30535 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMUTING 30535 0 5 3 5
RUILDINGDIVISIITN APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: �-'I I� � 0- I/ 1`_ Q / W i Ceq,+ "C0. ��a�I SANIfARV NO. AP1LICATION SUBMI aa? /I'ALUA'fE
OWNER'SNAME: IY ! vPH(O^N,E:: 6.11_ �•L-JICV-ON'I'RACI' R'S NAME: 4L.1 LIC N(l: N •O
NIC CONTROI-#
ARCHTrELT/ENGINE IL LIC NO: ADDRESS: ,F ❑
CONTACT: PHONE,: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
F ❑ ❑ ❑
LICENSED CONTRAC'TOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby afama mat I am licensed under pm W,m,mf Cbapmr 9 hommeacm, JOB DESCRIPTION
',0Z with section nglo)ofDnision3 none Rosiness and rraresamn.eWnana ler nemse i. RESIDENTIAL•
F0-c Vz
in full force ani effcc �,,/ PIiRA11T ISSUANCE?
aVU License Class - Lica WQ CShVWh ❑KITCHEN REMODEh
How Date cmarm r-j/,Ssp,[ APPLIANCES-RESIDENTIAL ❑ADDITION PLUMBING RE-PIPE
Fay ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z p y Z I understand my plans shall he used as public records MODIFICATION
OZ—a UPTO 200 AMPS ❑INTERIOR JjJCHIMNEY REPAIR
W Licensed Professional 20 1000AMPS IMPROVEMENT
may,_t OWNBR-BUILDER DECLARATION OVER MPS [I BATH RIiMOUEf/ PAIR CDEMOLITION
, Q 1 hereM1y sperm that I am exempt from the Contrucmr'a Licensee Lnw far the
K36U following mown.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER — It ox
LL O H which requires a permit to coosuum,aIle,improve,demolish,or report tiny arucmm
�' priormits issuance,alsorequires the applicant forsuch Permit to files signed statement SPECIAL CIRCUIT/MISC.
y that he is licensed tomorrow it)are provisions of the Contmctolse W
s Licenw(Chapter9
D00 (commencing with Seaimn 7")of Division Sof the Business and Professions CWO or TEMB METER OR POLE INST. COMMERCIAL:
a 2 eC that he is exempt ahcrefrom and the basis for the alleged exemption.Any violation of 0 NEW BLDG/ADDITION ❑DEMOLITION
,d:2 so Section 7031.5 by anyapplicant for Or permit subjects the opplicuum it civil penalty of POW17R DEVICES 0TENANT FOOD SERVICE
Or more Nan five hundred dollars(5501).
IMPROVEMENT
L] SWIMMING work.and pro pengmmyemntended withwsed for sale
compensation, SWIMMIYG roOLEL[CfRIC
f F 0 will donne work,C and are mmcureis tors Licensor ow does not apply to an Business C OTHER
a3w
and Professions Code:That Contractors License Low Jtes not aPP1Y m an owner of OIITI.LTS-SWITCHES-FI%TURES
proper who builds or improves thereon,add who does such work himself or through
his axle employees,provided the such improvements am not intended or offered for NEW RESIDENTIAL ELEC 41 SQ W.
sale.If.however the Wilding or improvement is sold within one year ofcompletion.the SQ.PE FXGFt VIA SISQ.FT.
7
nerbuilder will have ane burden of proving that he did not build or improve for pur 'r� �1 CC
posse of sale.y
TOTAL:
O 1.as owner of the proplen exclusively rnam
tcting with licensed contractorsproperty, to
'17 1996
construct the pm*t(See.7UW,Business and Prnfecxion,CodCode:)Th
Cee Conan come Li- TIT
cense law does not apply to an owner of progenym
who builds or improves thcrr.and QTY. PLUMBING PERMIT FEE V
whocontractsfor such pmjmt%with acconmctor(s)licensedpmsoaan to the Contracmes t'pTit BeU
License law. PERMIT ISSUANCE r1-�
0 1 am exempt under Sec. .B&P C for this mown S/
\ Owner Data ALTER-DRAIN&VENT-WATER(EA) /VA VALUATION
WORKER
WORKER'S COMPENSATION DECLARATION BACK I 'OW PROTECT.DEVI7
( � /) /_ / 07JI hereby affirm under penalty onTedury one of the following declarations: tF
O l have and will maintain a Certifies,ofComscnt to wif-mom for Worker's Campion. DRAINS-FT. ,BOOK A. ONO STORIES 11 TYPECONSTRUCION
saaion,as provided for by Section 3700 of the Labor CWe,for the performance of the 1
work for which this pcman is towed. FIXTURES-PER TRAP
0 1 have and will maintain Workees Compensation Insurance,as required by Section 1
37M of are labor Code.for the performance of the work for which this permit is issued. GAS-EA.SYSTE F11 .JO T TS OCCGROUP APN
My Worker�gmainn laysurmnce to
C.
_ GAS-EA.SYSTEM OVER G(hil)
Carrier. .i1�. c �A o
CERTIFICATE OF EXEMPTION FROM WORKERS' ' / / GREASF/INOUSTRL WAS TEINTERCEPTER COMPENSATION INSURANCE Y / BUILDING DIVISION FEES
(This section need not he completed ifahe Permit is forum hundred dollars(SIM) GREASETRAP
m less.) PLANCHECK FEE
I certify that in the performance ofthe work for which this Permit is issued,l shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any mannerso as to become subject to she Workers'Compen- ENERGY FEE
O z .if..low,of California.Date WATER HEATER WNENT&LEMR GRADING FEE
Z Applicant
NOTICE TO APPLICANT If,after making this Cenificam of Exemption,you should WATER SYSTEMITREATING
F ; become subject m Bre Workers Compensation provisions of the Labor Code.you must SOILS FEE
forthwith comply with such provisions or this permit doll he deemed fevoked. WATER SERVICE
Q
= z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLM B. SQ.fT. PAID Date Receipt#
L)O Thereby affima thin them is a construction lending agency for the performance of
e work for which this permit i,issued(Sec.3197,Civ.C.)
1-"' are
Lender's Name TOTAL:
WLcnder',Address TOTAL: BUILDING FEE
G 1 certify that 1 have read this application and state aha the above information is
iF. EM correct.l agree to comply with all city and county ordinances and slate laws relating to QTY. MECHANICAL PERMIT FEE
Ll z building construction,and hereby aahorim represenatives of this city it)enter upon the SEISMIC FEE
above-memloned proper for inspection purposes. PERMIT ISSUANCE
(We)agree tor save,indemnify and keep harmless the City of Cupertino against ELECTRIC FIiE
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in PLUM RING FEE
asequence of the granting of this peit.
ma
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 ) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING SNIT(OVEN) ,X)1 CF CONSTRUCTION TAX
Signmure of Applieool/Commonr Dae 1:%HAUS'r IIODUIW/I3UC HOUSING MITIGATION FEE
HAZARDOUS MAT17RIAI S DISCLOSURE
Will the applicant or forum building occupant store or handle Warddus maternal H EATING ON['I'(10 l 00.0K)BI GO
us Jefned by tnc Cupertino Municipal Code.Chapter 9.12,and she Health fail Swid,
Code,Section 25532(a)'! HEATING UNIT(OVER 100,000 BTU)
Yes ION.
- VENTII.ATIONFANISINGLp RE ID) PAID Daae Receipt#
Will Me applicant m future building occuEana use egoipnamt m devices which
emit Urania-air contamirmil,tis dinned by the Bay Are,Air Quality Management BOILHR-COMP(31IPOR hu,PPORIU) TOTAL:
District? BOILER-COMP(OVER 101.000 B ITU)
E]Yea ®No
I have re ad a he hostrloum
smerials requimmcaly under Chapter 6.95 o1'she Cali- AIR CON DI"PIONBR ISSUANCE DATE
forma Health&Safety Cede,Sections 25505,25533 and 25534.1 understand;hut i1'ahe N17W RPS(DENTIN,MIiCH. SQ.Pr.
building dam,not currently hove a mount,that it Is my responsibility In notify alae occupant
of the requirements whlchmuahemvpriar xonrec mf.C'mifinnc of Occupmay.
O a
Ownc lir authono, yen Dot TOTAL: ISSUED BY:
OFFICE l