S 0268 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PR§IT NO.
BUILDING DIVISIJ)N APPLICATION/PERMIT PLUMBING-MECHANICAL. J0268
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - SAN)"1'ARY NO. APPLICATION SUBMITTAL DATE
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OWNS 'S A L•: �1 �ACOW5 A�E. I� e NIC CONTROL
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ARCHITECT/ENGINEER: LIC NO: S: ❑
LeI ,
� NTAC'T; PHONE,: BUILDING PENMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
X ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT F
EE 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
F fLZ with Section7(N)fl)ofDivisinnJofthe Business nnJ Pmfessi...Cale.andmylicenseis RESIDENTIAL,
FNTIA
00 in PERMIT ISSUANCE
full force and effect. SFDWL ❑KITCHEN REMODEL
JUU Licenw Class Lic.a APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
W Dare Contractor
ARCHITECTS DECLARATION MULTI-UNIT C1 STRUCTURAL
p.,❑N> PANELS
z M.4 I mrdccsr d y hal public records MODIFICATION
::1f jJ�s UP TO 200 AMPS INTERIOR ❑CHIMNEY REPAIR
�(3 Licensed l' e o 201.1000AMPS IMPROVEMENT []SWIMMING POOLS
CCCC .,-1 O -BUILDER DECLARATION OVER 101X)AMPS BATH REMODEUREPAIR O DEMOLITION
6 ism I hereby aBthat I am exempt from the Commemit s License Law for the
XO S U following rectum.(Seale.7031.5,Business and Professions Code:Any city m county SIGNS ELECTRICAL �H1
u7It WO which requires a permit m construct,alter,improve,demolish,or repair any structure 1 / )
prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCU IT/M ISC.
�} that he is licensed pursuant to the pookiens of the Contractors]License Law(Chapter 9
�QpO )commencing withtheem
._ri 7.ID of Division 3 of the Business and Professions Cale)or TEMP.METER OR POLE INST. COMMERCIAL:
L q�C that he is exempt therefrom ad the basis for the alleged exemption.Any violation of Ll NEW BLDG/ADDITION ❑DEMOLITION
uXl 4th• Section 7031.5 by any applicant for a permit subjects the applicant no a civil penalty of POWER DEVICES
❑TENANT El FOOD SERVICEnot more than five hundred dellam(5500).
O O has owner of the prnpeny,nr my employees with wages as 0cir ode compensminn, SWIMMING POOL ELECTRIC LMENT
❑ THER
will do the work,and the suueture is not intended or offered for sale(Sao 7044.Business OTIiF.R
and Professions Code:The Commerce,License Law does not apply to an tuner of OUTLETS-SWITCHES-171XTURES
G, r impar,who builds or improves there,,.,and who does such work himself or through
his own employees,providedi that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
side.If.however.the building.,improvement is said within one yea,memopliumirthe SQ.FE FLOOR AREA LSQ.EL
owner-builder will have the harden of proving that he did not build nr improve for pur- p�
,,out sale.) IP AO h as owner of the property,um exclusively csuutding with licensed contractors ot )DIAL:
16
coaswet the project(Sec.7014,Business end Professions Code:)The Centmem,I U-
acrow Law does not apply to an owner of poyerty who builds or improves thercon.and QTY. PLUMBING PERMIT FEE JUL
whocontmed forsuchprojens witbaccnoactorsutr
rts)licensed puuanothe Conetors - JUL
License Law. PERMIT ISSUANCE
❑ I am exempt under Sec. ,B&P C no,this reason Cin/
ALTER-DRAIN&VENT-W (FA) ION
Ow er Dore `
\\ WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVI �r
I hereby oRrm under penult,of perjury one of the following declarations:
O l have end will maintain aCenificateof Convent to self-made for Workers Compen- DRAINS-FLOOR.ROOK AREA,COND. STORIES TYPE CONSTRUCTION
tion,as provided for by Section 37M of the Lalxr Code,for the performance of the
rk for which this permit is issued. FIXTURES-PER TRAP
-�\ I have and will maintain Worker's Compensation Insurance,as required by Section
37M.frhe"be,Code,for the perfmmmen m du,work for which this permit is issued GAS-EA.SYSTEM-I INC.4 OUTLETS OCCGROUP N'N
My Worker''C mpenwtion Insor artier and P,,licy n v
Cartier: ryGj/jl Policy No.: GAS-EA.SYSTEM-OVER4(EA)
"CE IF Cl ATE OF EXEMPTION FROM WORKER GREASFJINUUSTRL WASTF.INTERCEPTOR COMPENSATION INSURANCE. BUILDING DIVISION FEES
(9Lisscetionnxdnot he cnmplmed if ser pemrh is!come hundred tlodlars(61 W) GRBASETRAP
or lessd PLANCHECK FEB
Icmifyrhat m ilo,performaneaofthework ferwhich do,pennir isissaad.],hall SEWER-SANITARY-STORM EA.200 ET.
not employ any person in any manner so as to become subjecne the Week.Camper- ENERGY ITS
O Z infirm Laws idCalifotaia.Data WATER HEATER WNENIVELEC'Ut GRADING FEE
Q Applicant k
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/IREATING
become suhjcd to the Waukee.Compensation provisions of the LaMn Code,you must SOILS FEE
lfLyl G fonhwith comply with sochspoveirims or Ni,permit a hall be deemed revoked. 'WATER SERVICE
5z CONS'MUCIION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ T PAIDReccipnM
U 0 1 hereby affirm fast there is a construction lending agency for the peAotmana of Date
Ne work for which this pertFt is issued(Sea 3097.Civ.CJ
u" ULender's Name TOTAL:
Lender's Address TOTAL:
1 certify that I have read this application and state Nat the abnvc infamandon is BUILDING FEE
F.� t0 ,,career.l agree to comply with all city and county ordinances and state laws mining to QTY. MECHANICAL PERMIT FEE
V z building conswction.and hemby authonre retim,entatives ofnhis city to enter-upon the SEISMICMM
above-merni.ned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments.runs and expenses which may in any way aecmeagaim,said City ALTER OR ADD TO MECH.
PLUMBING PERin consequence of the starting of this purnei.
APPLICANT UNDERS%.A E�ANILL MPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000CFM)
AL FEE
SOURCE REGyLAT10 SS CONSTRICTIONT
�(—/t[/L�u �7 a_a� AIR HANDLING UNIT(OVER 10.000 CPM) CONSTRUCTION TAX
Signaturof ppli /Coritm /_ / /Dam EXHAUST GOOD(W/DUC) HOUSING MITIGATION FEL?
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant share untruths hmallous material HEATING UNIT(TO)!X).001 BTU)
as defined by the CLper i.o Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? HEATING UNIT(OVER 100,000 BTU)
❑Yes ON. PAID
VENTILATION PAN(SINGLE RESID) Dare - Receipt#
Will theapplievmor future building occupant.,a equipment or devices which BOILER-COMP(3HPOR IW,IIW BTU)
Smit hem"'a air a ... n.. as defined by the Bay Am Air Quality Management TOTAL
Distad^ BOILER-COMP(OVER](0,000 BTU)
C)Yes ONo
I have read the hazardous materials is under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
mqu"c
humin Health&Safety Cock,Sections 25505,25533 and 25534.1 understand that tithe NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have v tenant,that it is my responsibility to notify the mcuperm
of the i,quiremems which must be met prior to issuance of a Certificate of Occupancy.
Owner or amhonud agent Dae TOTAL ISSUED BY:
OFFICE
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ANtS 9if'gINANC i
JUL 91997
*1 ID.
f►ns ser of 1 BLDG.INSPECTION DEPARTMENT
k' iaf 5 ` sped, :�ati_ns CITY OF CUPERTINO 3
1�Vfe °A Ihcs MUS;
�1 !ob 2t ail hetes and it is un
rn�he arty c;,an
oh sa'� Witr"r ices or alteration, —-
the�.d ng DOut vFr.,en pe mission fe n
lhi*amprn r.pr 0 rY of Cupe,tino.
& f his ) -
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of rr+Y f,h� br�r e or
SCAL[: 1 +�•—�:
APPROVED DRAWN DY /✓.
ej
OFFICE COPf xf: F2MUL&W-r W Y�r�b Wb �1�� 897. 0363
(414r, LX164 AVC SS CA 85124 C61- 581506
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