30316 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUILDS -ELECTRICAL. PERMIT NO. army O w 16
BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MECHANICAL -J{ -Jt {l-�7
BUILDING PROJECT UNMIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
0 2 8 S 'r Vis �J, C� oG T/
O R'S NAMPHONE: CONTRACf NAME: LIC NO:
a4 0 IV
N/C CONTROLp
ARCHITECT/ENGINEER: VLIC NO: ADD S
�— `•
CONTACT': PHONE: C� Q,� e e CF s BUILDING PERMIT INFO
Y�8 ❑ Consults[I Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
04�42' ❑ o 0
LICHNSED CONT CTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I Hereby.affirm[hut 1 stn licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
yQj Op with Section 7000)ofDividial Sof Ne Busincs and Pmfessiona Code,end myliccnu is PERMIT ISSUANCE RESIDENTIAL'
y.Wr in full force and eReet. ❑SFDWL [3 KITCHEN REMODEL
Dm
aU41 License Class Contractor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
e � Contractor
I, y ARCHITECTS DECLARATION El MULTI-UNIT ❑STRUCTURAL
PANELS
Z O r/r/��zi 1 understand my plans shall be used as public records MODIFICATION
OZE7 • UP'1'O200AMP5 .,,
RIOR CHIMNEY REPAIR
NiLicensed Professional 201-UXXIAMPS IMPROVEMENT
q�2', atI materniaOWNER-BUILDER DECLARATION Contr ,ON OVER UXOAMPS - ❑BATH REMODEDREPAIR ❑DEMOLITION '
yCCy ff� 1 hereby aftinn thus 1 em exempt!tete rite Cunttacmr's License law imam
X 3ta U following teaun.(Section 7031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
YY1l W O which"uires a Permit m construct,alter.improve.demolish,or repair any...tort
5 prior to its issuance,also require,the applicant for such Permit to file a signed statement SPECIAL CIRCUIT/MISE.
?y that he is licensed pursuantto the provisions of the Contractors LicenseLaw(Chapter 9
QD (commencing with Section 7")of Division 3 of the Business and Professions;Code)or s TEMP.MFTEROR POLE INS'L COMMERCIAL: ,
o�p,a e' thus he is exempt @crtfrom and the basis fof Ne ullegN cxemptian.Any vinlmion of ❑NEW BLDG/ADDITION ❑DEMOLITION
i4Cl Yy Section 7031.5 by any applicantfor a permit subjects the applicant to a civil penalty of POWER DEVICES
Tt more man five hundred dollars($500). ❑TENANT FOOD SERVICE
Fa I,as owner aide o - - IMPROVEMENT
O ❑ pr pmy,or my as their 04,1,namion, SWIMMING POOL ELECTRIC
_ will do the wrnk,anJ[henmcwrcis not intendedoroffem4 for We(Sec.]044,busittcss ❑OTHER
and Prono hoe,Cade:The Contractors License law does not apply to an owner of OUTLETS-SWI'T'CHES-FIXTURES
'3 r property who builds or improves thereon,and who does such work himaelf or through La G\ 11
his awn employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECfR SQ 9 4
sale.If,however,the building or improvement is sold within one yearofcomplction,the SQ..FT.FLOOR AREA S/SQ.ET,
owner-builder will have the burden of proving that he did not build or improve for put,-
AUG 7+ 996
pose of ealeJ. "
I,us owner of the property,ain exclusively cotnmcting wiib licenud cotnmcton[o t, TOTAL'
construct the project(Sec.7044,Business and Professions Code:)The ContmcmeLi.
aeoaeLaw does not apply 10anowner ofpropenywho bull&m improves[heteem,and QTY PLUMBING PERMIT FEE I I-UI- GUI-Lft I Alli
who contracts for such Projects with a contracmgq licensed pursuant o the Compactors o
License law. PERMIT ISSUANCE
❑lam exempt under Sec. ,B&P C fonhis reason
ALTER-DRAIN&VENT-WATER EA) VALUATION B
Owner '� � Dam
t WORKER'S COMPENSATION DECLARATION -
I hereby afr O under BACK FLOW PRO!ECT.DEVICE 0 C' ,
Penalty of pepury one of following declarations:
❑I have and will maintain a Certificate of Consent m ulf-insure for Workers Camper- DRAINS-FLOOR,ROOF.AREA,COND.
.tion,as Provided far by Section 3700 of the Lahor Code,for the performance of the 'TORIES, TYPE CONSTRUCTION
work for which this .it is issued. FIXTURES-PER TRAP
❑1 have and will maintain Workers Compensation Insurance.as required by Section
3700 of the Labor Code,fon he performance of the work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number are:
Cartier: - Policy Nn: GAS-EA.SYSTEM-OVER 4(EA)
CCRTIFICATH OF EXEMPTION FROM WORKERS'
. COMPENSATION INSURANCE - GREASOINDUSTRL WASTE INTERCEPTOR
(This section need nm he complied if the permit is forone hundred dollars(S1BE BUILDING DIVISION FEES
or less.) - _
GREASE TRAP
I wanly thatform
in the perunce of Ne work forwhich this permit is issued,label] PLANCHECK FEE
not employ any Person in an manner so m to become subject the Workers Com n- SEWER-SANITARY-STORM EA,200 PT.
Y J a ENERGY FEC
sppli"used California.Date'
O Applicant - WATER HEATER WNENT/ELECfR
77 pP GRADING FEE
, Gro
NOTICE camesubject
j APPLICANT If,after Comptauationng this Certificate of Labor to d you,you ouldmost WATER SYSTCM/fREATING SOILS FEE
a become subject y the Waters Compensation provisions of the Labor Code,you must
GTa forthwith romply with such provisions or this permit.ball Fe Deemed rcvnkcJ. WATERSERVICE '
d n
,�. z CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PLMB. SQ.PC PAID
U0 herchy which
thin them issue(Sec.3 .Ming agency for the performance of - Date Receipt
u. F me wink rte.teen tai,perms is issued(Sec.3M.civ.c.) .
0 U Lenders Name _ TOTAL:
Lender's Address - TOTAL: l�a�
t�" y I certify that 1 have read this application and state that the.hove information information is - BUILDING FEE
�•� IA coma.]agree to comply with.1 city and county on inances and stet.lawn relating[. QTY. MECHANICAL PERMIT FEE
U� building construction,and hereby authorize representatives ofmis city m emerupon the SEISMIC PCE b
abovementioned prnpeny for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cupertino Using ELECTRIC FEE
liabili0eajudgmenb,costs and expenses which stay in any way acme against said City ALTER OR ADDTO MECH.
in con"iscrna of the granting of this Permit. PLUMBING FEE
ICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT 00 Ig000 CFM)
SOU CRE UL 3N5. MECHANICAL FEE
41 JAIR HANDLING UNIT 10,000 CFM) CONSTRUCTION TAX
Sig mofAp icanl/Contaleer, Date t 6HAUST HOOD(WMUCT) L
'HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building occupant some or handle hazardous anterial HEATING UNIT,(TO 100,000 BTU)
av defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code.Sectimn 532m)T HEATING UNIT(OVER I OL"BTU)
[2 Yea UNo VENTILATION FAN(SINGLE RESID) PAID
Date Receiptp
Eadecll e oil coamorfmure building by upant the
Are.
QuordManaemes ent BOILER-COMP(3HP OR I00,0008TU
earl hezadoun air cnntuminuma as def sed by the Buy Area Air Anality Management )
Uiatricfl TOTAL:
❑Yea ❑No BOILER-COME(OVER 1(11,1X10 BTU)
I have read the huzardnus mated.],teyuiremen.s under Chapter 6.95 of the Cali- AIR CONDITIONER
ISSUANCE DATE
fitmi Health&Safety Cade ecd..25505,25533 ars 25534.I undmmd that if Bre NEW RESIDENTIAL MECH. SQ.ET.
ding a.nacuremly ate. tit is my.Pamildlity to notify the occupant
of req ircmena le', he rtoias once nfu Certificateof0c,,rancy.
e
Owner or ottani agent _ Uate TOTAL: ISSUED BY:
OFFICE'