30274APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
PERMIT NO.
7
BUILDING DIVISION APPLICATION/loo PLUMBING -MECHANICAL.
BUILDING PROJECT IDENTIFICATION
30274 O 2 1
ILDING ADDRESS:
ZZ.,� Y /!�O_ ce -
SANITARY NO.
APPLICATION SUBMITTAL DATE
7.2A_4 t'6
O ER'S NAME: a PILON'
M.rf
C< A ORSN 1P'. !d LIC NO:
NIC
❑
CONTROLp
RCHITE IENGINEER: LIC NO:ADDRESS:
/1
LL c Ea./C/� Aw
PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB MECH
❑ ❑
WOO,(Il)ofDivision
F��
UU1.iak
W
FCOWA�
LICENSED CONTNACfON'S DF.0 .ARATION
hereby atio n that 1 am licensed under pmvisions of Chapter 9 (commencing
3 alone Business and Pmfessiens Ced,ond my ho,amols
eff«I.
Data Cannot
QTY ELECTRIC PERMIT FEEC=Z
JOB DESCRIPTION
RESIDENTIAL'
❑SFDWL ❑ KITCHEN REMODEL
❑ADDITION [I PLUMBING RI'rPIPE
El STRUCTURAL
MODIFICATION
[I INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT
EKOTH REMODEUREPAIR El DEMOLITION
❑ OTHER
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
Q
~ y Z
p Z, I: _
p
ARCHITECTS DECLARATIONElMULTI-UNIT
I understand my plans shall to used as public records
I ANUS
UPTO 200 AMPS
1-Nf-Y1
�YF,;
C Q
K3 a U
W L y
F"1='fig
Licensed Professional
OWNER -BUILDER OHCLARATION
1 hereby affirm that I nm exempt from the Contractors License law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a pemdt to construct. alter, improve, demolish, or repair any structure
prion to its issuance, also requires the applicant for such permit to file a signed statement
201d000AMPS
OVER 1003AMPS
HCOMMERCIAL'
SIGNS ELECTRICAL
SPECIAL CIRCUTUMISC.
Eay
u1�0C,
E.
X M LL
I—Z
F X>'
iSC❑Las
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thin he is licensed pursuant to the provisions lithe Contramts License Law, (Chapter 9
(commencing with Secrien 7").f Division 3 ofthe Bromessaod Pmfessiens Calc).,
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section ]031.5 by any applicant for o permit suhj«Is the applicant to a civil penalty of
not more than five hundred dollars (SSW).
ownerof the progeny. or mycmploy«swish wages as their xul<cnmpensaion.
will doth, work. and the structure is not intended oroffcred for sale (Sec.JOJ-1, BusinessTHER
and Professions Code: The Comractor's License law does not apply to an owner of
who builds or improves thereon, vM who docs such wed himself or through
TEMP. METER OR POLE(NST.
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT ❑FOODSERVICE
h1PROVEMENT
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES -FI%TURES —�
progeny
his own employ«s, provided that such improvements am not intended or offered for
sale. If. however the building or improvement is sold within one year ofmmpletion. the
owne,builder will have the burden of proving that he did not build or improve for per-
NEW RESIDENTIAL ELEC R SQ FT.
SQ, FT, FLOOR AREA
$/SQ. FT.
pose of sale.).
I, as owner of the Mo,my, am exclusively contracting with licensed contractors to
omanti the project (Sm. 7046, Business sad Professions Com,The Cnnaowan. Li-
JUL 2 9
1996
TOTAL:
Law does not apply to an owner of property who builds or improves thereon,
nu la
Q TY PLUMBING PERMIT' FEE
who contracts for such projects with a contmctorts) licensed pursmnuo the Contranoes
License Low,
1 im exempt under Sec. .B& P C fur this ..,,an
f Ur li(Jf LIsI IIY(J
l PERMIT ISSUANCE-jl
-
Owner
N
WORKERS COMPENSATION DECLARATION
ALTER - DRAIN & VENT- WATER IEA)
VALUATION
RACK FLOW PROTECT DEVICE
1 hereby affmn under penalty ate perjury one of the r
iog declket's
7poa
insure C
❑(nave and will forSectionCommeate3700 of the LmnoCode. for Chef Workers Compiler-
.workfas fur by Section 3]INI of the Who Code. for the performance of the
DRAINS-FL(I(3R.ROOEANHA. COND,
STORIES
TYPE CONSTRUCTION
hick this
work far which Iris permit is issued
FIXTURES - PEN'fRAP
_ `
❑ I have and will maintain Worker's Camlwmmi required by Saurian
3700 of the Labor Code. for the performance ofthe work for which this permit is issued.
My We penention
m6 }� nd Policy numbernrc:
I1-6;A
C,miuc0� t GAG! 90 '^'y'olicY No,:
CAS -IiA. SYSI'IiM-I INC. 4OUTLETS
OCC GROUP
APN
GAS - EA. SYSTEM OVER 1(I?A)
GREASI]INDUSTRL. WASI'I? IN'TERCF.p R
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
BUILDING DIVISION PEES
(This section need not he completed it permit is fmnne hundred dollars fSI1Nl)
nr IesaJ
CREASE '1'RAP
PLANCHECK FEE
I certify that in[tic performance ofthe work fn which this permit it Issued, I shall
parson employ any pein any maernnsat us a+ nest.., suhjun to the Worker,' Con+,pn.
SEWER -SANI'PARY-S'rORM EA. 2W IT.
in
ENERGY FEL
WAT IiR HEATER WNEN'I ELECTR
DING If
,z
7�
qy
F
=z
V -
0 V
a,i.a Laws of California. Date
Applicant
NOTICE. TO APPLICANT: If. after making this Cenitieme of Hacmption, you slu+WJ
become subject to the Workers Compensmme provisions oI he Lahor Code. You mus,
fortoxahcomplywith such pmvisions or this pennh shall bcdumted revoked.
CONSTRUCT ION LENDING AGENCY
I hereby affirm that there is a conometion lending agency for Pero mmice of
,he work for which this permit is issunl(See NAT. Civ. C.)
Lenders Name
WATI7R SYS' I'1?MnRIIAI'I NO
WAI'17R SERVICE
S FB
Dam Receipt Of
NF:W HESIUEN'TIAI. I'I,MB. SQ. FT.
JAID
TOTAL:
TOTAL"
Isander's Address
is
Gcorrect.
1 ccnify that I have rend this application and sonic that the Nice information
I agree m comply with all city and county ordinances and slate lows relating m
conswction, and hereby authorise representatives of this citym enter upon theMIC
QTY. MECHANICAL PERMIT Fbuilding
FEabove-mcmi
PERMIT ISSUANCECTRIC
'E
mrd property for ins,«tion purposes.
AL.I'ER OR ADD TO MECH.ince
MBING E
liabilities.' gmerim'.asandexpenses which may in anyway acerae against said City
qu cell the gmmi gofl sperms.
OCFM)
AIR HANDLING UNIT(TO IQfA
MECHANICAL
\
'LIC .T UNDERSL. AND WILL COMPLY WITH ALI. NON -POINT
O rREGULATION
MAIR
HANDLING UNIT(OVER 10.WOCFMI
CONSTRUCIIO TAX
EXHAUST HOOD(W/DUCD
HOUSING MITIG TION FEE
+gnamre of ApplicanUCommctor Dae
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (ND I00,000 BTU)
Will the applicant or future building occupant store or handle hexarders material
as defined by the Cupertino Municipal Cooc. Chapter 9. 12, and the Health and Safety
Code. Section 2553200'
If EATING UNIT (OVER IW." BTU)
❑Yes ❑No
Will she applicant or future building occupant use equipment or devices which
ami, haucandmis air conlaminants as defined by the Buy Area Air Quality Management
Dnstnm]
El Yes 0 N
VENTILATION FAN (SINGLE RFSID)
PAID
Data Receipt p
BORER -COMP OHP OR 000.000 BTU)
TOTAL:
BOILER - COMP (OVER 100.000 BTU)
AIR CONDITIONER
(have rtad the hamrdoux rmrenaL sn uMer Chapter 6.95 of one Cnli-
require
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. IT.
forma Hcnftb & Safety Cada Senium , that i 25533 anal 25534, 1 understand that if the
of bus,.,a. not currently have a team,, that it is ua responsibility to notify the occupant
ter IM requiremenu which moxa he met prior I. issuance of a Cenificam of Ottupaocy.
ISSUED BY: _
TOTAL:
Owner or authorised agent Dote
OFFICE