30312 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY , '
CITY OF CUPERTINO , lI - BUILDING-ELECTRICAL. PERMIT NO. a� O
BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MECHANICAL J{ x{J
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: Q�_ /r . SANITARY NO. APPLICATION SUBMITTAL DATE
7 IWS ill o & L'.GAJ ru 1 .
OWNS :S NAME: PHONE: CONTRACTOR'S NAM - LIC NO:
�y NC NIC CONTROL#
ARCHITF,CT/EN INF.F.R: LIC NO: ADDRESS: ❑'
CONTACT: PHONE: - - BUILDING PERMIT INFO
r ❑ Consultant Fees Paid by Applicant(Initial)CBLDG ELECT. PLUMB MECH
❑ El ❑ . .
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that I tan licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
aZ with 9wtlo.7IXq)af Divisioti3ofthe HusinesvhnA Professions Code,and mylieemeis
00 PERMITISSUANCF. RESIDENTIAL, .
F In full force and effect {
PW Id _ ❑SFDWL El KITCHEN REMODEL
UzU License Class Lim. APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
yES Date C'S DECLARATION
p.7m , - ARCHITECTS DF,CLARATION PANELS ❑MULTIUNIT [I STRUCTURAL
Z O iA Z I understand my plans shall be used as public records - MODIFICATION
P4F,0 UP TO 200 AMPS [_1 INTERIOR El CHIMNEY REPAIR
f;�HWq Licensed Professional - 201-IOWAMPS IMPROVEMENT
s .] OWNER-BUILDER DECLARATION OVER 1000 AMPS
q Q 1 hereby affna,that i xm exwnpt from the Cnntraeor'e License Law fnr the F1 BATH RP.MODELtR• AIR ❑DEMOL]TIOP
ip5,O y U following reason.(Scene.7031.5,Business and Prefessions Cade:Any city or countySIGNS ELECTRICAL
❑OTHER
FI" which requires a permit to c...tmet,site,improves demolish,or repair any mrucmre
to prior to its issuance,also requires the applicant for such permit to rile a,signed statememHE
SPP.CIAL CIIICUIT/h115C.
q that he is licensed purser t.,he pmvisions of the Commoner',license Law(Cleans,9
00 (rimearncing with Section 700h)of FhAsion 3afthe Business and Professions Code)., TEMP.METER OR POLE INST. COMMERCIAL:
pry a that he is exempt theafrom and the basis for the alleged exemption.Any violation of -- [_1 NEW BLDG/ADDITION ❑DEMOLITION
y
f5sC1 SeriesIBII.S by any applicant fearssnts th
permitbjeee.ppli,ent to n civil penaltyof ,POWER DEVICES- ❑TENANT ❑FOOD SERVICE
amore than five hundred dollars($SW).
q ❑I,ns owner of the propeny,ar my employees with wages us their hole campensmion, I SWIMMING POOL.ELECTRIC IMPROVEMENT
will do the work,and the structure is not intended or offered for sale(Sea 7044,Business ❑OTHER
and Professions Code:The Contractors License Law does net apply to an owner of OUTLETS-SWITCHES-FIXTURES
p' property who builds car improves thereon,and who does such work himself or through
his awn employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECTR SQ FP
sale.If,however,the building or Improvement is sold within one year efcompletion,the .FT.FLOOR AREA $ISQ.FT.
owner-builder will have the burden refereeing that he did not build or improve for par,
Ease of sale)..
❑ 1,aser of the property,x exclusively contracting with licensed contract...to TOTAL:
construct the project(Sea 7040.Business and Professions Code.')The Comments Li-
cemse Law does not apply to an owner of pantety,who Imidg of improves prepeor,and QTY. PLUMBING PERMIT FEE JUL 311996
who contracts for such projects with a corrections)licensed pursuant to the Contractor's
License Law PERMIT ISSUANCE
I am exempt under Sec. ,B&P C for this r...an
Dare'/JL++ei ALTER-GRAIN&VENT-WATER(EA) rad
Owner WORKER'S�0 NS� ATION DECLARATIONe 'VALUATION
yy�� HACK FLOW PROTECT.DEVICE s3��
I hereby affirm undo peual�f per]ury ane of the lbllowing detlamt,.a,:
El I have and will maintain a Certificate ofComenno self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
nation,as provided for by Section 3900 of the Lobo,Code,for the performance of the _
work fnr which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Worker's Cm,pensation Inaumers.as require)by Section
3700 oflhe Labor Code,for the permanence ofthe work for which his permit is issued. GAS-EA.SYSTEM-ZINC.4 OUTLETS OCC.GROUP PN
My Worker's Counterirritant Insurance carrier and Policy number urs: -
Carrier: Policy NO.: OAS-EA.SYS'I'GM-OVGR'4(BA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTR,WASTE INTERCEPTOR 8U14UING DIVISION PF,ES
(This section need but be completed iffle permit is lbmne hundred dollars($100) CREASE TRAP
or Isix) PLANCUECK FEE
. I terrify that in the performance ofthe work for which this permit is Issued,Ishan SF.WIiR-SANITARY-STORM EA.200 FT
not employ any person in any manner so as to become subject to the Workers Cmopen- ENERGY PLG
s..am Laws of Czlif.mia.Date
Z O Applicant WATER HEATER WNENT/ELECTR GRATING TEE -
ti y NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should- WATER 9VSTEM/TRP.ATINO
H become subject to the Workers Compensation provisions of the Labor Code,you must SOILS FEE
W „y fatthwith nomplywith such provisions orchis permitsball he deemed revoked, WATER SERVICE
ow
Q
VCONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,FT. PAID Q thereby affirm that thea is a construction leadiag agency for the performance of - Date Receipt#
{Ir H the work for which this permit is issued(Sec.3097,Civ.C.)
OLearners Name TOTAL;
fUL) Lenders Address TOTAL
I certify that I have m.d this application and state that therbove information Is BUILDING FEE OV
fa7/1 carmen.l agree m comply with all city and coedy ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE .�
.Ua building construction,and hereby authorize representatives cards city to eater upon the SEISMIC FEE ''
.brave-mentioned property far mapactioo pappears. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
Iiahilities,judgments,costs and expenses which may in any way aveme against said City
in consequence of the granting of this permit. ALTER OR ADD TO MECH. PLUMBING EEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT To 10,000CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applwant/Contractor Date EXHAUST Hoot)(W/DUCT) HOUSING MITIGATION FEB
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stare or handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by Ne Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)7 HEATING UNIT(OVER 100,000 BTU) ,
❑Yea FIN. VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use uryipment or devices which . Dale Receipt#
emit hazardous air contaminants as defined by the Bay Area Air Quality Management 'BOILER-COMP DUE OR 100,000 BTU) -
District' - - .TOTAL:
FI Yes No s BOILER-COMP(OVERFaLMOBT6)
I havcread me hazardous materials requirements under Chapter 6.95 of the C.li- AIR CONDITIONER ISSUANCE DATE
- - I..in Health&Safety Code,Sections 25505,25533 and 25534.I understand that if the NEW RESIDENT MECH. SQ.FT.
building does not currently have a anon.that it is my responsibility to notify the rucutant
of the requirements which most be met prior in issuance ofa Certificate of Occupancy. -
Owner orxu imized agent Date TOTAL: ISSUED BY:
OFFICE