S 0396 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING'-ELECTRICAL PERMIT No.
BUILDING DIVISION APPLICATION/PERMIT11I,UMBING-MECHANICAL S 0396
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS:,,a ^� ^ oe ' ,r SANITARY NO. APPLICATION SU11M1IITTAL I)AI
OWNER,4is " �Sr�nIHO ^/ ^ CONTRACT IC
NIC CON'I'Nol.x
ARCHITECT/ENGINEER: LIC NO:
I WEN
NryyOEE: AUDRLF$S� /. G(N�W /) ❑ .
CONTACT: PH7i1 ❑�/�✓Consultant Fees Paid bbyyy Applicant(Initial) BLDG BULG PF.Rht;�yNPO
NW
LICENSED CONTRAC'Ii1R:S DECLARATION QTY. ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby i flims that 1 am licensed under pmvLsions of Chapter 9(commencing _
DXZ with Sution/0X0of Divi.vion3ofthe Businessun 1 rtes.ons N nJ my licenses is RESIDENTIAL:
w p PERMIT ISSUANCIi
�1— in full force and effec �O - ❑SPOW'I, [I KITCHEN RE.MOD1i1,
FFQ,Z� ;itrnw Cl cs Cunamcar APPLIANCES—RESIDENTIAL ❑ADDITION 0PI.UMBING RE-PIPIT
NQL - ❑MULTbUN1'T ❑STRUCTURAL
AHCHITECI'g DECLARATION PANELS
Z O r"Z I understand my plans shall be used m public record. - s hIODIFlCATION
pZip UP TU 200 AMPS El IN'] _ ❑CHIMNFY REPAIR
�4(:W Licem,d profassioval 201-1000AMP$ IMPROVEMENT �SWIMMING POOLS
C W f; OWNER-BUILDER DECLARATION OVER 10(0AMPS ❑RATII RI MODIi11REPAIR ❑DEMOLITION
C=6 ' 1 hereby.ffirm that I am exempt from the Contractor's License[.me for the
XOWU following reason.(Section]031.5,Business and ProficWoas Code:Any city or county SIGNS ELECTRICAL El OTHER
W LL N which requires a permit In comma,alar,improve,demolish,or repair any structure
0 5 prior to its issuance,also requires the applicant for such permit file a signed stamnicnt SPECIAL CIRCUIT/MISC.
� } (hal he is licensed pursuant the provisions of the Contracmrs License Law(Chapter 9 COMMERCIAL'
W p (commencing with Section](XX)of Divi.aon 3 of the Husiness and Professions Oxide, TEM IIMETERORPOLEINS'n
that he is exempt thereGmn and the basis for the alleged exemption.Any vlolmion of ❑NEW BLDG/ADDITION ❑DEMOLITION
W N
Section 7031.5 by any appli9unt turn Nmul n.hj,,I,Iap
haplicant to a civil Faulty of POWER DEVICES ❑TIiNAN'I' ❑FOOD SERVICE
FZ)- nal more than live hundred dollars($500). IMPROVEMIiNT
F.=G ❑Las msecr ofthe Propcny.m myempluyecs wnb wages as Heir sole aamPensntinn, SWIMMING POOL ELECTRIC
F. will dnthe work.and lhestmcmre is not intended nroBemd far said(See 70,U1,Hminess ❑OTHIiR
W�ro and Professions Cade:The Commaor's License law dexs not apply m an owner of OIITLIR'S-SWITCHES-Iq%TURES
S�' property who builds nn.improves thereon,mal who does such weak himself 9r through
his own employees,-provided thin such improvements are not intended or offered for NEW RESIDENTIAL CLECTR SQ if.
nalc.If,however thebuildingurprovemem is sold within one year efcompletion.the >LOOR AREA $ISQIT.
,
o
owner-builder will have the harden of proving that he did not build err Improve for pnry CEIVE
pn c of sale.). TOTAL: -
0 L as owner of the pmpeny,am exclusively cormcting with licensed c+nd a,,or,u,
msmad me pra;ecl(See.20W.Business and Pmfcssiemx C:ded The Comment-Li- SEP 3 01997
cense law data.net apply to an owner of propony who builds or improvm thereon,and QTY, PLUMBING PERMIT PEE:
who contracts for such prejecis with a cuntraaot(s)licensed pursuant o the Conlmclors
License taw. PE 1*1 SUANCE BY.
1 am exempt under Sec. .B&P C for this rccwm 1
LTER-1 &VENT-WATER IEA)
Owner Dale
WORKER'S COMPENSATION DECLARATION HACK FLAW 1' 1.DEVICE .9
1 bred will onunderpouchy ud Perjurydncof thefollowingdcclannionn: o
(have and will mainmine CertiOca¢of Cnnwnnn mlf-insure for Wnrk.r's Cnmpen- DRAIN R iA.COND. STORIES TVPIi CONSTRUCI'10
sermon,as Provided for by Section 31W of the IaM,r Cade,for me performance of the
work for which this pencil is issued. FIXTURES—P ,
mq I haw and will maintain Workers Compensation Insurance,as required by Section
39BDofine Labor Code.for the peRormance of the work for which this panni)is issued. GAS—ITA.SYSTEM- 1 OITfI.F.7 OCC.GROUP APN
My Work eryn ren Wu IRT. and Poli, '
Cartier: i letad
Nay m•� .`�"�� GAS—IiA.SYSTLM1I-OVFEE4 )
CERI'117ICNI'1:OF EX EM PTION FROM WORKERS' GIt1iASNINIll15TR1.WASTE IN'1'IiRCE1TOR
COMPENSATION INSURANCE BUILDING DIVISION ITIS
(This section neat not he completed lfthe panni)is limon,hundred dollars sI(XH GRP.A.SETRAY
PLANCHIiCK 19i1i
less)
Icrod"hm in the performance of the wnrkfor whichnhispermit isiasaeJ.l shall SEWER—SANITARY—STORM E.A.2011 FT.
not employ any person in any manner so as m became subject the Workers Compen- ENERGY 19iIi
Z stand Laws of C.lifomi..Dale WATER BEATER WNENT/T:LECTR GRADING FEE
Z O Appccam 1
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMO'REATING
h SOILS IOHi
a !" Ruthwi xubjd<t nt the Workers Compensation pmul 0.1 of the Lahr Cade•you nmsl
G fnnhwilh mntply wnb such prnvisiom ur thx permit shall be decin,d tnvokeJ. WATER SERVICE
¢7
= z CONSTRUCTION LENDING AGENCY NII W RESIDENTIAL PCMB. SQ.FT I'A1D .
I herebyaffimt that thele is.communion lendingagency forthe pedomtanttof Uta Receipt a
I.I.v- the work for which this permit is issued(Sec.PN],Civ.C.)
QLcnder's Name TOTAL:
U Lender's Address TOTAL:
r 1 I certify thin I have rad this application and slam that the above infnaci ion is BUILDING ItiE
y correct.I agree to comply with all city and county ore irnaov, of.tae laws relming m QTY. MECHANICAL PERMIT FEE SEISMIC FEE
U building construction.unit henchy autheebe mpmsammlves ofmix city to emsr upon the ]�
d,uvu-mcntimad p,,,,Hy hump dam purpooas. PERMIT'ISSUANCE D ELECT RIC ITB.
(We)agree ma save,inderaanlfv and keep handless the City of Cupenion against
liahiliaies.judgmmns,c 1,and v.,muwhichaay in any way,accrue agaimt.said City AITERORADDTOMECIL PLUMBING ITH
in consequence of the gmming of this permit. p
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000CFM) MECHANICAI,FEE n.7 ❑
SOURCE REGULATIONS.
W
DLING UNIT 10.000 CFM) CONSTRUCTION TAX
Slgnamre m Applicant/Canlraclor Dvm I HOOD(W/DUCT') I IOUSING MI'1'IGA'TION FEE
I IAZARDOUS MATERIALS DISCLOSURE /�Will the applicant sur home building occupant store or handle Inuarde-mumrisl UNIT UTO 100.0X1 BTU) F-��as defined by the Cupenine Municipal Ccdc,Chapter 9.t,2,and the 11,nilh and SafetyG UNIT(OVIiR IIXLIXMI PTU)Ccdc.Sxlio.25532(.)'!❑Yes No ATION FAN(SINGLC:RESIDI PAID Dvm RceeiplWill the applicant nn.future building occupant use equipment or devices which —COMP(SBP OR 101.1X(IITUIroil hamrdnus air Contaminant,as defined by Ilia Buy Area Air Quality Management _ TOTAL:D"Incf! �/ —COMP(OVER I('ditt"'fU)❑YesMNi(have re:d tits haevJaws mamrial..requimmcros under Chapter h95of lits Cali- CONDITIONER ISSUA(N�CE 1))iTIi,,,���///
humin Health&Safety Cade,Sections 25505.25533 and 25531.1 umkr.tand that if the NEW RESIDENTIAL MECIL SQ.FT /'
hmldm,dms tcu Iy have a tenant,that is is my resrymaibilirymnn'fy lit occupant / V /
ofthe •max c muse be 7t prior ur issuance of a Can m d y.
ori'eed Igen) )m - TOTAL: g O ISSUlUR, A 7-p/may/�)
`�
OFFICE