30493 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO I I BUILDING-ELECTRICAL PERMITNO, O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING 1'ROJECI'IDI:NTIPIGT'ION
HUILDINGADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
,� y, a ' n/cce :fi e- .. , .1
OW*11i96 PHONE:
t ALICNO:.
LfORu
ilozie N/C t CONI'Rod.p
•ARCHITIiCDENGINEER: LIC NO: ADD ESS: ❑
r COC0 PHONE: BUILDING PERMIT INFO
, �C - •c�e�r ,��/'/I ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ' . ❑ ❑
LICENSED CONTRACf R'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby arum that 1 Bill licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Q00 with Section 7000)of Division Sof the Busmassond Professions Code,Bud my license is
�WO y PERMIT I$SUANCB - RESIDENTIAL:
n full force arrd effttt.
�U� License Class Li@k - ❑SFDWL _ El KITCHEN REMODEL
Dene Comaemr APPLIANCES=RESIDENTIA1.
F.Zµ� - []ADDITION ❑PLUMBING R&PIPE
Z Oto<< ARCHITECTS DECLARATION PANELS 'C1 MULTFUNIT ❑STRUCTURAL.
rn T„{ 1 understand my plans shall he used as public reroNa MODIFICATION
OZ� UP T0200 AMPS t
LicenuJ Professional _ ❑INTERIOR ❑CHIMNEY REPAIR
201-IfkEnd AM r' " IMPROVEMENT
J
Oan I am exempt
from
DECLARATION Conti ON OVER if%%TAMPS
C�¢ . 1 hereby affirm that I nm exempt from the Ctmrucmr.License Law For the ❑BATH REMODEUFtF.PAIR �DEMOLITION
O 4 U following reason,(Section 7031.5,Business and Pr(desslmu Cole:Any city or county SIGNS ELECTRICAL P ❑OTHER
ligO I' which requires a Permit to c muses.alter,improve,demolish,or repair any xtmnure
prionnits issuance.nlsn reyuircsthe upplicam fir such permino Bien signed xmmmcnt SPECIALCIRCUIT/MISC.
[[Fppp.+Ivy� shut tie is licensed puommto the prockiu l,.fiho Contmnor'a License Lou(Chuptcr 9.
4^'p0 (commencingsvith Section7001)ofDi,ism.3ofthe Bmincssand Profusions Cole)nr T BMP.METER OR POLE INST. COMMERCIAL' If
that he is exempt therefrom and the basis for me alleged exemption.Any violation of NEW BLDG/ADDITION El DEMOLITION
�qq Y•
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of r POWER DEVICES
ul^h ❑T17NANT z TOO[)SERVICE
Bill nmom then Dow hundred dollars(SS(I)
N .
Z^O ❑l.as owner of the propeny,or my employees with wages as their sole compensation. SWIMMING POOL T:
ELECTRIC IMPROVEMENT. '
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business ❑OTHER
and Professions Code:The Contractors License Law docs not apply to an owner of OUTLET'S-SWITCfiES FIXTURES
property who builds or improves thereon,and who does such work himself or through - -
his own employees,provided that'such improvements are not intended or offered for NEW RESIDENTIAL ELECIR SQ urr
sale.If,however.the building or improvement is sold withi a one year of completion,the _ SQ.Fr.FLOOR AREAL, $ISQ.FF.
poowner builder will have the hunlen of proving that he did not build or improve for Pur-
you of seleJ.' '
C11,as owner,of the propeny,am exclusively contracting with licensed contractors to TOTAL: 6
construct the proJmt(Sec.7044.Business and Porfiessions Code:)'I'he Counselor's LI- SEP 6 ��g$J
cease Law does not apply no on owner ofpmpeny who builds or improves thereon,and QTY PLUMBING PERMIT FEE
who contracts for such projects wim a commclons)licensed pursuantto the Contractor's
Licemc Law. y)
❑lem'cxcmpt unAcr Sec. ;B&PCfonhisreason PERMIT ISSUANCE a(/ !.1111-. 4'WFL.t I1 Hls�'
ALTER-DRAIN&VENT-WATER(G) VALUATION
Owner nate _
WCHUMIR:SCOMPRNSATION DECLARATION BACK PLOW PROTECT.DEVICE
1 hereby alarm under penalty of perjury one of the following deelmneima
•C]I haveand will maintain.Cenificam of Cmaam ul,ribinsure for Worker's CamperDRAINS-FLOOR,ROOF,AREA,COND.
smion,s movlAcd sorb Sec,on 3700 of the Lubar Code,for the STORIES TYPE CONSTRUCTION
Y Ix'rl'nnnunm of Ore _
work I
have
this maintain
issued. FIXTURES-PCN TRAP
1 hove and will main win Worker.Compensation ceofthw Irk for which
h required pon by Section
3]fXl of the Labor Code,for perfnnnunce of the work liar which thix pcmrit is issued, GAS-BA.SYSTEM-I INC.J OUTLETS OCC.GROUP APN
My W.Cameerkss;CnocuMmumance etmieand 1'<N�y n GAS-IIA.SYSTEM OVER 4(EA)
CERTU RcATE or E%Emi-HoN FRIM WORKERS' y
COMPENSATION INSURANCE GREASzdNDUSTRL.WASTE INTERCEPTOR
BUILDING DIVISION FEES
'- ) section ction need not be completed Nt
if thepcnis Forane hundred dn)less($1did - GREASL TRAP
nr
us..)(This
FEE _
'I certify the(in thelxrfnrmunccofthe work For which this permh is isxucd,Ishull SEWER-SANITARY-STORM EA,20)PI'.
not employ any person in any manner w m subject to to become subject the Workers'Cnmpen- ENERGY FEE
,Z ..tion laws of Califomi..Date
Applicant WATER BEATER W/VFNTAiLECfR GRADING FEE.
w� r�yr
NOTICE'TO APPLICANT:IL aficr making this Cenificam of Excntptium you should WATER SYSTEMG EBATING
(" become.uhjem to the Worked Compensation provisions of the Labor Cade,you man SOILS FEE
Wi�•r forthwith comply with such provisions m oris path)-,shall he deemed revoked. WATER SERVICE -
CONSTRUCTIONisa7cLFNDlNGAGENCY NEW RFSLDEML'IAL.PLM 11. SQ.<T. PAID
�Z work
by which chum that them ibard(Sect3aD,lending agency for performance of Data Rtteipta
LULU thewnrk for which this permit is isaucU(b .3147,Civ.C.)
U Lender 'TOTAL;'s Name - -
{4I LerNerAddress TOTAL:
I<enily that L have mud This epplicanion and stem that the aMwe information is BUILDING FEE
tt1i cornea.l agree to comply withsll city and county oNinanees and state luwsmutingm QTY MECHANICAL PERMIT FEC
V Z building concoction,aced hereby authorize representatives ofthis city to enter upon the SEISMIC FEE
above mentioned propeny for inspection purposes. PERMIT ISSUANCE
•(We)agrco m save,in lcmnify and keep no.1c,s the Cityt of Cupeninn against ELECTRIC FEE
liabilities.judgments,costs and expemes which may in any way accrue against said City ALTER OR ADD TO MECH.
in consequence ofthe granting of this Permit. PLUMBING ITH
APPLICANT,UNDERSTANDS AND,WILL COMPLY WITH ALI,NON-POINT AIR HANDLING UNIT(TO 10,O)I)CFM) MECHANICAL,FE6
SOURCE REGULATIONS: MECHANICAL,'
AIR HANDLING UNIT(OVER.10,011)CFM) CONSTRUCOONTAX
Signature of Applicam/Contnmtur Drum EXI IAUSTHOOD(W/DUCU HOUSING MI'1'IOATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant snore or handle Imzablous material IMATING UNIT_(TO 100.000 BTU)
' as Maned by the Cupeninn Municipal Code,Chapter 9.12,and the Health unit Safely
Code,Section 95532(a)] ' I 1 IEAGNG UNIT(OVER I(it BTU) t
❑Yes ❑No VENTILATION FAN(SINGLE.RESID) PAID t
Will the applicant or future building occupant use equipment or devices which _ Date Receipt M
thazallous eir contaminants ndefined by the Bay Atex Air Quality Management BOILER-COMP(3HPOR 100.000 NTU)
District �-
-1 Yea No BOILER-COMP(OVER 100,1100 BTU) - TOTAL:
I have read the hazerJous.oren.is requirements under alnue,695 of the Cali- AIR CONDITIONER ISSUANCE DATEV
bums Health&Safety Crvle,Sections 25505,25533 and 25534.1 understand that bribe NEW RESIDENTIAL.MF.CI{, SQ.14.
buildingdoes not currently have a tenant,that it is nDrespumsibility toraifytheoccupant - a
of the requirements which now be met Pdmw issuance of.Cenifeme m0ecupancy.
Owner nr.mhurisJ agent Dam TOTAL: ISSUED BY:
OFFICE