S 0473 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPFRTINO BUILDING-ELEC'T'RICAL PERMIT'NO,
NUILDING DIVISION APPLICATION/PF,RMIT PLUMBING.-Nn!Ct1ANIC'U. S 0473
BUILDING PROJECT IDENTIFICATION,
SANITARY NO. APPLICATION SUI3M1'1-TA1.DATE
ILUING ADD .SS:
/1/// �! q
NER'S NAME PHONE: N'RACTOR'S NAME. LIC NO'.
t �V X NIC CONTROL#
ARCHITECT/ENGINEER: LIC NO: A DRESS: ❑
CONTACT:
PEON'
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT' PLUMB MECB
A
LICENSED CONTRACTORS DFCI ARATID QTY. ELECTRIC PERMIT -FEE
1beans ef0rm th sI 1 l d p dChapter (commitments
JOB DESCRIPTION
DaZ with Section 7000) lluluss and Form
is Ede in I', w R RESIDENTIAL
Y100 wr PERMIT ISSUANCE
I`_IyF in full force and effect ❑SFDWI, ❑KITCHEN REMODEL
QUU 1.iccnse Class Lie k
APPLIANCES-RESIDEN'I'IAI. C1 ADDITION El PLUMBING RE-P[PE
FFZ DartContractor
y6G' ARCHITECTS DECLARATION ❑MULTLUNG7 ❑STRUCTURAL
Z p m I undersand Illy plan,,hull he mcd as public record, PANELS MODIFICATION
UP TD 200 AMPS
pZtQ OINTIiRIOR ❑CHIMNEY REPAIR
14,F'.,
� aT Licensed Professioal OWNER-BUILDER DECLARATION 2111-IaWAMPS IMPROVEMENT E]SWIMMING POOLS
.•.•11
OVER 1000 AMISS ❑BATH REMODIi1JR1iPAlli ❑DIiMQLITIUN
C Q I hereby affirm That 1 am exempt from the Cnnins Co License Law for @t
4050 W U following reason.Permit
t Ton 5,Business and Profession Code:Any city or clotty NS F.LIiCTNICAI. ❑OTHER
W 3 LL F' which requires a permit m corstmet,alae improve,h pevademolish, fill
repair any swcwre
In.,he ,licts esedpralsore,o ffic theapplicant for sucConlonlol, kende wm stmement 51'E AL CIRCUIT''/MISC.
W999sss 4. thotheencinrmdpursuamunheprmision lithe Commemr,l-imn,claw lChepmr9
tYpO (cornmeneingwiOi Smtinn]IX10)nf Dividinn3rftM1e l{unincss and Pm@s,iomGde)rr [EMP. + ERORIINS'C COMMERCIAL
dp,c that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BIAG/ADDITION ❑DEMOLITION
xmlr- Section 7031,5 by any appl'urim,Ran permit subjects the applicant o a civil penalty of POWER DI: IC'S OTHNAN'T ❑FOOD SERVICE
Imo, y not rnaro than 0vc hundred Jnllurs(ESfO). IMPROVP.MENT
F�
F1 1,as owner of the property,or my employees with wages as their srlecompenatio., SWIMMING P L :LEC IC
Sa will do the work,and the sumcmre is not imendedoroffetcd forode(See.7044.Business ❑OTHER
W and Professions Code:The Contractor's License Law does not apply in an owner of OUTLETS-SWI\ IES-F 'TURES
property who builds or improves thereon,and whe does such work himself or hrough
his own employees,provided that such improvemcms are not intended or.(Trod for NEW RESIDEN'TAL .'1SQ IH'.
sale.If,however.the building or improvement ismldwithlnoneyerrofcornpletioii,the _ S0.FT.FLOOR AREA $/SQ.II'.
caner-builder will have the burden of proving that he did not build or improve for pur-
pose of sola).
E] 1,as owner of the property,an exclusively contracting with licensed contractors to 'TOTAL:
consoler the project(Sec.76 .Business and professions Cadc:)I'he Contractor's Li-
nseLaw does nor apply n+an owner of property who builds or holnowls thenen.and QTY. PLUMBING PER IT FEF.
who comanch for such projects wall.,conaacmds)licensed pumaenuo the Cantnnne,
License law. PERMIT ISSUANCE
•Fl I ma exempt under Sec. ,B A,P C for this reawnis
ALTER-TRAIN M VENT-WATER 1' VA LUAI'[ON
Owner Dae
WORKER'S COMPENSATION DECLARATION BACK FLAW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the following declamtions.
I have and will maintain.CiniOcumrfConenOoselbinsnre for Workers Compcn- R ,COND. STORIES TYPE CONSTRUCI ION
smarm,as Provided for by lection 3700 of be Labor Ctde,far the performance l4.the
work for which this permit In issued. "U PC-1'E TRAP
❑1 have and will maintain Workers Compensation Insurance,as required by Sethics Iss
3700 lithe labor Code.for the perforators of the work for which this permit is issued A. - .gYSt ii N L: . OCC.GROUP MIN
My Worker's Compensation Insurance carrier and Policy number am:
Cartier. Policy has:
CERTIFICATE OF EXEMF GON PROM WORKERS' MAP
COMPENSATION INSURANCE G ;A ' 1,T A R BU 1) +D ISION FEES
This secular need not be completed Line permit is Toren,hundred drllam($100)
or less.) - PLANCI U CK FE
I certify that in the performance of the work for%inch this permit is issued,Lsholl
not employ any person in any manner so as to beer subject to the Workers'Compete A -S • 21X1 IT, I?NERGY FEI:
,Z sotion laws of California.Date
Z Applicant - GRADING FEE
is
NOTICE TO APPLICANT.if,after reeking this Cenificme of Exemption,you should TER SYSTEM/TREATING %MITTGATTON
G
f+ ; become subject m the Workers Crmpennaran provisions of the lane,Cade,yon must
Wforthwith comply with such previsions or this permit shall he deemed revoked. Wp
CL Q
CONSTRUCTION LENDING AGENCY DEQ AL
7 z Iherebyaffimvhatthe.is a cnmswction lending agency forthe performance of Dae Receiptp'w the walk fr which this permit is i,ned(Sec.3097,Civ.C.) 'F(YI'AUU Lcnder's Name I Lender's Address Da TO'T'AL: GP1cetie thatIhavereadthisty andciuntyodram that the above infnmmtion is h correct.(agree to comply with all city and county ordinances and sate laws rupon tto QTY. M HA GALPERMIT hEEZhullAing ammrumion.and hereby amhorize representatives ofthis city to enmrurym the - FEhabove-mentioned prnpeny for inspection putpases. PERMIT ISSUANCE(WO agree ui save,indemify and keep harmless the City of Cupertino againstC FGEliabilities,judgments.costs and expenses whichmayin anywayaccme against saidCity ALTER OR ADD'FO MECH.in conseqence of the grating of this permit. G FEEAPPLICANT UNDBRSAND�. \ND WWILL COMPLY WITH AALL NONN--PPOINT AIR HANDLING UNIT(ToIR000CFM) ICAL FEES U EG I s/C/VVPAIR HANDLING UNIT(OVER10,(0 CFM) CTIONTAXSigna Appli_ant �gtmdor me EXHAUST HOOD(W/DUCT] MITIGATION TEE
H Z RDOUS MATERIALS DISCLOSURE
Will theapphrom ar furore buildingrccupatn store or handle ht,amousniaedul HEATING UNIT(TO I(0J00 PTU)
o,dcOnul by the Cupertino Municipal Code.Chapter 9.12.and the Ileahh and Safety
Code,Section 2553260? HEATING UNIT(OVER 100,000 BITE
❑Ye, ❑Nr PAID
\ VI3Nl'ILAI'ION PAN(SINGLE RBSID) D.te Receipt
Will the applicant or future building occupant use eyuipaund or devices which BOILER-COMP(3HP OR 1000 00 BTU)
emit hazardous air contaminants as def ned by the Bay Area Air Quality Management TOTAL:
District?
❑Yen ❑Nn BOILER-COMP(OVER Hillock B'TU)
I hove teal the hazardomanicrials on,maralm,under Chapter 6o5 of the Cali- AIRCONDITIONER - ISSUANCE DATE:
Rmiia does
n Safety Code.Sections 8505.25513 and 25534.1 understand that if thRESIDENTIALW RESIDENTIAL MECH. SQ.Ff.
buildingg ddes s mu currently which hast a met p that a is tea ce ofa hility to notify the occupant
of the reyuiremems which must be met prior h+issu�nce of a CeniOcam of Occupancy.
Owner or authorized agent Dam TOTAL' ISSUED BY:
OFFICE
Inspection Query for a Specfic Permit 10/14/97
FERMI ; �S.I_Ti S d TU3$TRE �C 00410,001
S0473 19111 IPRUNERIDGE REBAR 9116/97 9/16197
S0473 19111 PRUNERIDGE UNDRGRND ELECT. 9/17/97 9/17/97
50473 19111 PRUNERIDGE REBAR ROLLED-CH 9/17/97 9/17/97
50473 19111 PRUNERIDGE FRAME 9/18/97 9/18/97
S0473 19111 PRUNERIDGE ELECT. 9/18/97 9/18/97
50473 19111 PRUNERIDGE SR 9/18/97 9/18/97
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Inspection Query for a Specfic Permit 10/14/97
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IRS—59407, Wilts Pass/F,all[Codeel
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