28745 APPLICANTTO'FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATIONIPERMITPLUMBING-MECIIANICAL ' 28745
RUH.BINO PROJECT LDEN1'IFICATION
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
moi. s*-.%i IFM4-vwpo c►30
OWNER'S# PHONE: CO TR '&�& 5 N/C - CONTROL#
•ARCHITECTA NGINEER:' LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
���` ❑ Consultant Fees Paid by Applicant(Initial) pc ELECT PLUMB MECH
LICENSED CONEHMUTORS DECLARATION
Q'I'Y. ELECTRIC PERMIT' FEE
1 hereby af0rm that I vm licenied under pnrvirions ol'Chaper 9(commencing JON DESCRIPTION
C=Z Z with 5ection]Of10)of Uivisiun3of Ne Business and Profesaians Cade,and mylicense is
+�FOp . PERMIT ISSUANCE RESIDENTIAL:
W F m full force and etfecl.
�UMODEL
License Class Lie.is - OSFDWI, El KITCHEN
DataCounselor APPLInNCES—RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
RF.-PIPE
ARCHITECTS DECLARATION PANELS [I MULTI-UNIT ❑STRUCTURAL.
zpr�y lunderstand myplvn.shall be uredos public records MODRICAT'ION
pz..Q UPTO 200 AMPS QINTP.RIOR ,❑CHIMNEY REPAIR
�+'a�,J Licensed Prnl'essional 201-1000AMPS IMPROVEMENT'
X ' .
OWNER-BUILDER DECLARATION OVER l"AMPS - QBATHREMOD UREPAIR tMOLITION
C 6 I hereby,(firm that 1 1. exempt from the Contractors C's License Law En the
iq$O tY U fallowing rented,Permit
]W 4.5, t.linaes and 1deioar Code:Any airy or county SIGNS ELECTRICAL El OTHER
W O vI"r' which requires a permit to construct.die alter,d,inrush
improve,demolish, file
repair any swoon
priortoslts censesa pursuant to the provisions o for Contrannluoicense Law
PCatement SPECI AL CIRCUIT/MISC. ,J
y.
chat surnariia,,ilparsuonuONeprovi,cam ol(the(he
License law(Chapmr9 _
OC pynnmenc8tg whb Section 7lHMp of DivlsinnJ nfthe Businms and Professions CnJe)ar TEMP.METER ON POLE(NST COMMERCIAL:
6 e C Not he is exempt Nerefmm and the basis for the alleged exemption,Any violation of ❑NEW BLDG/ADDITION Q DEMOLITION
Ic Smion]OJLS by a ay applicant for v permit subjects one
appliconnou civil penally of POWER DEVICES ❑
n rn TENANT ❑FOOD SERVICE
0 of mre Nan five hundred Dollars($S(X).
[] I,as owner of the property,or my employees with wages as their sale compensation, SWIMMING POOL ELECT RIC IMPROVEMENT
F will do the work,and thenrucfure is not intended or offered fmsale(See,704,L,Business 'OOTHER
Wm and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES
property who builds or improves thereon,and who does such work himself ur through
his own employees,provided that such improvements are not intended or offered for NEW RE.MENTIAL ELEM R
sale.IL howevice Ne building or impntvemem is sold within one year of cnmpleinn,the •L RARFA $/SQ.PT.
er-builder will have the burden of proving the,he did net build or improve far pur-
°W"'f sole OC 3 01995
I,as r of the proper},a exclusively contracting with licensed contractors is 'TO?AL.
amennet the project(Sec.7014.Business and Professions Code:)The Contractor's Li-
se law ds not apply m an owner of proper}who builds or improves thereon,and Q1 Y. P MBING PERMIT FE
wh «
oemmmele far such projects with a conover... )licensul pnt,uam m lie Conti DEPARTfJyG{ �l
y
License law. PERMIT ISS 'E
O larrommutunder See. ,B&pCfur Nismastm ERDHO
LPUI
ALTER—DRAIN ER(EA) 'a
Owner ❑nm VALUATION
• WORrmKEROMPENSATLON DECLARATION BACK FLOW PROTECT,DEVICE
thereby affiunder COMPENSATION
perjury me of Nefollowing Jedvatione
have and will maintain o Certificate of Consent to sel6imure for Workers Camper. DRAINS—FLOOR,ROOF AREA,COND. STORIES TYPE CONSTNlJCT10N
,.lion,on,provided for by Section 3700 of the Luhur Coda,liar the parform in s,ol'the
work far which this permit is iuuul. FIXTURES—PER TRAP "—
I have and will maintain Weaker's Compensation Insurance,as required by Section
3700 oflhe Labor C c,fur the performance of the work for wh h a ed. GAS—EA.SYS] INC.40UTLETS OCC. ROUP APN
My Wor 'a Co sminn la,uruntt curler unJ Policy tt a retx GAS—EA.SYSI'EM-OVER4TA)
Carrier: - Policy No:
'F.RTIFICCO OF EXEMPTION FROM WORKERS'
COMPENSATION eperm INSURANCE GREASPIINDUST'RL WASTE?INIERCF,
(This sedinn necA not he completed if Lha permit Is for ono hundred dollam($FIM)) 4GILDING DIVISION PEES
' nr less.) GREASIi TRAP P I{I TEE
(certify that in Ne perfurman<e nfNe work for whichthn,arnitisissued,lahall SEWER—SAND'ARY—ST)NMEA.200FT.
nal employ any person in any mannerso us to become subjcsno the Workem'Compen-
zz smiom Lawson C,lifuinia.Dam WATER HEATER WNENLELECTR
0 Applicant ING FEE
p) NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMJTREATING
(~ "' become subject to the Worker's Camisons.use no okma,of the Labor Code,y u n ail % LS all IL I
forthwith comply with such provisions or this permit shall he Jeemedrevaked. WATER SERVICE sIe
ms
sCONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLM9. SQ.PT.
V O I hereby vffrm Nnttbere is acansuudimt lendingagene,far tbeperforamo.of D eceiptp
I, H no work far which this pencil is issued(Sec.3097,Civ.C.)
O Lenders Name K3jOTAL:
{U Lenders Address TOTAL:
y 1 certify(hut I have rout this nppl nation and state that the above information is BUILDING WE
Z) correct.I agree to comply withal city and county ordinances and state)aws minors to QTY. MECIIANICALPERMIT FEE
U z building construction,and hereby amhoriee reprcscmatives of Nis city us enterapon Ne SEISMIC FEE
above mentioned property for inspection purposes, PERMIT ISSUANCE
(Wes)agree to save.Indemnify and keep harmless the City of Cu,smino vins
gnt ELECTRIC FEE
Fiabilities,judgments,costs and expenses which may in any way accrue againstsaid City ALTER OR ADDTO MECH.
in nscquence of the granting of this permit. PLUMBING FE
APPLICANT UNDERSTANDS ANDjVILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO Id,000 CFM) MECHANICAL FEE
SOURCE s .MTONS
IO ;O� S AIR HANDLING UNIT(OVER IO.MM CFhf) CONSTRUCTION TAX
Si of plicrmVCon nor Dote E%HAUST HOLD(W/DUC'O
HA
X)101 MpfER1A1.5 DISCLOSURE MITIGATION FEE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT IT'D I0100)BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Coda Section 25532(01 HEATING UNIT(OVER 100,000 BTU)
F1 Yes QNo VENTILATION PAN(SINGLE RFS ID) PAID
Dare Receipt N
Will Ne applicantor infurore building bycupantuse
ea Air uordevices which BOILER—COMP(3HP OR 100(HIO BTU)
emit hazardous air contaminants as defined by(m Bny Area Air Quality Management TOTAL:
District?
El Yes No
BOILER—COMP(OVER IM."BTU)
❑
1 have nestle,meaNnus materials re rentetns Camper under 695 of Ne Cali- AIR CONDITIONER
qui p ISSUANCE DATE
foodsHealthdoes n SafetyCode, a ter 25505.iss5JJand ns5J4.E to
tat if the NEW RESIDENTIAL MECH. SQ.IT.
building does not currently have v tenant,that it is my responsibility m omit}the«cupant
of Ne rwluirememx which most be,mel prior m ivmvntt of.Certificate of Occupancy.
Ownerorauthu ood.gent ❑me TOTAL: ISSUED BY:
OFFICE