31318APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO HUILDINc- ELECTRICAL
HUIHDING DIVISION APPLICATION/PERMIT PLUMIIING-MECIIANICAL
CONTACT: - PHONE:
❑ Consultant Fees Paid by Applicant (Initial)
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
p0z with Section 7000) of Division 3 of the Biesinessnud PmNpswus Crate, and or, license is
p� m full frice avd effaet.
Q License Class Lick
CW�V
Ilam Comractor
ARCHITECTS DECLARATION
Y ON
1 underxtand my plans shall be used as public records
O !: 4M
Nv
gF -; Licensed fessionel
iCCK.. ..1 Oat I am exeLDERmpt
urthe DECLARATION
Ly5� Q 1 hereby a(Ertn that I am exempt from the f ssion, Code:
License Lair for the
W 3If following rens a Permit
er Tian ]onstru t, alters and improve,
demolish,
Gtde: Any oily oaomre
rs7
If -ort requires ,,,lea re construct, otter, nI suhpermit1 ores it anystructure
that hoits is galwrt to theres he ppii,icn, f inn Container's
License
Lae(Chapt r9
a <� wouraialiceng withSrsunrn to the pmvisigns of thee Businssand Ponfissions (Chapter
0.W' thamm<o exemiNSection 7000) mandofhaosnfr the
Business aatlon. Any
ni vi Code) or
d neG that lie is exempt thn frrmand the helsfmrhoalleged exemption. AnylPeninn of
Y• Smion]OILSve anydreddamfor apermit subjects the applicant toacivil penalty of
not more than five hundred ty, or y e ).
'F7 C O Lm Beeak, the property, re is employees with wages r their Soltcompensation,
S will da e weak, and the he Cona acuirnot inbnded Law do s not apply to
ownerss
of
and Professions who b illsCode: The C es dinner,
License Law does not apply Rs if owner of
a' property who builds or improves thebon, and who does such work himself or through
his own employees, e If building
Nm pooh nent is sold within me nm imar of cot offend for
owns Lhnwer will hav ilmebroien of ant isat hedon build or improve
the
owner -builder will have the harden of proving that he did not build or improve fur pur-
pose of sole.),
❑ 1, as owner of the property, um exclusively contracting with licensed contractors to
nswm the project (Sm. ]IW, Business and Profession Qufe:)'1'he Convectors Li-
cense Law Nes nm a y to an If o patty who builds or improves thereon, and
who commas fors ns with tr torts) licensed purauanto the Contractor'sLicense Law.
❑ lam exemy3p�,B,CPC f¢rlhis�psyn
- - WOKKEKS ATION DECLARATION
I hereby ufB rpenaltyof equ, one of the following declarations:
❑ Ihavennd will in alta Cenificat ofComenuo self -insure for Workers Compete
salon, as provided for b cion 3 of the Lebo Code, far the performance of the
work for which this permit is issued.
❑ I have and will maintain Workers Compensation Insurance, m required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance .,far and Policy number ore:
Cartier. Policy No.:
_ CHRTI PICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section coolant be completed ifthe partial is foronc hundred dollars ($IEt)
last.)
I certify arm in the performance of the work for which this sm d is issued, ) shall
not employ any person in any manner of ten h notne soldier, ,, the Workers' Compcn-
,Z amion Laws of California. Dae
O O Applicant
NOTICE TO APPLICANT If, after making Ibis Cenificae of Exemption. you should
a become subject tome Want Compensation provisions of the Labor Cask, you must
{2a forthwith comply with such provisions or this permit shall he deemed revoked.
a
CONSTRUCT c ON LENDING AGENCY
affirm V O (herehy arm tbani
there seanvrvminn lending agency for performance of
". 1-+ the work for which this pemtit is issued (Sec. 3100], Civ, C.)
O yU- Lenders Name
L7•I Lender's Address
1..t iL L certify that 1 have read this application and state that the above information is
fir h7 correct. 1 agree to comply with all city and county ordinances and ante lows relating to QTY.
V F7 building convection, and hereby minimize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the Ciry of Cupertino agaimm
liabiliaes,judgments. costs and expense which may in any way name again i said Cd
in asequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Signature of ApplarousCoutracmr Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fumre building occupant store or handle liniments material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Capon 25532(x)?
No
Will the applicant or furore building occupant use equipment or devices which
(mit hilarious air conmminams as de uent by the Bay Area Air Quality Management
District?
❑Yes 71 No
I have read the notorious materials requirements under Chapter 6.95 of the Cali-
fornia Health & Safey Calc, Salinas 25505, 25533 and 25.134. 1 undersand that if the
building does not currently have a brant that it is my responsibility to notify the aecupant
of the "Wearrents which moil be met prior it lusuan.a of a Catifieate of Occupancy.
Owner or authorized agent Dab
ELECTRIC PERMIT
PERMI"T ISSUANCE
APPLIANCES - RESIDENTIAL.
PANELS
DPTO200AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIDMISC,
TEMP. METER OR POLE INS('.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
N17W RESIDENTIAL ELECTS SQ FT.
PLUMBING PERMIT
PEIIMI'I ISSUANCE
ALTER - DRAIN & VENT- WAl'ER WA)
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, EDGE, AREA, COND.
FIXTURES - PER TRAP
GAS- EA. SYSTEM. I INC. 4 OUTLETS 1
GAS -F.A. SYSTEM -OVER 4 (EA)
GREASEINDUSTRL WAST II INTERCEPTOR
GREASETRAP
SEWER -SANITARY -STORM I3 .20011E
WATER HEATER WNENT/T:LECTR
WATER SYSTENUT BEATING
WAI ER SERVICE
NEW RESIDENTIAL PLMB, SQ. FT.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECIL
AIR HANDLING UNIT (TO 111.010 CFM(
AIR HANDLING UNIT (OVER to." CFM)
EXHAUST HOOD(W/DUCT)
HEATING UNIT (TO 100,001 BTU)
HEATING UNI -[ (OVER 100.000 BTU)
VENTILATION FAN (SINGLE. RESID)
BOILER - COMP (3HP OR 100,000 BTU)
BOILER - COMP (OVER 101,000 BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECIL SQ. FT.
OFFICE
FEE
Nu 3131
NI'PARY NO. APPLICATION SUBMITTAL
16 c6 U
N/C CONTROL#
BUILDING PERMIT INFO
BID ELECT PLUMB MECH
❑ ❑ ❑
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL
❑ KITCHEN REMODEL.
El ADDITION
El PLUMBING RE -PIPE
❑ MUI.TI-UNIT
❑ STRUCTURAL
MODIFICATION
El INTERIOR
s ❑CHIMNHYRBPAIR
IMPROVEMENT
❑ BATH REMODEUREPAIR 0DEMOLITION
❑OTHER _
COMMERCIAL:
❑NEWBLDG/ADDITION ❑DEMOLITION
[]TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
UUrthiiNp
6=1W
PLANCHECK FEE
ENERGY FEE
GRADING FEE
SOIIS FEE
DIVISION
PAID
Date Receipt#
TOTAL:
BUILDING FEE
FEE SEISMIC FEE
ELECTRIC PEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTIONTAX
HOUSING MITIGATION FEE
PAID Dale Receipt N
TOTAL.:
ISSUANCE DATE
I
lv/�y /9G
CIN OF CUPERTINO
Encroachment Into
rear setback (see below)
II 10' min. 1st floor rear setback for rear
yard encroachments. Allowable only
If rear yard area §z3za
exceeds 20-11mes the lot width
25' 2nd floor rear setback
Rear yard area
10'min. 2nd
floor side setback.
Combined 2nd
floor front and side
setbacks must be
Increased by 15'.
5' must be applied
to the side
setbacks.
51st floor
side setback
(I side only)
40% maximum site coverage
.45 maximum floor area ratio
25' front 2nd floor 20' 1 st floor front _
setback. Combined setback
2nd floor front and
side setbacks must
be Increased by 16. SMEET
5' must be applied to
the side setbacks.
pmr
20' 1st floor rear
setback
10' first floor
side setback
(1 side only)
Bulidng line
2nd floor
building line
Me
i1076350o2
/0/,1/96
Oct. 06 1996 24:= -FFM F1
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FR01I TU COhdST I NC
PHONE NO. 510 234 622E
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