29380 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMI F NO.
BUILDING DIVISION APPLICATIONIP6RMIT PLUMBING-MECHANICAL. �n �O O
BUILDING PROJECT IDENTIFICATION .7 O
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
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OWNIeR'S NAME:rew I E OP 7Z$-08V.4
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\ftCHl9'ECq'/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ 'k
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby alum that 1 antlicensed te Im iocA provisions of Chapter 9(commencing JOB DESCRIPTION
map= with Serum
full rce ndSOofOivlsi0n9of the Business and Profusxious Coda and my license ix PERMIT ISSUANCE RESIDENTIAL,
Fly LiceneClass detect. ❑SFDWL ❑KITCHEN REMODEL
IIt U~ License Class Lie.#
6 z ad U APPLIANCES—RESIDENTIAL. []ADDITION ❑PLUMBING RE-PIPE
Nato UJIc C'S DE L
FU,� ARCHITECTS DECLARATION PANELS []MULTI-UNIT C3 STRUCTURAL
_y p y mmMODIFICATION Z 1 unde
d my plans shall be used as public records MODIFICATION
____14_0 UP TO 1-10YEA)AMPS INTERIOR El CHIMNEY REPAIR
� Licensed Pnsfessional 201-I(1p0AMP5 IMPROVEMENT
gay YY,� OWNER-BUILDER DECLARATION OVER 1000AMPS ❑BATH RF.MODEUREPAIR [I DEMOLITION
G C�� 1 hereby affirm Thal 1 ant exempt from The Gsmmctnr's Limnse Luw for the'
X3 c.U following reason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAI. ❑OTHER
41 a. which requires a permit to Construct,alter,improve,demolish,or repair any structure
0 prior bilk,issuance,also requires lhr.ppliwm fonmrh permit to rluasigncd stammer, SPECIAL CIRCI]IT/MISC.
oo�oo That he is licensed pursuant to the Provisions of the Contractor's License Law(Chapter 9
tY�p (commencing with Section 7")of Division 3 of the Business and Professions Code)nr TEMP.METER OR POLE INST COMMERCIAL:
6 60 1� That he is exempt tbcrefmm and the an...for the alleged Cxemption Any violation nT ❑NEW BLDG/ADDITION ❑DEMOLITION
_ Section 7031.5 by any applicant for a permit subjects me applicant to a civil penally of POWER DEVICES oe tmme than five hundred dol[.P$5D)), ❑ PR V ❑FOOD SERVICE
C=O ❑ La,novaerof the propcny,or mycntployeeswhh wugexaxmeirxolccnmpcnsxtian. SWIMMINGPOOLCLECfRIC _PR
wilid.IhC work.emllheswnurc is notimendcd ur uffercdforsale(Sec.]Ua4.Business ❑ LER
I�al and F'rofessims Calm'Me Commences License Law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES
property who builds ar Intpnrves thereon,and whc does such work himself or thrcour
his own employees,providr4 that such improvements are ore intended or offered for NEW RESIDENTIAL ELECTR SQ EF.
sale,If.hi the building or improvement is sold within one year of completion.the SQ.IT.FLOOR AREA Sl%Fr.
own
er-builder will have the burden of proving that he did not build or improve for pur-
pose of inde.).
L us owner of the property,am exclusively contracting with licensed comraaors to TOTAL: {{
m he project(Ser.]044.Buxine.a and Prdessions Codc)'Itm Commoor'e Lr P 4A
vsumc L.wdoes not applytoan owner ofprepcny who builds or Improves lhcmrtn,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a commends)licensed pursuant to the Commit BFCPCfor thixrtason MAR
License Law. PERMIT ISSUANCE MAR 5 1996
❑ lamcxcmpt and Sc .
11
ALTER—DRAIN at VENT—WATER(EA) VALUATION
Owner Dale ' C�CY IIICV
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE Ur uurt;n
I hereby affirm under penalty of perjury one of the following declamtio®:
I have and wi 11 annuitant.,Petri ficale of Consent to sdi-nmre for W..or's Comped- DRAINS—FLOOR.HOOF,AREA,GOND, STORIES TYPF.CONSTRUCTION
sation,in provided for by Section 37W of me Labor Code.for the performance of the
_ work for which this pandit is issued. FIXTURES—PERTRAP
❑ 1 have orad will maintain Worker',Cn a,mmion In,a....a,as required by Section
370a,ofthe tabor Code forme performanceofthe work forwhich this permit is issued. GAS—EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUT' APN
My Worker's Compensation Imumnce carrier and Policy number a2:
Carrier; Policy No.: GAS—EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXIiMPT10N FROM WORKERS'
COMPENSATION INSURANCE GRE,SFANDUSTRI.WASTE INTERCEPTOR
BUILDING DIVISION RIES
(This section need not he completed ifthe permit is fnnme hundred Aullurc IS I INl)
or less.) GRIiASE'I'ItAI' PLANCIIECK PEE
I certify that in the performance ufthe work for which This permit is issued,Ishall SEWER—SANITARY—STORM EA.201 FT.
mol emo
ploy any pen in any monx0 som
o, x to heme nahje,I to the Workers'Gmpa
tn- ENERGY FEEi
OZ ,.tion Unsaid Califumia.Doc WATER HEATER WNEW112LECI'R GRADING FEE
Z 0 Applicant
N NOTICE TO APPLICANT:If,after making this CCnilicne of Lxmaiaian,you should WATER SYSTEMfl BEATING
a ; become subject o The Worker's Compensation pmvisiorre of the Labor Code,you and SOILS FEE
DJ fordwiTh comply with such provisions or this permit shallh deemed revoked. WATER SERVICE
a. Q
CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
U p khereby
for
mithnmere isacans See,
lending agency lm me pedomnnm of Date Receiptp
the work for which This permit is isuod(Sm.3047,Civ.CJ
0 F' Lonsi Name T0'1'AL:
Lenders Address TOTAL:
1[roily that 1 have rend this application and state that the above Infnmation is BUILDING FEE
V0.) correct.L agree to comply with all city and County ordinances and state laws relating to QTY. MECHANICAL PERMIT 17EE
U Z building construction,and hereby mnhorizempresentatives ofthiscity Renter upon The SEISMIC FEE
aMwc-mentioned property for inspection pwposcsPERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cupenino against(WO PGE
liabilities,judgments,costs and expenses which may in any way accrue against said City AL'IERORADDTOMECH.
in consequence of granting of this lwrinit, PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIH HANDLING UNIT(TO 10.0(111 CFM) MECHANICAL FEE
SOURCE REGULATIONS. q71 170
AIR HANDLING UNIT(OVER 10,001 CFM) CONST RUCTION TAX
Signature of ApPliwm/Cornmear Date EXHAUST HOLD(W/DUC) HOUSING MITIGATION FEE
HAZARDOUS MAFERIAI-9 DISCLOSURE
Will The applicant or future building occupant.store or handle hazardous material IT HATING UNIT(TO 101LOOD BTU) w
as defined by The Cuperino Municipal CWe,Chapter 9.12,end the Health and Safety
CMe,Section 11532(a)'? HEATING UNIT(OVER 100,000 BTU)
Yu Nn
❑ V6YTILATION FAN(SINGLE RFSID) PATO Date Receipt#
i Will the applicant Or fmure buildup Occupam use equlpmcnt e,devices which
I hazsNms air contaminants m defined by the Bay Area Air Quality Management BOILER—COMP(3HPOR 1001100 11111)
TO'T'AL:
DistrictT BOILER—COMP(OVER IOOA00 BTU)
E]ye,' Fl No
I have read the hvandous materials requirements under Chapter 6,95 of The Cali- AIR CONDITIONER ISSUANCE DATE
form,Health R Safely Code,Section 25505,25593 and 25594.1 understand That if the NI7W RESIDENTIAL MECH. SQ.FT.
buildingdoe urn curently have.tenant.and it ism,responsibility sootily To,occupant
of the requirements which must be met prior m issuntce of a Cenifie.of 0ecupancy.
Owner or authorized agent Date Wq,AL ISSUED BY:
OFFICE