30765 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO
I BUILa ADIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 1�� F
IIUII.DIN(.PROJF.C'1'IDEMI'IFICNI'If1N �1N VV V
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
Q SC eN/G CSI V D l �fsj Q
.. W�TrA4g ,, d I1Z PHONE: S COyTRALTfOR'S NAME: �STQI LIC
0 0
I :I'f !r �,Ll] ,
NIC CONTROL,
\RCHITECT/ENGINEER: - LIC NO: - ADDRESS: ED
6 76 AMUTEXEV PLO SAN IrE
CONTACT: PHONH: IBUILDING PERMIT INFO
�D T3/42 LDL_ 9413- 2212/ 1:1Consultant Fees Paid byApplicant(Initial) HLDG EL_ ECJ PLUMB ME
-
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm and I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
aWQR'Z with Section 7000).f Division 3ofuc[Immexamil Professions Code,and my license is RESIDENTIAL:
C) In full force andcnben. PERMIT ISSUANCH a�
aUZU License lass Lic.pp'7 ❑EFDWL Je7fN'!•CHGN kF:#ODI?f.
HGL Uate Commcmr APPLIANCES-RESIDENTIAL 1/t- ❑ADDITION 7770 PLUMBING RE-PIPE
ARCHITECTS DEC ATION - []MULTI-UNIT ED STRUCTURAL
PANELS
ZOrnZ I understand my plans shall m used as public records MODIFICATION
OZ—0 UP 7b Nq AMPS El INTERIOR ❑CHIMNEY REPAIR
[-�1" LiccnseJ I'rofessirnal 201-IOW AMPS IMPROVEMENT
�] V OWNLR-BUILDER DECLARATION OVER IOIq AMPS
CC w Q 1 hereby affrm mat 1 am asempt from the Contractor's License Law for the ❑BATH REMODEUREPAIR 0 DEMOLITION.
aggqS O y U following reason.(Section 7031.5.Business and Professions Caste:Any city or county SIGNS ELECTRICAL []OTHER
FO F•' which requires a permit to construct,alter,improve,demolish,or repair any structure
odor.its issuanca,Nsoregnires theapplicant for such permit o rile a signed achnico SPECIALCIRCUU'IMISC.
<�
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
(commencing with Section7IXg0 of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
a e C that he is exempt therefrom and me basis for the alleged exemption.Any violation of 0 NEW BLDG/ADDITION ❑DEMOLITION
{iy5
Section 7031.5 hym,.,licam for a ormit subjects theapplicunuo a civilpenalty of POWER DEVICES
F_Zv. ❑TENANT ❑FOOD SERVICEman fire handed dollars(SSW).
IMPROVEMENT
Esq not more 01,as owner of the property,or myemployees with wages as their sole compenst ion, SWIMMING POOL ELECTRIC
will Jo the work,and the swnure Isnot intended oraRoted for sole(Sce.7044,Business []OTHER
6,3 and Professions Code:The Comecmrs License Law does not apply to an owner ofOUTLETS-SWITCHES-FIXTUR1IS
proper,who builds or improves thereon,and who does such work himself or through
his own employees,provided that such impmvemems are not intended or offered for NEW RESIDENTIAL ELECfR SQ FL
sole.If.however.the huildingor improvemcmin,old within one.carof enmpletion,the SQ.F'p.H'LOO •4SRRD F/SQ.FT.
ownephuilder will have the burden of proving that he did not build or improve for pur- Com' M 1 XJ
pose of sale.).
❑ I.as owner of the ternary am exclusively contracting with licensed commcm%to
construct the project(Sm.7D44,Business and Pmfcssions Code;)The Contractor's Li- - JAN 9 EEC'®
cense Law does not apply to an owner of poi who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who crmmets former projects with a ctmmactons)licensed pursuant to the Connector's
Licca Low. PERMIT ISSUANCE CP Ur UUrthlINU
lamesemptunder Sec. ,B&PCfmduE.oson
n.r
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Date
WORKER'S COMPENSATION IIECLARArEON BACK FLOW PROTECT.DEVICE at M Eli
1 hereM1y effimt under penalty of ExTjury one of me fallowing dalemtions: W
I have and will maintain a Cauriame ofConsent to self-imam for Worker's Compeer- DRAINS-FLOOR.ROOF AREA,GOND.
171W'
on,as provided fnr by Section 3700 of the Labor Cale,fnr the performance of theSTORIES q'YPCCONSTRUCION
ak for which this permit is issued. FIXTURES-PER TRAPI haveand will maiium.Workers Compensation Ina...ce,.s required by Section
of the Labor Cale.for the performance of the work for which this permit is issued. GAS-CA,SYSTEM-I INC.4 OUTLETS OCC,GROUP APN Wnrk Cum�e inion InsurotlI�Se carrier and Policy no, heryrCrtier: TA C Ft.N 4-T Policy No.: Jg A S T�9 GAS-I:A.5Y.STtiMOVER 4(EA)
CEBLlppcA•I'R OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIIINDUSTRL WASTE INTERCEPTOR
(This section need nal# pahum
completed iDhe ntie is an hundred dollar's(S 100) 1 0 DIVISION FEES
m less.) GREASE TRAP PLANCHECK
1 employ
any than in the performance of the work for which this permit is issued,l shell
notate to mbanmc sob aeon the Workccc'Com cn- SF.WEk-SANITARY-STORM EA.200 FT.
1 PtY any Person In anY manna sr nn J P ENERGY t'C
Z salmon Lawsof C.lifomia.Date
z O Applicant - WATER HEATER WNENT/ELELTR GRADING +C
tti N NOTICE.TO APPLICANT:IL aBar making mis Certificate of Exemption,you should WATER SYSTEM/TREATING
a ^t become subject mora Worka's Compenula ,..Won,.[me[..be,GWe,yoo must SOILS FEEjEll
[iI foMwim comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q
�Z 1 CONSTRUCTION LENDING AGENCY NEW RESIDENT IAL PLMB. SQ.FT. PAID
U� I hereby affirm that them lsamnsa..him lcnd'mgagenoy for theperfmmanceo( 4Du4 _7,7_c,,1
V. 2 0-c work her which this permit is issued(Sec.307,Civ.C.)
Q U Lender's Name endersAddress - TOTALI certifthm I have read thi .,,1jv;e om.nd side that the above information is BUILDINftl correct.lagree.comply withal)city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEEbuilding construction,andhembyauthorimrepresentativesofthiscitytoenteruponthe SEISMIColwve-mentioned property fnr inspection purposes.(We)agreemwvgindamnify.nJ keep hannlexs the City of Cupertino against PERMIT'ISSUANCE? ELEC'E'REliabilities.judgments.costs and exenses which may in anyway acerae against said CityALTER OR ADD TO MECH.in consequence of the granting of this permit. - PLUMBINAPPLICAN UNDERSTANDS A WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10800CFM)SOMECHANAIR HANDLING UNIT(OVER 10,000 CFM) CONSTRU
mureof Applirmt/Contrad.r Date EXHAUST HOOD(W/DUCT} HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will nheatplicamor fare building occupant snare or handle hmardous material HEATING UNIT(To list BTU)
as defined by the Contrition Municipal Code,Chapter 9.12,ad nhe Ihealth and Safety
dd1kCode,Smniun 25532(x)7 HEATING UNIT((EVER I00.oW BTU)
❑Yas ON. VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices whichDate Receipt#
.
ran
eartlrnta air contaminants as defined by the Buy Arca Air Quality MunagManagementBOLI-T:R-COMI'f3HP OR 100.000 BTU)
Di,nd,tria7 TOTAL:
D,Ycs ❑No , - BOILER-COMP(OVER 100,000BTU)
I have read the hadma materials re macrnund
ems er CTapter 6,95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomia Hw
ealth&Safety Code,Sections 25505,25533 and 25534 1 understand thm if the NEW RESIDENTIAL MECH. SQ.Irl'.
building does not currently have o tenant,that it is my re,vitchil,,mnntify a he re....in _
of me requirements which muu Is,met poor m is,.anro of a Carotene of Occupancy.
Owneroradhorized agent Date TOTAL: - ISSUED BY:
OFFICE
EX/sr/uv Wi.�,10,✓
ECENED
' ' M JAN 9 1997 r
! ; G� I SPECTION DEPARTMENT
f I I ITY OF CUPERTINO
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N,cacw.+vE /{ALL JAN 13 1997
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BLDG.INSPECTION DEPARTMENT
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CupE.•r/uo CA </08- L5S Sy9 3
i/Z _ /�O! APPROVED BY: DRAWN BY
SCALE:
DATE: ///��O' �J 'REV SED
t� � ,000414 690, QoU9N Rl"M61a 7 .Poapw &&41 ) .400"y", lYrew.
OFFICE -C osopY
. i DRAWtH6 NUMBER
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