30395APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - E LECI'RICAL m ^ PERMIT N0. 0
HUII,DINC DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL 5
D '�.S Ariivn e
CONTACT: PHONE:
❑ Consultant Fees Paid by Applicant (Initial)
1 hereby shim that I um licensed under provisions of Chapter 9 (commencing
O0.'Z w{th Section]OW)of Division Sof the Businns and Professions Code, nnJ mylirenxe is
W- in full (ase and effect.
G U U License Class _ Lic. Jr
4s%R Ilam CaW
nclar
Vi -5 ARCHI'I-ECFS DECLARATION
Z O 1 understand my plant shall M used us public records
OZ--
P4 LL� Lac ns dProfessimcd '
,] OWNER -BUILDER DUCLARA11ON
G I hereby uffrm Nat 1 tan exempt from the Contractor's License Law for the
x�x O L U following mann. (Section 7831.5, Business and Professions Cade: Any city or county
W � O which requires a permit to construct. alter, improm
ve, demolish, or repair any svumnrc
prior lo its issuance, also requires the applicant lar such pennit to file a eigncd ormmem
an, that he is licensed pursiumb, theprovislonsof the Contractor's License Law (Chapmr9
�tYOO (commencing with Smoma700(d of Division 3ofthe Rusinevsand Professions Code)or
fY a shat he is exempt therefrom and the Isis (a, the alleged complier. Any violation if
an Section 703 L5 by any applicant for a permit subjects she applicanno a civil penalty of
ynor num than H va hundred holhrrs(S50B.
C❑ I, as owner of the pmpeny, or my employees with wages its their sole compensation,
will do she work, trade street isnot intended or oHerW for ade(See 7044. Business
m and Professions Cole The Contmmo's License Law dues not apply to an owner of
lY a ^
popery who builds or improves thereon, and who does such work himself or through
his own employees, provided that such impmvensems am not intended or offered Ino
sale. If. however, the building or improv em is sold withinone yearofcoundetourshe
en builder will have the burden of proving that he did not build or improve for put -
Pose of sale.).
1, as owner of the pmpeny, am exclusively comeacti ng with licensed contractors to
construct the project (Sec. 9DW. Husiness and Professions Code) The Contractor's Li.
cense Use dons not apply to an owner of pmpeny who builds or improves thereon, and QTY,
who connotes, forxuch prejeces with a cantations) licensed pursuant o she Cormacteei
License Law.
I tan exempt under Sec. , B& P C fnnhiss.son
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby union under penalty of perjury one of the billowing declarations:
I hoc and will nmirtem a CeniOcam nt C....sent to self -into for Wnrkeft Com(mm
called, us provided for by Section 3700 of the Labor Cade, for Ne perfo mum of the
work for which this permit is home,
❑ I have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Cmle, for the performance of the work for which this parmil is issued.
My Workers Compensation Insurance easier and Policy number are:
Carrier Policy Na.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Hots section need not he completed Ella, permit is forma, hundred dollars ($((NI)
;or less.)
I certify"a', eperfonnanee of wn ld rwhich rhis permil isissued, )shall
nos employ any pe in one,, a to 7 1 esu et to Ne Workeri Compen-
O z nasion Laws of 2 (r int
16
NOTICE
to NOTICE TO &PLICAITT: 1, a 1 mak i rix Ccrtilicnm of Cxmnptioad you should
biotomes comp a the Wnhers umpe ration emotions of the Labor CMe, you must
Ws -s forthwith comply with such provisions or this permit shall Mdeemed revoked.
i
COt SI them RUCTION LENDING ng ager V
U Q work I hereby
which
on his
a Nerc issued (See inn lending agency boobs performance of
U. theLe work for which Nis permit it issued (See. 3119]. Civ. C.)
0 C.1 Lender's Name
ow
Leader's I tend,Address
(n I reale, that 1 have also Thirty ad ,...and arm that the above inlormatian Is
C.)Zy building I ogre to comply with all city end countyamlive of and scam laws relating a QTY.
doosongconaedmo,nd hereby uuthodze mpreunutives nflhis city memerupon the
above-mentioned property lar iZn�-h
scs
(We) ogre, It, save, indean
harmlessthe CityofCulwninnu,,nmt
liabiblaw,judgmcats, costs and � anyway accrue alidrut said City
in canu9uersffaa fthe gmnsing AIII12Aa'NDERSTANDr PLY WITH ALL NON -POINT
HAZARDOUS MAVERIALS DISCLOSURE
Will the applicant or four, building occupant sure nr handle beard is am.:,]
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Hedth and Safety
Code. Section 25532(x)?
❑Yes 0 N -•
Will the applicant or future cut Icing occupant use e,idlunem or device, wldch
[emit hamrdoue air contaminants as defined by the Bay Amu Air Quality Management
District?
❑Yes E3 No
1 have mail she hrzmduus fictional, requ[remenns under Chapin, 6.95 of the Cali.
burns Health & Safety Code, Sections 25585. 25533 and 25534. 1 understand that if the
building does not currently have t mount, that it is my mxpansibility m mnify the occupant
of the requiremenu which most Ie met priorto tome of a Certificate of Overtone,
Owner ora ithami d.,car Date
ELECTRIC PERM IT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UPT02MAMPS
201.1000AMPS
'gtloMl2k5g
NEW RESIDIX07KI, ELEC'I'R YI. - SQ FP.
PLUMBING PERMIT
ALTER -DRAIN & VENT- WATER (RA)
BACK ROW PROTECE DEVICE
DRAINS- FLOOR. ROOF, An EA, COND.
FIXTURES - PER TRAP
GAS - EA. SYSTEM -I INC.4 OUTLETS
GAS - EA. SYSTEM -OVER 4 (EA)
GREASMNDUSTRL WASTE INTERCEPTOR
GRIiASHTRAP
SEWER -SANI'T'ARY -STORM EA. 200 FT.
WATER HEATER WNEN3'IELUM11
WATER SYSTEMaREATING
WATER SERVICE
NEW RESIDENTIAL PLMII. SQ. FT.
MECHANICALPERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,000 CFM)
AI I< IANDLIM3 UNIT (OVER 10,000 CPM)
EXHAUST HOOD I W/DUCT)
I MATING ON IT J1 0 100,001 BI Of
HEATING UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE RESID)
BOI I.ER - COMP (3HP OR I00,(XM BTU)
BOILER -COME (OVER 000.010 BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ, Fr.
OFFICE
TOTAL:
4 -i+ a IL
FEE
AUG 15 1996
BUILDING DIVISION FEES
PLANCHECK FEE
ENERGY FEE
GRADING FEE.
SOILS PER
PAID
Dae Receipt#
BUILDING IME
FEE SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCI'IONTAX
HOUSING MITIGATION FEE
PAID
Date Receipt#
❑ ❑ ❑
FEE
JOB DESCRIPTION
RESIDENTIAL
❑SFDWL 11 KITCHEN REMODEL
❑ADDITION p UMBING RE -PIPE
(] MOLT] 4UNIT '/(`-'3 S-TRUCfURAL
MODIFICATION
❑ INTERIOR ❑ CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEUREPAIR ❑DEMOLITION
❑OTHIiR
COMMERCIAL
❑NEWHLDG/ADDITION C2 DEMOLITION
❑TENANT ❑FOODSERVICE
IMPROVEMENT
❑ OTHER
4 -i+ a IL
FEE
AUG 15 1996
BUILDING DIVISION FEES
PLANCHECK FEE
ENERGY FEE
GRADING FEE.
SOILS PER
PAID
Dae Receipt#
BUILDING IME
FEE SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCI'IONTAX
HOUSING MITIGATION FEE
PAID
Date Receipt#