31020 -APPLICANTTO.FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUILDING•RLRCIMICAL PERMIT NO.
31020• LUMRING•XICIANICAIAPPLICATIONPRRMT BUILDING PRDJCT DHTIFICATIfNBUILDING DIVISION
BUILDINGADDRESS: SAND'ARYNO. APPLICATION SUBMITTAL DATE
/01*96 Toh►l 1�6 (A, ert in o , CA 9X'6/4
WNER' NAME: I'30NE: CONTRACI'OR;S NAMC: LIC NO:
-Llan (4op)<46-so o wG CONTROL«
%RCHITECOENGINU•ER: LIC NO: ADDRESS: ❑
CONTACT. - PHONE: 13UILDING PERMIT_INFO
❑ COpSnitdnt Fees Paid by Applicant(Initial) RLDG ELECT PIA MECH
1 11
❑ o . ❑
LICENSED CONTRACTORS DICLARA'OON QTY ELEC•I'RIC PERMIT FEE
I hemby afflnn that 1 um licensed under,owitlons of Chapter 9(commencing JOB DESCRIPTION -
FO�aZ wish Section 7600)of Division Sof the Business snit Pardesaiona Code,and my license is RFSIDF.NTIAL:
O iniullformicadeffect. - PERMIT ISSUANCE -
t gdr ❑SFDWL , ❑KITCHEN REMODEL
Q V U License Class Lic.p
rF�a Data C...row... 'APPLIANCES-RISIDI!NTIAL ❑AUDITION ❑PLUMBING RE-PIPF:
Z Ooi ARCHITECT'S DECLARATION PANELS ❑MU171-UNIT '❑STRUCTURAL
rV'7 I understand my plans shut[be used as public retards MODIFICATION
OZr30 r UPT0200AMPS [-]INTERIOR INTERIOR CHIMNEY REPAIR
F r?E'41 Licensed Pmfessi...I W 201-IOAMPS IMPROVEMENT
Sof; OWNER-BUILDER DECLARATION OVER IOOIIAMPS ❑BATH REM DEL/REPAI DEMOLTITON
y Q I hereby affirm thin 1 am exempt Fourche,Contractors License law far the
p(O 4 U follawing maxum.(Sectio"7031.5.Business and limfeesions Cate:Any cit,atrocity - ❑OTHER
3 4 SIGNS ELECTRICAL
F r4.O f& which requires a pmnit m m.the epee improvq demolish,or mpan any eemerc
m.Q.l ChErrit he itsiis ensed e,almmquime the fm Contractor
s License
Law(stmmnem SPECIALCIRCUM'/MISC.
thatmecing with
pursuant in the provisions of theeeBusinessa License Loons Code)or
GQ�O
(commencing with Seclinn711(Il)of Divisinn3of the Business and l'rofessiansCWe)nr 'TEMP.METER OR IY31.Ii1NST. � COMMERCIAL: :
4 p,o rG that he is eacmpl Ibcrefram and the basis for the alleged exemption.Any vinlation of ❑NEW BLDG/ADDITION' ❑DEMOLITION
y Section 1011.5hyanyu,plicant for a permit subjects theupplinmt to a civil penalty of POWER DEVICES 'I
W annum lhnn live tumbled dollar,($500). - TE ANT ❑FOOD SERVICE
F dLas owner of the nn n n 1 ROVEM17N'1'
❑ I tw y,or my employees with wages as their sole compensation„ SWIMMING I'OOLIi1.ECl'ItIC
$4� O will do the work,unit the mrucmre is not intended omffertdfor sale(Seo.71W4,Business - ER
W4, � and Professions Calc:The Contractor's License Low dins not apply to an owner of OUTLETS-SWITCHES-FIX1'URIS
property who builds or improves themo,and who docs such ,,,it himself or through
his own employees,provided that such improvements am not intended or offered for NEW RESIDENTIAL ELECfR SQ PT.
sale.If,however,the building or improvement is sold within ancyearufcnmpledion the SQ.FC FLOORRAR $/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for par- ,y- ' D
pue of axle.).
❑ 1.us owner of the pmpeny,am exclusively contracting with licensed sit
to TOTAL:
conswctthe Pmject(Sce.7O41,Business unit Professions Cale,.1m Cnmrvntor'c Li� NIAR - � RE IJ
T
cena law dine not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEV,
who cotnmcts pusuah projects with a contracmgs)licensed personal o the Contmatmes
License law: PERMIT ISSUANCE• CII r Ut- (;Ul 0
❑ Laempanders . R&rcfor micereman t {fIIIV
ALTER-GRAIN&VI?NT-WATER(EA) VALUATION
Owner
Dole "
WORK]IR-S MPENSATIONDECLARATION BACK FLOW PROTECT DEVICE
I c by l tuinclpen Ilyofpep y fthefallowingdoclurut ons
•❑ Ihave and ice int Cerif00ft It II hittlar WorkersCampem DRAINS-FLOOR,ROOF,gltl3A,GOND. 1'
en o provided I J 1 r by Se I< J]00 or the Lab Code for the penin nonce of Ibe STORIES- TYPE CONS'I'RUC'1'ION i
walk far which lhn Fe, is asued. FIXTURES-PI7R TRAP
❑ I haveand will mainmin Worker's Compensation Insurance,as required by Section
3700.fdo Luton Cos1nj do,erformanceofdoworkfor which this permit is issued. GAS-EA.SYSTEM-I INC.40U'TLfil OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number am: -
Cartier: Policy No.: GAS=EA.SYSTFMOVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE OREASETNDUSTRL WASTE INTERCEPTOR
(This section need not be completed ifrw permit is for one hundred dollars(S ICI) - BUILDING DIVISION FEES
or letG MAP
i'LANCIIF.CK FI3E -
Ioyanythin
persnthe inanymannereofthewmkfor wubjectch iittheWiker,'edom,en- SEWER SANITARY-STORM EA.2ao IT.
not employ an,person i"any manner so as to become subject m the Wnrlcrn'Compcn- ENERGY n3li
Z O of Coilhmia.])am
Applicant TER HEATER W/VRNT/ELCCTN GRADING FIE
«7 NOTICE T'O APPLICANT`.IL me,making this Ccnificmc of I?xcmptian,you shnulJ
a � hccome subject the Worker's Compensation WA'fERSVSTI3MRREATING
pence" provisions of the meed rGolc,you must Sons PI312
CLl fonhwitM1 comply with such provisions or this permit ehallMJecnmA rcvnkeJ. , Wq'fER SERVICE
� Z .. CONST'RUCTION LENDING AGENCY NEW RESIDENTIAL PI,MII. SQ IT. PAID
U 0
I hereby ufhm rthat them is a contraction lendingageney for the perl'onnance of Dam Receipt#
Ilia work for which this permit is issual(Sec:3097,C1v.C.) ) - -
Q U Lenders Name TOTAL:
[2a lender's Address '-` TOTAL:
FOr 1 certify Ihut 1 hove read this application and state that the okwe infomtutian ie BUILDING FTE
rr Vn coram.l agree to comply with all city and county ordinances unit state laws relating to QTY. MECHANICAL PERMIT FEC
L) Z buildingconstruction,and hereby authodzere mstmoddies ofthis cit to enteru m
the SEISMIC FEE -
r•t above-meet neal agree to save forinspectionkepis. PERMIT ISSUANCE
(We)egret m save,indemnify and keep harmless the City of Cupertino mgninst ELECTRIC FEE
lisbiliticn,judgrnmts,imsand exp:nscs which may many wayaccrueugainst said City ALMRORADDTOMECIL
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0,06ECFM
.E ) MECHANICAL PEE
C
SOU REGULATION ,/
� f 3/� : AIR HANDLING UNIT(OV[R Ig000CPM) CONSTRUCTION TAX
Sigaamreof ApplicanUContre r Date / EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stere or handle hdnurlaus material HEATING UNIT(IO 100,0g)DT'U) -
ae dehnte by Ihb C.,cromo Municipal Care,Chapter 9.12,and the Health and Snlbty
Code,Scetion 25532(019 I, HEATING UNIT(OVER 100,09)(1 BTU) -
❑Yes .• ❑No ` . ` u.
VENTILATION VAN(S INGLE RES ID) - PAID
Will the applicant or future building occupant use equipment or devices which - Dme Receipt is
u hazardous air codominants as defined lyq by the Buy Area Air Quality Management BOILER-COMP(3HP OR11fli III U)
-
:.eoixtnct? BOILER-COMP(OVER 100.000B'1'U) TOTAL:
❑Yes ❑No
I have mml the hmallous materials a under Cha ter b.95 of the CUi- AIR CONDITIONER -
'5.255 3 p ISSUANCE DATE
forma,dow,&Safety Cap,Sections.Ell i is my ural 23531 I undersmnd Nm if the NEW RESIDENTIAL MECH. SQ.FT.
huildi gdoes nm cmrtntly havemmmmle Naf ibis my mspmsibility to nmify the cecupanl.of emymremcnts ch man be tall rcsumlce ofa Cenihcal forte party.
Done, a/s/Q�
Owner ser omhnrized.gent pale TOTAL: ISSUED RY:
OFFICE