31496 =APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITYOFCUPERTINO - BUILDING-ELECTRICAL PERMIT NO. p
BUILDING DIVISION "APPLICATION/PERMIT PLUMBING-MECHANICAL 314 9 6
BUILDING PROJECT IDENTIFICATION e ' N V
BURDINGADDRESS: - _ SANITARY NO. APPLICATION SUBMITTAL DATE
to l_ ockcR
�11- n ryN.
'S NAME: PHONE:JC1 C rtp "JVJTIC) NIC e..
- CONTROLg
ARCHITECTIENGINEER: LIC NO: AD
jR11` 1 " ❑
CONTACT. exoNe: �Tl-Th BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
VV iT ❑
LICENSED CONTRACTOR'S DECLARATION Q•j•Y ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
, 00 with Section 7")of Division 3 ofthe Businessand Professions Codninl my license is RESIDENTIAL: !
nd O mf ull force and IT p PERMIT ISSUANCE QUp�p' License qle,.- Lin.M ( ❑A DWL ❑PLUMBIKITCHENREMODEL
FXtli Date-1''\fl�Y�'jT,'-Q"{'^'--'--'Contractor APPLIANCES-RF.SIDENTIAI:" []ADDITION [I PLUMBING RE-PIPE
10N D y ARCHITECTS DEC R ION PANELS ❑MULTI-UNIT ❑STRUCTURAL
I.O.y❑ 1 understand my plans shall be used as public records MODIFICATION
;4x0 UPT0200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
,� Licensed Professional - 201-IOfOAMPg lMPROVEM
f aV
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor s License Law for the OVER 1000 AMPS ❑BAT ODEDREPAIR ❑DEMOLITION --
a G U following reason (Section 7031 5 Business and Professions Code Any city or county ER
which r a ermit 1.consumer,alten improve.demolish SIGNS ELEL"IRICAL
req p p par any sWmure fa 5
priori its issuance,also requires the applicant for such Permit to file as signed statement y n/N
h„] B SPECIAL CIRCUIT/h1I$C' 00
M that(commentinnsedg
pursuant 0 the7")of Divions sion 3 me Contractors License Loons Codrer9
q oa�0 (commencing with Section 7")of Dlvislon3of the Business and Professions Code)or TEMP.METER OR POLE INST.
e' that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITR) ❑DEMOLITION
4X1 W Section]031.5 by any applicant fora permit subjects the applicant to a civil penalty of POWER DEVICES.' ❑TENANT El FOOD SERVICE
fF.. p. net more In..five hundred dollars($500).
q�6 �l,as owner m tc property:many employees with wages us their sole compensation, SWIMMING POOL ELECTRIC. IMPROVEMENT ,
C2C2 Q will do me work,and the or. is not intended or offered tarsale(gee.7044,Business DOTHER.
and Professions Code:The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTUR
R'3 propeny 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 ELECfR S
sale.If,however,the building or improvemends sold within one year ofcompletion,the - SQ.FT.FLOOR AREA, $/SQ.FT.
owner-builder will have the burden of proving that he did not build of improve for put. p�, AID '•
poseofsaleJ. 'Ir A I
❑I,as owner of the property,am exclusively contracting with licensed contractors to §FEE
onwset the project(Sea]0EL Business and ProfessionsCoda:)The Cmancmr's Li. tcense Law does nm apply to an owner ofpropeny who buildsor improves thereon,and Q'py, PLUMBINGPERMIT NOV.27 1996,
who contract for such projects with a contractor(s)licensed pursnanrto the Contractor's
License Law.
❑lamexempttinder Sec. ,B&PCformis owrap PERMIT ISSUANCE
ALTER
�'
ALTER-DRAIN&VENT-WATER(EA) G 1 uF IgUGGFI V
Owner Date V AT ON
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
I hereby affirm under penalty of NrjuU one ofthe following declarations:kb� -
r(l have and will maintain.CertificiatifConsetn to self-insure for Worker's Compen- DRAINS-FLOOR.ROOP,AREA,COND. DRIES TYPE CONSTRUCTION
sation,as provided for by Section 37W of the Labor Code,for the performance of the
0�ofto for which Nis permit isissuod. FIXTURES-PERTRAP i
w 1 have and will maintain Workers Compensation Insurance,as required by Section
.]0
he Labor Cade,for the performance ofthe work
.lic for
pwhich
this permit is issued GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC GROUP PN
My -,-->C`tkppdt\�Ipp.syiEp_r�a 10 Polroaicy No No L[fdll�1�`�1 GAS-EA.SYSTEM-OVER 4(EA)
Cartier: \I I �-k-_ll l\ -
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE RCEPTOR BUILDING DIVISION PEES
(This sectionneed not be completed if thepermitis forone hundred dollars($Efro GREASETRAP
or less.) - PLANCHECK FEE
I certifythm in the perfirommoeofthe work forwhichthis permit is issued,Isbell maintain, SEWER-SANITA -STORMEA.200 PT.. •
not employ any person in any mr so as to become subject to the Workao,Compen- - - ENERGY FEE
O z
station Laws of California.Date WATER HEAT WNENT/ELECTR
z O Applicant k GRADING FEE
ry y NOTICE TO APPLICANT:IL after making this Certifeme of Exemption,you should WATERS T EREATING -
!•'c become subject to the Workers Compensation provisions of the Labor Code,you must SOILS FEE,
Qforthwith comply with'such provisions or this permit shall be deemed revoked. WqT SERVICE
z. CONSTRUCTION LENDINGAGENCY EW RESIDENTIAL PL l SQ.FT, PAID
U C) • I hereby affirm that there is a construction lending agency forthe performance n( Date Receipta
W l-+ the work for which this permit is issued(Sec.3097,Civ.CJ m
0 U Lenders Name TOTAL:
67 Lenders Address TOTAL:'
Ly.., 1 certify,that I have read this application and state that the above information is BUILDING FEE
correct.I agree to comply with all city and county ordinances and state laws relating to QT-y. MECHANICAL PERMIT FEE
U building contraction,and hereby authorize representatives of this city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes, .. +' PERMIT ISSUANCE
(We)agree to save,Indemnify and keep harmless the City of Cupertino against •W ELECTRIC PBE
habilides,judgments,costs and expenses which may in any way sector,against said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBING FEE -
APPLICANTUNDERSTANDSANDWILLCOMPLYWITHALLNON-POINT AIR HANDLING UNIT(TO 10.000 CFM) 'MECHANICAL FEE /
SO1/ylyC EGULATIONS.. - ,
N.,1/ EE�rgg)) et�_G ' I �1I(•V AIR HANDLING UNIT(OVER 10,05)CFM) CONSTRUCTION TAX
ValulaoIApplicanoConcoutor bLD e'7lG EXHAUST HOOD(W/DUCq
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
• Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU), , OO
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety !
Code,Section 255320? , HEATING UNIT(OVER 100,000 BTU) alb iy
t ❑Yes E]No . PAID JZI `7
VENTILATION FAN(gINGLE RESID) Dem Receiptp
iillthe applicant or future building occupam use equipment or devices which fI(10 DEC)HP ORJOO
COMP( , /
emit Meanders air contaminants as def nd by the Bay Arca Air Quality Management BOILER- _ TOTAL: O
�DmamdO
Yes (]N. BOILER-COMP(OVER 100,000 BTU) m '
I have read the hazardous materials requirements under Chapter 6.95 of the Cali- - AIR CONDITIONER ISSUANCE DATE- -
fomia Health&Safety Code,Sections 25505,25533 and 25534,I understand that if the NEW RESIDENTIAL MECH. SQ.FTi m
building does not curtendy have n tenenL mat it ie my responsibility to notify the«cupant
of the roquiroment which must ba met print m iesuana of a Cutifcam of Oaupnney. - ,
Owner or authorized agent Date TOTAL: t
B •W ISSUED BY:. '
OFFICE