29996 APPLICill FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY ' - -
CITY OF ' BUILDING-ELECTRICAL - PERMIT NO. }<UJ^9I(9 6^
BUILDING*DIVISION APPLICATIONIPERMIT PLUMBING 'LJ'.MECHANICAL
BUILDING PROJECT IDENTIFICATION
- BUILDING ADDRESS: - _ .SANITARY NO.. APPLICATION SUBMITTAL DATE
OW 'S NAME: HONE. CONTkACT k'S NAME: LIC N4
C N/C CONTROL#r
RCH ECTMN E - 'CLIC NO: - AD ESS: -
. 3 A S.
CONTACT:') e � PHONE: BUILDING PERMIT INFO
5 ❑.Consultant Fees Paid.by Applicant(Initial) BLDG ',- ELECT -PLUMB MUCH'
LICENSEDCONTRA ORSDECLARATION_ _ QTY. ELECTRIC PERMIT FEE' ,
1 hereby affirm that I am Ilcensof -p tions of Ch
r 9(commoncing - JOB DESCRIPTION
CmZ waM1 Secf n70W)of Df L' n3of the Bustne dMofesdon C de and my license is - RESIDENTLIC:
00 nfull fmceenJ off t - PERMITISSUANCE
WF'„ 3 S CSFDWL El KITCHEN REMODEL
.Zpp License slu Lic.# APPLIANCES-RESIDENTIAL []ADDITION El PLUMBING RE-PIPE
yW� Dote ••��TbConwemt _ _
22 ARCHITECT:SDECLARATI ❑MULTI-UNIT ❑STRUCTURAL•
Z 0'/aq IunderntanJ my plans shall be used
as
public records ,PANELS_ MODIFICATION
pZr30 UPT0200AMPS, 'R El INTERIOR El CHIMNEY REPAIR
9 Lice ed Professional 201-IMOAMPS IMPROVEMENT
m •.t OWNER BUmptfr U[CLARATION OVER IWO AMPS BATH❑BATH REMODEUREPAIR 0DEMOLITION
6 I hereby so :(S ct that l V exempt s N C t t L e Law far the
ip5t O EEE U I'.11. g (Sect ID315 Busing.and P f nn C de A oy ar county SIGNS ELECTRICAL' at D,OTHER.
F W�
which q perm t 1 .t t alterimprove,demolish. era r sttvcmre _ -
prix t t I q th ppl atmf h"pardt flee gnc t tement SPECIALCIRCUI'VMISC
Ihat h licensedpursuant t theprovisions ofthe Commence L e La ( pter9 _
p (.oro g with9 t 7000) fD "on 3 ofthe Business and Pmf ' C )or TEMP.METER OR POLE INST. COMMERCIAL, ,
d e a that h exempt therefros and the box's r thealleged exemption A y 1 t �f - ❑NEW BLDG/ADDITION ❑DEMOLITION
ti�5 C Semton]031 5 by any applicant for a term v bl is theapplicant t 'I p t Its POWER DEVICES , �p.
tuv - - '' ENANT ❑FOODSERVICE
ii not more than five hundred dollars($500) s IMPROVEMENT
G ❑I as owner offle property,or my employees with age.a their lecompensation, SWIMMING POOL ELECTRIC
will do the work,and the structure snot intended r fferelf r (Se 70,34 Business LJtifHER
' and Professi Cade The Ourroulms License Law does not apply,,.na owner of OUTLETS-SWITCHES-FIXTURES
6 property who builds or improves thereon,and who dues such work himself or throughIV4;p
-
his own employees,provided that such improvements arc not,intended or offered for .W RESIDENTIAL ELECTR SQ PC
sale.IL however,the building or improvement is sold within ane year ofemapleti.n,the' SQ.FT.FLOOR AREA a $/SQ.ET.
owner4milder will have the burden of proving that he did not build or improve for put-
Prop of sale.). TOTAL:
❑1,as owner of the property,am exclusively contracting with licensed emonscims to Nx
Q JUN g
vscros I dmpr.ject(Sp,.9014,Business find Profession.Cade)The Contractor's Li..
cense Law data not applyioan owner of pr.penywho builds or improves thereon,and QTY. UMBING FEE 1996, `
who..nlmelsf.rxuch projects with u contractions)licensed pursuant to the Contractor's v
License La,
r7I am exempt under Sec. B&P C for this reason PERMIT ISSUAN (eurCn j NO y
ALTER-DRAIN& NT-W,TE ) VALUATION
Owner Dam _
WORKER'SCOMPFNSATIONDECLARATION BACK FLOWPROTECT. EVICE
I hereby affirm under penalty of perjary one.f the following declaration, -
❑I have and will maintain it Certificate of Consem to self insure for Workers Codger- DRAINS-FLOOR,ROOF,A EA,CONE. 'STORIES TYPE CONSTRUCTION
sultan,as pmAded for by Section 37M)of the Labor Codeperformance,far the perrmance of the ,
work far which this permit is issued. - FIXTURES-PER'PRAP _
e t 0 1 have and will maintain Worker's Coup,me timi Inamence,as required by Section
3700 ofthe Labor Code,lbnhe peffmmance ofthe work for
pwbhiiicchthis
Permit is issued. GAS-EA.SYSTEM-1 INC.4 DO TS OCC.GROUP APN
My.W'rt rynjlerp��nlA refc�ierolay NorPot y-LJ3.41J 00 GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE.OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE OREAS DUSTRL WASTE INTERCE R _ _
(This section need not be completed ifthepefmit is for ane hundred dollar,(SIM) , 5 AUILDINO DIVISION FEES
.r less.) ,j GREAS pLANCHECK FEF,
I certify that in the performance of the work for which this permit Is issded,I shall
nm employ any person in any manner to as wherefore subject m the Workers'Cowper- SEWER Y T FEE
action Lows of California.Date
Applicant
Uj NOTICE TO APPLICANT.If,aftermaking this Crofflo m of Exemption,you should WgTER S 1
a' become subject to the Worker's Compensation provisions of the Labor Code.you most f E
w forthwith comply with such provisions obis permll shall M1e deemed revoked. WATER v -
A ,
� •CONSTRUCTION LENDING AGENCY '' v
U y f^ m NEW kE ID L L PAID
L)rnr lb. whihthi thanhereisacomwcti0n len di,agency fonhc performance of -Date , Receipt#
G4 (~ the work for which This permit is issued(Sea 3017,Civ.C.),• ! -
O U Lenders Name Pm* 91
noon ` TOTAL:
Leader,Address
Will
G 'I certify that I have red this_application d state that the bo " formation is iLDING FEE
re r 1 gree i comply with I city d ty d d state laws relating to QTY. I I
V' b.ild gconswction,and hereby vuth.rize repmsenfe6vos ofibtsuuy to enter upon the Q FIj1111 =r SEI ICFEE
above-mentioned property for inspection pialtowx. - pERMITISSUANCF. "
(We)agree wr save,indemnify and keep harmless the City of Cupertino against ELECT CPU FEE
liabilities,judgments,costs and expenses which may in anyway sector against said City ALTER
In conseNuence of the granting ofthis penult. _ _
NWOM
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR H D NGUNIT(T 0,0 PM
SOURCE RE//tp_ULATIONS. - / MECHANICA P�EE
AIR H Al
Signa mwAUlicandCmw - Date EXHAUST HOOD(W/DUCTI - HOUSING MITIG '
HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant stere s handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defiand by the Caperton Municipal Coda Chapter 9.12,and the Health and Safety
Code,Section 25532(.)? HEATING UNIT(OVER 100,000 BTU)
E]Yes No I rs, VENTILATION FAN(SINGLE RESID) • PAID s
Date Rv4ipt#'
-
Will the fit muant.diture building by apart use the
Are.
ipment or Aur
Management
BOILER-COMP(3HPOR 100,000BTU)
mit hazardous air contaminants as JefineJ by the day Area Air Qualify Manegemenf T L
District? - -.
❑YesBOILP.R-COMP(GVBR'111II,IMId BTU) .,
I have read the hazardous mmen'als AI R CONDITIONER r' - -
r5.25533imc under Chapter 695d that f1he y ISSUANCE DATE
fomle Health&Safety Code,Sections t,me"25533 and 25534.I understand that If the _ NEW RESIDENTIAL MUCH. t, •ESQ.PT. '
t building mopro iNnormallywhich have.tenant that f y p biltyf poor,the recup.m ..
of fh req ' nt which must bajnu pnort anrcs,.fn Cerrificam,ofOccupancy.'
Oovacrorainjawixed.,ew - - Date ' TOTAL, ISSUED BY: -
" OFFICE
Inspection Query for a Specfic Permit 4/7/97
I
FURNMI'MM,$5T19310 PRUNERIDGE UNDERSLAB 6/10/96 6/10/96 CC 5P
19310 PRUNERIDGE PLMBG 6/10/966/10/96 CC 2P
19310 PRUNDRIDGE FRAME 7/11/96 7/11/96 CC 2P P
19310 PRUNDRIDGE FRAME 7/11/96 7/11/96 CC 2P P
19310 PRUNDRIDGE SHEET SCREWS 7/16/96 7/16/96 CC 2P P
19310 PRUNERIDGE GREASE DUCT 8/22/96 8/22196 J6 2 N
19310 PRUNERIDGE FRAMING 8/23/96
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