B 0288 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNOZO
LAJILDING DIVISION APPLICATION/PERMIT ' PLUMRING-MFAAANICAL 50001 288
BUILDING PROJECT IDENTIFICATION O
r BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITI'AI.DATE
/039/ /P1Ver C✓est ��' 1 04" er /Ad
OWNER'SN E' / x�As PHO': — � CON'TRACTOR'S NAME: LIC NO:
Luc JJ N/C CONTROL#
.2CHITECTIGNGINF.F.R: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
tin I/
✓/ Qf 732^/79� ❑ Consultant Fees Paid by Applicant(Initial) BUID NR
ICH
PLUMB TH
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LIC SED CONTRACT'OR'S DECLARATION QTY. ELECTRICPERMIT FEE
I hereby ufdrm that I am licensed under previsions of Chapter 9(commencing - JOB DESCRIPTION
qaZ
with Section 7000)ofDivisioo 3 afro Business and Professions CmU,.ra my licensers RESIDENTIAL:
{{yy00 wt PERMI'I'ISSUANCF.
License full force Class eiTed. ❑SPDWL El KITCHEN REMODEL
i-UU License Class Lich APPLIANCES-RESIDENTIAL El ADDITION ❑P MHINGRI PIPE
Z Dale California.,ARCHITECT ARCHITECT'S DECLARATION El MULTI STRUCTURAL.
Zp.Z I understand my plans shall be used as public records PANELS MODIFICATION
UP TO 200AMPS
�+t3,I;W Licensed Professiomi
El INTERIOR 'O CHIMNEY REPAIR
r4t� 201-1000AMPS IMPROVEMENT ]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER IOIXIAMPS [_1 BATH kEMODF.IAREPAIR El DEMOLITION
I hereby affirm that 1 am exempt from the Corractor's Licenee Luw for the
{i�S O0,U following reason.(Section 9031,5,Business and Professions Coda Any city or county SIGNS ELECTRICAL ❑OTHER
I++W W y whicM1 requires a permit to constmd,filer.improve,demelish,or repair any stmcture
a)d Frito it,issuanat,aIs.requires the applicant forsucn pwmhm file.signed smtemat SPECIAL CIRCUITIMISC.
that he islicenwdpumuammthe provisions ofheContraetorsLicense Law(Cmm09
(commencing with Section 7000),dDivision 3 oflhe Busbusss.nd Professions Cale)m TEMP.METER OR POLE INST COMMERCIAL:-
GWJy e e' that he is exempt Therefrom and the basis for the alleged exempder.Any vidZiumn of ❑NEW BLDC/ADDITION ❑DEMOLITION
W^m Seclum 7031.5 byany applicant foraperaincojeets ths.pplimmt too civil penally of POWER DEVICES El TENANT ❑FOOD SERVICE
r more than five hundred dollars
F'Z�Y � IMPROVEMENT
6 N',as owner ofthc property,or my employees with wages as their.sole compensation, SWIMMING POOL ELECTRIC
$y�FO will do the work,and the structure,is not intended or offered for sale(Sec.7044,Business El OTHER
W 3� and Professions Code:The Contractor,License Law dws'not apply to an owner of OUTLETS-SWITCI IRS-FIXTURES
property who builds ocoup..a,thereon,nod who does such work himself or through
his own employees,provided that such improvements are not intended or oRend for NEW RESIDENTIAL ELECTR SQ Irl:
sale.If,however,the building or Improvement is sold within one year ofcmnplaror,the SQ.FI'.h;b F.A SISQ.FT.
ter-builder will have the burden of proving Mm ho did not build or Improve torpor-
1,
orper-
1,s owner of the property,am exclusively contmding with licensed cmmbranrs to TOTAL: JUL 10 ANSI
cor,towt the project(Sec.7044,Business and Profession,Code:)The Gmmanor's Li- -conse Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBINGPERMIT - FEE
who contracts for such p jells with a contrador(,a)licensed purwanfo the Contractor's CITY Ur I.,UrrhIINQ
License Law. I PERMIT ISSUANCE
❑ I am ar empl under Sec. .R&P C for Nis rosea
Owner ])areT
ALER-DRAIN&VENT-WA'I'ER(FA) VALUATION
WORKER'S COMP SATION DECLARATION BACK PLOW PROTECT.DEVICE
I edy affirm under penalty of perjury one of the following declarations:
-i have and will maintain a Cenifcate of Consent to hell-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIESTYPE.CONSTR UCTION
nation,as provided for by Section 3700 of the Labor Code for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section
37M of Me Labor Code,for or performance ofrhe work for which this permit is issued. GAS-IIA.SYSTEM-1 INC.40UTLH'IS OCC.GROUP APN
My Worker's Compensation bwumncb carrier and Policy number are:
Canis: Policy No": GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFJINDUSTRL WASTE INTERCEPTOR -
(Thisscedon need not becompleted ($I ifthe Permit is forone hundred dollars W) BUILDING DTVI@IQN PEES
or less) GREASE TRAP PLANCIICCK Ptltl
I certify that in the performance ofthe work for which this perrlit is Issued,I shall SEWER-SANITARY-STORM EA.200 NC.
not employ any parson In buy manner so vs to become subject or the Wrrkeri Crandi ENERGY FEE
O ,Z wrier Laws of California.Data WATER HEATER W/VE DELEC'IR
Z 2 Applicant GRADING FEE
r-t sNs NOTICE TO APPLICANT:if,after making this Cenifiess,of Exemption,yen should WATER SYSTEM/I'REATING
a , become subject to the Workers Compensation provisions of the Labor Code,you must _ SOILS FEE
aF-t forthwith comply with such provisions of this permit shall be deemed revoked. WATER SERVICE
Q
U CONSTRUCTION LENDING AGENCY NEW RF.SIDF,NTIALPLMB. SQ.FT PAID Date Receipt#
1 hereby affirm that mitthere,is s ed IScc,10 lending agency for the performuaae of
LAlive work for which Mie permit is issued(Sac 31Yl7,Cie CJ
Lende's Name TOTAL:
FULL Lender's Address _ TOTAL-
1 ceni[y That I have reed this application and spite that Tho.heel w,m minor,
is BIlIlA1NO FEB.
.r
h agree to comply and wlMall airyand county of
stat to ever upon the QTY, MECHANICAL PERMIT FEE
C.) �
building constnaloq and hereby authorize representatives of Ibis city to enter upon the SEISMIC f>Gtl
above-mentioned prnparty for inspection proposes PERMIT'ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino againel "62 HLEG ERIC FEE
liabilities.judgments.costs and expenses which may in any way aceme against said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit.
PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY Will]ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE D
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION"TAX
Signature of Applicant/Contractor Data EXHAUST HOOD(W/DUCT) HOUSING MITIGATION PEC -
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant slow or handle hazardous material HEATING UNI'PLED 100,OW BTU)
as Behind by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Service 25532(a)'t HEATING UNIT(OVER IBOXX)BTU)
E]Ya, ❑No VENTILATION FAN(SINGLE RESIDE PAID _
Will the applicma or future building occupant use equipment or devices which Data Receipt#
mit Freudians air conmminnew.1 defined by the Bay Area Air Quality Manogemenl BOILER-COMP(3HPOR I00,000RTU)
Moml - TOTAL:
❑Ver No BOILER-COME(OVER IW,OW BTU)
1 h:ree revel Me hvmNous materials requiremenw under Chapter 6.95 of the Cali- AIR CONDITIONER ^ ISSUANCE DATE
Romall&Safety Code,Sections 25505.25533 and 25534.1 understand that Bthe NEW RESIDENTIAL MUCH. SQ.FT.
building does net currently have a tenant,that It is my responsibility to notify the occupant
.fit.requlmmenm which must bound pnmr in issuance of a CertiOcmo of Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE
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OFFICE COPY
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RECFvpnD
JUL 10 1998
ol'l;ee SLOG. INSPECTION DEPARTMEI T
Co/ne/ Exist�il S�Ltds
I ✓� CITY OF CUPERTINO
—�I