Lic.a APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
{.7•W Dale— Contm�T� ��fXl6�
rn G6 ❑MULTI-UNIT ❑STRUCTURAL
F]y ARCHITECT'S DECLARATION PANELS MODIFICATION
I understand my plans shall W used as public records
0z n UP TO 200 AMPS :1 INTERIOR ❑CHIMNEY REPAIR
I-.l2 Licensed Professional - 201-1000AMPS IMPROVEMENT ❑SWIMMING POOLS
J OWNER-BUILDER DECLARATION OVER I(NIIIAMPS ❑BATH REMODEUREPAIR DEMOLITION
W 6 I hereby affirm thus I am exempt from the Contractors License Law far the
Xci6U following paxam.(Section 7031.5,Business had Professions Code:Any city or county SIGNS ELF.CTRICAI. ❑OTHER
r'7 3 6 which requites a permit la cmoloor,,almq improve.demolish,up repair any xtmaure
,�0 prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIDMISC.
ay thmheixlicensdpursuvnuothepr.visio of heComuctnYsLiccnulnw(Chap¢r9
COMMERCIAL,
CC
(commencing with Section 7000)of Division 3 ofthe Business and Professions Col)or
T
EMP. POLF.INST.
6 6 �' that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
�m
Section 70315 by any applieam for a permit subjects the applicant to a civil penalty of ❑TENANT ❑FOOD SERVICE
^ na more than five hundred dollars($50H. IMPROVEMENT
EaC ❑I,as owner of the property,or myemployeea with wages us lbe]r sole compensation, ELECTRIC ❑OTHER
will do the work,and the structure is not intended oroRered for sale(See.90,1.4,Business
d3
and professions Cade:The Contractor's License Law does not spiffy to an owner of CHES-FIXTURES
property who builds or improves thereon,and who dies such work himself or through
his awn employees,provided that such improvementa are not intended m offered for AL ELECTR FT.
sale.IL however,the building.,improvemcnl is said willionne yearm"manpletion.the SQ.FT Fl.00R AREA EISQ.FT.
owner builder will have the buten of proving Ihot he did nm(wild or improve for put- PAID
To
of salad. p
Mal,as owner of the pmpeny,am exclusively contracting with licensed cooracnas m
construct the projat(Sec.9044.Business and Professions Calc:)The Gmtracmr's Li- �I Q�
cense Low does not apply m an ownerofproperty who builds or improves thereon,and QTY PLAN
IT '*EE VVV` /gyp PeD
whocommets for such projects with accountants)licensed pursuant m the Conm ons's IIC(�
License Law. PERMIT ISSUUj-
❑1 am exempt under Sec. .B&P C for this reason
ALTER-DRA (EA) 41�AIIJIN
Owner Date
WORKER'S COMPENSATION DECLARATION BACK PLOW �
1 Starchy uRrm under penalty of perjury one of the fallowing decimal imv.
I haveand will harmaina Cetfi-le ofCa...I m self-insure for Workers Cmai DRAINS-FLOND. $TORICONSTRUCTION
cation,hs provided far by Section 3900 of the Inbor Cade,for the performace of the
work for which this permit is issued. FIXTURES-PER TRAP1 have and will maintain WmUcr's Compensation Insurance,as required by Section3900ofthe Lbs,Code,far the fame prows orihc work for whichthis permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLU ICC.GROAPNMy Worker's Compensation Insurance comer and Policy number are:
Comer: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OP EXEMPTION FROM WORKERS' GREASOINDUSTRI.WASTE INTERCEPTORCOMPENSATION INSURANCE I
(This section need not he completed ifthe Repair is forone hmndreddollars(S 100) GRP.ASETRAP
PLA TP.
or less.) -
I certify that in the performance of M1e work for which this Perrot is issued,I shall SEWER-SANITARY-STORM EA.200 PT,
notemplay any�' an in any cohost, gLm nu)ecfl.the Workto 'appen- E F.
,7. which Laws
lifrrou.Dau sa gL �-� ��7 WATER HEALER WNENTMLECTR
�j0 0 ARpliwnlMALTERORADDTOMECH.
G IN FE
q y NOTICE TO�'PI.ICANT.If,after nwking this CeniOcate of Exemption,you should WATERTIiM/1'RLATING SOILS IFE
{'t been.subject m the Workers Compenmtion provisions of the Inbar Cade,you must
Qforthwith comply with such provisions m this permit shot]In,deemed revoked. VICE (y
CONSTRUCTION LENDING AGENCY ENTIALPLMB. SQ.FT. PAID Dae Receipt#
U z I bcrebyaffirm that the.iso conamcfion lendingogucy for the performance of
U the work for which this permit is issued(Sec.3099,Co.C.) TOTAL:
U.U.V Under's Name _
Lenders Address TOTAL.
Cis 1 certify that I have read this application and state that Ne above information isBUILDI G FEE
W correct.l agree m comply with all city and county ordinances and sure laws reading toECHANICAL PERMIT FEE SEISMI FEE a_
U Z building construction,and hereby,a iloriu representatives of this city a enter uqm the
above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep hamleva the City of Cupertino againstSUANCE ELECT' IC PEE
liabilities,judgments,casts and expemes which may in any way accaw againstsaid CityADDTOMECH. PLUM NG FEin colaequare.of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.POINTLING UNT F 0010.0(10 CFM) MECH [CAL PF.F.
S IRCEREGULATIONS.-
'1., AIR HANDLING UNIT(OVER IR"CFM) CONSTR 'ION TA
naureo'ApplicanVConvamm Date EXHAUST FOOD(WIDUCf) HOUSINGMTOGATION
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future buildingwcupant store or handle),.it....material HEATING UNIT(TO 1(10.000 BTU)
as defined by the Cu aphow Municipal Crdc,Chapter 9.12,mudthe Health and Safe[, HEATING UNIT LOVER I(p.(gU BTU)
Cada,Section 25532(u)?
O Yes ON. VENTILATION PAN(SINGLE RESID) PAID Dam Receipt
Will the applicant or future building occupant use equipment or devices which BOILER-COMP CHP OR 100,000 BTU)
emil humorous air conuminceno as defined by the Bay Area Air Quality Management 7
Dixtdct? BOILER-COMP(OVER 100.000 BTU)
0 Yes 0 Na
IW.read the beaudme,maerri requiremeosunder,Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
humin Health&Safely Cade,Sections 25505,25533 and 25534.1 undersmal that if the NEW RESIDENTIAL MECH, SQ.FT.
bvilJingdas no cunzntly hhvea¢nvnt that it is my responsibility to notify the occupant
of the requiremenu which must be met prior to ixmalse of a Ccnificme of Occupancy.
Owner or amhomed agent
Date TOTAI.o ISSUED By.
OFFICE
RESIDENTIAL PROJECT COVER SHEET
nY ar
' Cupertino
Assessors Parcel Number: .— (o.2, 2,G
Name of owner. K/, pAii I
Project address. SSG [ 7b (and f Yv Ao-(.P
Contact person. 3>alt�r` Phone.
Fax.
Net square footage of lot.
Fxistine Propose
Square footage: First floor: ` 7_O (ox Ln Fro r�fi�o rc �+ 12DSp FT
Second floor: OO
Garage:
Are there at least two 10 foot by 20 foot clear}yspaces inside the garage? Y N
On what floor(s) is work being done? I ��
Brief description of work.
Code editions: 1994 UBC (Y-N)1994 UFC (Y -N)1994 UIVIC (Y-N)
1994 UPC (Y-N)1993 NEC (Y-N)
Plan Review Process Work Book Pale -7-
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41 A-O RECEV`n
JUL 2 81997 • "
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Copy BLDG.INSPECTION DEPARTMENT
CITY OF CUPERTINO
IV
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PLYWO. PLATFORMq.
FUR-- N—�� �•i:;
SEE T-24 FOR
RECOMENTATIONS 30' MIN
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AND BTU I �O'
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I INSTALL FURNACE '-PER —� CATWALK
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SECTION:-S19. U.M.C.;:' \ I i> -
2 PROVIDE FLEXIBLE -'GAS i I '•ti:`''_ "
CONNECTORS .FOR. ALL
.GAS 'A PLIANCES
3 FURNACE 'PLATFORM SHALL AbG2.
MEET il9cl4UNIFORM BUILDING G — — — —
CODE;SEISMIC. STANDARDS
4 PROVIDE COMBUSTION .AIR
AS .PER U.M.C.
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