30598APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY -
CITY OF CUPERTINO BUILDINf.-F.LN:CTRICAL
BUILDING DIVISION APPLICATION/PERM IT PLUMBING -MECHANICAL
BUILDING PROJECT IDENTIFICATION
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^PERMIT N030598
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BUILDING ADDRESS: Cy
SANITARY NO.
'APPLICATION SUBMITTAL DATE
OWNER'SNAME: PHONE:
CONTRACTOR'S NAME: LIC NO:
en CLSOJ
NIC.
❑
CONTROL
Re ITECDENGINEER: LIC NO:
A RES / 1
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ONTACT. PHONE:
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❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECT PLUME MECH
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LICENSED CONTRACTOR'S DECLARATION
1 hereby afrrm that I um B«Died under provisions of chapter 9 (commencing
wim S.ti.n7").fDi,i,i.n3.lfth,B.Ii..,,.nd Professions CWl..ndmylicenseis
in toll force and of
Limn loss c _ Lic.p bJ.33fSG
Data Cenvacmrl-S'^s- fM �fC�neT
ARCHITECTS DECLARATIONpgNGLS
I understand my plans shall be used as p#ic m orls
QTY. � ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
❑sFowL ❑KITCHEN REMODEL
❑ADDITION - 0PLUMBING RE -PIPE
❑MULT6UNIT ❑STRUCTURAL
�,MM�ODI�DIFICATION
0MERIOR �. Ak MNEY REPAIR
IMPROVEMENT'
❑BATH REMODEL/REPAIR (] DEMOLITION
❑OTHER
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
-
- I. -
UP TO2(IO AMPS -
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sr' a 6 U
4477 O
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LicensW Lhofasinnal - -
OWNER -BUILDER DECLARATION'
I hereby affirm maattI am
m eexempt from the Contractors License law for the
following reason. (Section 7031.5. Business and Professions Code: Any city or county
which rectums a permit to construct, alter. improve, demolish, or repair any strucstructure,ctu
prion,its hareac'.1s.requins the applicant forsuch Permit o file u signed statement
that he is licensed pomuant to the provisions ofma Contractor's License Law (Chapter 9
(commencing with Section 71100) of Division 3 mfthe Business and Professions Code)or
that he is exempt dreamer and the basis for the alleged exemption, Any violation of
Section 7031.5 by anyapplicent faro pemlitmbjceu meapplicant me civil penalty of
not more menfivehundral dofms($5t0)'
❑Lxs owneruf the pr openy..1a employees with wages as their compensation,
will dm tha work,mW the suuclum is rot intended oroffered for sale (Seo. 7044, Business
and proration, Code: The Contractor's License Low does root apply m an owner of
property who builds or improves theeon, and who does such work himself or through
his own employees, provided that such improvements are not intended or normal for
safe. If, however, the building or improvement issold within one yearofeompleim, me
overver-budder will have the burden of proving mut he did not build or improve for pur-
mmaxle.).
0 I, as owner or the property, am exclusively contracting with licensed contractors m
construct the project (Sec. 7044, Business and Professions Cade:) The Contractors Li-
cense Low does not apply m an owner f property who builds or improves thereon, and
who contracts for such projects with a cono.ctogs) licensed Panama tome Contmemer
License Law.
❑ lam exempt under Sec. ,B& P C for this reason
201 -IO WAMPS -
OVER 10(10 AMPS
SIGNS ELECTRICAL
.SPECIAL CIRCUITIMISC.
TEMP. METER OR POLE INST.
COMMERCIAL:
❑NEW BLDG/ADDRION DEMOLITION
0NEWBLANT 0DEMOLOFOODSDION
RVICH
IMPROVEMENT',
❑OTHER
POWER DEVICES
SWIMMING POOL I
OUTLErs-SWITCHE FI
NEW RESIDENTIAL KLEcTir
SQ. FII FLOORAREA
SEP 2 51996
$ISQ. FI'.
TOTAL:
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER - DRAIN & VENT- WATER (EA)
Owner Dote
'' -"VALUATION
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WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of me following dmlamtions:
I have and will roar in.Caulicamof Comenuu selGinsure for Wmkcrs Co.,..
sation, as pnrvided for by Section 3701 of the Labor Cade, for me unfoamunce of the
work for which this permit is issued.
❑ 1 have and will mountain Worker's Compensation Insurance, as required by Section
37M of the Labor Cade, for the performance of the work for which this Permit is issued.
My it ' C. m^jp'�ecaminn- umnc carrier and Policy nurrPFper�¢'�
CardeeSla:` Policy No.:—!S] IK/"/
CERTIFICATE OF RX MPTION MOM WORKERS'
COMPENSATION INSURANCE
(This section need not he anoplecd ifthe permit is for one hundred dollars ($ 100)
or less.
I certif that in the Performance ofthe work for which this
Y Ix the Ikes'Com hall
nor employ any person in any manntt se as to become subject m the Wmkcn' Compen-
store. laws of California. Date
Applicant
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOP. AREA, CONTI.
STORIES
OCC GROUP
TYPE CONSTRUCTION
APN
FIXTURES -PCR TRAP '
GAS - EA. SYSTEM- I INC 4 OUTLETS
GAS - EA. SYSTEM -OVER 4TEA)
GREASPANDUNI'RI, WASTE INTERCEPTOR
BUILDING DIVISION PEPS
_
GREASE'[ RAP
PIANCHECK FEE
SEWER -SANITARY -STORM EA. 200 Fr.
ENERGY FEE
WATER HEATER W/VENT/ELECTR
GRADING ME
NOTICE TO APPLICANT,If. after making this Cenilicate of Exemption, you should
become subject m the Workers Compensation pnikions of the Labor Code, you most
forthwith comply with such Provisions or this permit shall he deemed revoked.
CONSTRUCONLENDINGAGENCY
that issuconstruction (See0lending agency for me performance of
Uk for which
the work for which this permit is issued (Sm. 7097, Cie C.
Lender's Name -
Lender's Addrtss
WATER SYSTEMITREATING
SOILS FEE
WATER SC BY ICI' -
PAID
NEW RESIDENTIAL PLMtl. SQ. FC
Date Rettiptp
TOTAL
TOTAL:
1 civti(y that I have read this application and state that the above information is
coma. lagme to comply with all city and county ordinances and sale laws relating to
building construction, madhereby suthoro, reprerenmrises ofmis city to enter upon the
above-mcminnW property for inspection purposes.
(We) as., to s.ve, indemnm
ify and keep lu sless the City of Cupertino against
liebilaiea,judgmem,aammod expenses which may in any way accrueugain.at said City
in nseqce of the floating of this permit.
consequence
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
BUILDING FEE
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE.
O
PERMIT ISSUANCE
ELECTRIC MU
ALTER OR ADD TO MECH.
PLUMBING FEE
AIR HANDLING UNIT CIO Iq(gxI CFM)
MECHANICAL FIeC
AIR HANDLING UNTT(OVER W." CFM)
CONSTRUCDONTAX
Signature of ApplicanUCtomemr Data
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant or future building occupant store or handle haaardous mamrial
ss deftnW by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code. Section 2553200?
❑Yn ❑No
Will the applicant or future building uccup u l um,equip rcut or devices which
mit harardous air contaminants as defined by the Buy Area Air Quality Management
iatrict7 -
0Yea ON.
- - I have mod the hmardous materials reappointments under Chapter 5.95 of the Cali-
forms Health & Safety Cade, Sections 25505, 25533 and 25534. 1 understand that if the
building Bees net currently haveumnun that it is my responsibility to notify lire occupant
the requirements whic must he me rioneissuance of. Certificate of Occupancy.
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION FEE
HEATING UNFFO70 I00,000 BTU)
HEATING UNIT (OVER 100,000 BTU)
PAID '
VENTILATION PAN (SINGLE RESID)
Data Receipt p
. -
BOILER -COMP IJHP OR 100,0(X1 BTU)
TOTAL:
BOILER- COME (OVER 100,000 RTU)
AIR CONDITIONER
ISSUANCE DATE
ISSUED BY:
,NEW RESIDENTIAL MECI1. SQ. Er.
Owner or nuthorirW e t Date
TOTAL
OFFICE