29744 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY - -
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO, /1 9/N ra /1
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING.-MECHANICAL. 2 4 4
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
Bao 11h !l
O R'S NAM2:" - PHONH: C TRACTO 'S NAME: LIC NO:
4JSA. c"P ^ 38 �� rv/c cDNraol.w
ARCHITECT/ENGINBER: LIC NO'. AD ESS. ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT. PLI7UrAQy.-L� ID LICENSED CONTRACT'OR'S DCCLARAc11 1:1F ON QTY. ELECTRIC PERMIT FEE
I hereby a)Ern than a.1 l tine B.under and
Profession,
of Chapter 9(commencing JOB DESCRIPTION
F-aZ with Section
and
effect.
Divisinn7of the Business and Professions CnJe,and my license is RESIDENTIAL
WOO I'ERMI I'ISSUANCE RESIDENTIAL
in effete. ❑SFDWL ❑KITCHEN REMODEL
�U License Class Carucci.,
_
0. hate Conuactor APPLIANCIS—RESIIIENTIAL
L.Z ❑ADDITION ,$ThUMHING RBPIPE
V�Q ARCHITECTS DECLARATION PANELS ❑MULTI-UNI T' ❑STRUCTURAL
Z p Z I understand my plans shall be u.A as public records MODIFICATION
OZ-- UP TO 200 AMPS 0INTERIOR 0CHIMNEY REPAIR
�
q J Licensed Professional 201.1000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVER Ip00AMP5 ❑BATH REMODEUREPAIR ❑DEMOLITION
d I hereby affirm that I am exempt from the Contractor's License Law hoe O N I.U. tidlowing moron.(Section 0(13 L5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
WO yj which requires a'cour In amsnact,alter,improve,denmlinh or repair any someone
-61 prior to its issuance,also reforms the applicant for such permit n file a signed statement SPECIAL CIRCUI'P/MISC.
j. that he in licensed pmxuant to the mo,niomofthe Commuter's License Law(Chapter 9
OQ (commencing with Section 7000)of Division 3 ofthe Business and Professions Carbine TEMP.METER OR POLE INST COMMERCIAL:
6 X K
in.,he is exempt therefrom and rhe basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION. ❑DEMOLITION
Win, Section 7031.5 by any applicant for.pnmitsabjems the applicant tea civil penalty of POWER DEVICES OTENANT ❑FOOD SERVICE
^S} t mom than five hundred dollars(8500).
Q Q Las owner of rhe property.onny employes wioh wages es lhcir sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
[.A will do the work,and the srmcmru is not intended oroffered forsale(See.70V4,Business ❑OTHER
and Professions Code:The Contractor's License Law docs not apply to an owner of OUTLETS—SWITCHES—FIXTURES
4";^ property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such inspmvemiants amain Intendedor offered for NEW RESIDENTIAL.ELECTR SQ FI'.
sale.If,however,the building or improvement is sold within one yearof emn,letiogthe SQ.FT.FLOOR AREA S/SQ.PT.
owner-builder will have the burden of proving that he did not build or improve for put- [y
pom of sale,. L'� 8
❑1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
construct the project(Ser.II44,Business and Professions Cure:)The Contractor's Li. ,
manse law does and apply to an owner of property who builds or improves thereon,and QTY PLUMBING PERMIT FEE MAR 11. 199{
who csmtmcts for such projects with a commcmgs)licensed pursuant to the Contractors VV
License Law. x I PERMIT ISSUANCE
Owner ij V
I oro exempt under Sec. ,B&P C for thi'milson GII r 11 1
ALTER-DRAIN&VI7NT-WATER(EA) A Atli
Date
WORKER'SCOMPENSATIONDECIAItATION BACK FLOW PROTECT.DEVICE
I hereby affirm under l xibby of perjury one of the kolnwing declarations:
I haveand will mainmina Certificate sdf-inwrc far Warkcrs Co.,.- DRAINS—FLOOR,BOOK AREA.COND. 5'I DRIES TYPE CONSTRUCTION
smion,as provided for by Searle.37M of the labor Cssle,for the performance of the
work fur which Nis permit is issued FIXTURES—PER TRAP
have and will maintain Worker's Compensation Insurance,as required by Section
70(l oftbe labor Cede for the perfommine of the work for which this permit is issued GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My won 'SCo rpensu ten lnsum➢c a carrier and Policy�tyt)he{
Curies f �e+ - 'policy Nn`%Yy 97^ OAS—F.A.SYSTIiM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERSS
COMPENSATION INSURANCE GREASIbINDUSTRL WASTE INTERCEPTOR
(This section need nod he enmplet W ifrhe permit is forone hundred dollars 1%100) BUILDING DIV]910N PI?HS
or less.) GREASE TRAP PLANCHIiCK FEE I
I certify that in the performance¢fthe work for which this permit is issued,Ishall SEWER—SANITARY—Stt)Rh1 EA.200 FT.
nt 1 employ any Nrmn in any manner so as to become subject m the Workers' ENERGY FHB
z, satiun Lows of Califamia.Date 7�� Applicant - WATER HEATER W/VENT/ELECTR GRADING FEE
q y NOTICE TO APPLICANT:IL after making this Certifimm of Exemption,you should WATER SYSTF.MOREA'1'INO
(~ become subject to the Workers Compensation provisions or the Labor Cade,you must SOILS FEE
Lok) forthwith comply oldh such provisions a this permit shall he be ad mvoknd. WATER SERVICE
Q
CONST RUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.14. PAID
V O (hereby atrrm that them is a constmction lending agency ferthe performance of Date Receiplw
Llw `+ the work for which this permit is issued(See3097,Ci,C.)
O U Lenders Name TOTAL:
} UJlenders Address L. C
F.., y 1 certify that I have read this application and state that the above information is BUILDING PEE
Lt to correct.l agree in comply with all city and county ordinances and state laws relating to Q'TY. MECHANICAL.PERMIT FEE
V building continuation and hereby amhorizempmsemmlvesofthln city to enterupen the SEISMIC FEF.
above-memmind property for Inspection purposes. - PERMIT ISSUANCE
(We)egree m sac,indemnify and kap hannlosx loo Chy of Cupertino against P.LELTRIC FEE
liabilitics,judgments,costs and expanse hich may many any same against said City ALfERORADDTOMECIk
in cPLUMBING FEE
onseque sof the raining of th' il.
APPLICANT I' DF STAND WI COMPLY WITH ALI.NON-POINT AIR HANDLING UNIT TO 10,000 CFM)
URCE U IONS. MECHANICAL
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCf1ON TA% '
Sig ureof AppliemmC rn Date EXHAUST HOOD(WMUC) HOUSING MI
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant or future building occupirtamsre fir handle hazardous material HEATING UNIT(TO 100,000 BTU)
ra
refined by he Cuperlim,Municipal Code.Chapter 9.12,and the Health tend Safety
Code,Smile.25532(a'1 HEATING UNIT(OV HR 100.100 PTU)
Yes ❑No VENTILATION PAN(SINGLE RESID) PAID
Will the applicant or fudurc building«spam use a,m,mem m devices which Date Receipt w
mu hammous air contaminants ere defined by the Bay Area Air Quality ManagementBOILER—COMP(311P OR 100,000 BTU) -
District 9 BOILER—COMP(OVER Itn"BTU) TOTAL:
❑Yes ON. s
I have read the hasanlous materials mquiremems under Chapter 695 of the Cali- AIR CONDITIONER ISSUANCE DATE
forme Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL.MECIL SQ.FP.
bonding dotes noremremly hnvc u tonnnt,that it is my mspnnsihllity to notify Tho Weapon
of the mquiremems which must be met prior to Issuance of a Can ificate of Occupancy.
Owner or amhorud agent Doe TOTAL: ISSUED BY:
OFFICE