30290 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 30290
(
BUILDING DIVISION APPLICATION/PF.RMIT PLUMBING-MECHANICAL V O Z Q�/O
BUILDING PROJECT IDENTIFICATION
UQWSLSUG L1RE1S SANITARY NO. APPLICATION SUBMITTALDA
s - L e_ , - 13- g6
p11nNCON9'RgCLOB'Sj'p.Wli: LIC NO: v
/G>IR NIC CONTROL b
ARCHITECT/ENGINEER: LIC RO: ADDRF : ❑
CONJACT"Q' frsf\k GAk PHONE N f•� BUILDING PERMIT INFO
'T' � o,.�3'V(�1 T$ ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMP MECH
❑ ❑ R_ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby uffnn that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
ki with Saturn 7000).f Division 3af Ne Businessman Professions Coda,ond my license is RESIDENTIAL
in full force and clfec PERMD'ISSUANCE
RUL) Limnse C�asy �— Lic.4 ❑SFTIWL ❑KITCHEN REMODEL
Nab Date—si_l Contmemr APPLIANCES-RFSIDF.,VI'IAL ❑ADDITION QTTT!!VBING RE-PIPE
.Laa •'[ A CHITELTS DECLARATION PANELS ❑MULTI-UNR ❑STRUCTURAL
Z p-Z 1 undersand my plans shall be used n public records MODIFICATION
O_Z UP 10 200 AMPS
P-�fW Lacrimal Pndnsionl C1 INTERIOR [I CHIMNEY REPAIR
SaydB-',4 OWNER-BUILDER DECLARATION 201-1000AMPS IMPROVEMENT
{ C W Q 1 hereby of rat that 1 um exempt from the Contractor's License Law rim the OVER HNO AMPS El BATH RIiMUDEf/REPAIR L1 DEMOLITION
{??LL55 0 t1 V following reason.(Section 7031.5.Business and Pndersion.s Code:Any city or county SIGNS ELECTRICAL ❑OTHER
0•+3 0.F" which requires m permit m construct,alter,Improve,demolish,or repair any stmdurc
LLA t its issuance.also theapplicant mrsuch uo lileazi dsatemem
F' 0
poor to requirespcnni gne SPECIAL CIRCUIT/MISC.
p• mat he is licensed pursuant to the Lovsk ons of the Contractor's License Law(Chapter9
tyC�0 (commencingwim Section 7000)of Division 3ofthe Business and Profession.Gose,or TEMP.MB]'ER OR POLE INST COMMERCIAL
d 6 c C that he is exempt therefrom and the basis for the alleged exemption.Any violation of
��m Senion]03 LS by any applicamforapemrir subjects the applicant maovil penalty of POWER DEVICES [_1 NEW BLDG/ADDITION El DEMOLITION
F Z i not more Nan five hundred dollars($500). ❑TENANT El FOOD SERVICE
❑1.as owner of the prnpeny,or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
CF' will do the work,and the structure is not intended m offered for sale(See.]IW Business OTHER
iy and Profession.Cale:'The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
pmpcny who builds or improves thereon,and who does such work himself or through
his own employees.provided mat such improvements are not intended or offered for NEW RESIDENTIAL ELECTR ESQ \
sole.IL however.the building or improvement is sold wiml n one year of completion,the \ SQ.FT.FLOOR AREA &/SQ.FT.
ownsm-builder will have the burden of proving that he did not build or improve for f nuleJ. par- ,
,,,,a"i
❑ 1,as owner of the prnpeny,mm exclusively contracting with licensed comracmrs to TOTAL. \
onstmet the project(Sm.0044.Bin
usess and Professions Cale:)The Convector's Li- ,
cense Law does not apply to an owner of property who builds or improves thereon.and QTY. PLUMBING PERMIT FEE.
who ta
concts for mch projects with a mw
nemta)licensed pursuant m the Contractors
AUG 13 199
Lissom Law. v s t
❑I am exempt under Sre. ,B&P C far this reason PERMIT ISSUANCE
Owner Data ALTER-DRAIN&VENT-WATER WA)• VALUATIOM•'•v
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE I hereby offrnn under Penalty of perjury one ofthe following declarations: . .
❑I have and will maintain aCenifcme of Consent m self-insum for Worker:Cooper- DRAINS-FLOOR,ROOF,AREA,COND.
moon,ass provided for by Section 370()mf the Labor Calc,for the Ccrfonnance of the STORIES TYPE CONSTRUCTION.
work for which this panni,is issued. - FIXTURES-PER'I'RAP
El I have and will maintain Worker's Compensation Insurance,as required by Section
37W ofthe Labor Code.for the performance of me work for which this permit is issued GAS-EA.SYS TEM-I INC.4 OUTLETS OCC GROUP APN
hly Worke' oat ratio In. cal arrierand Policy number
Carrier: , Policy No.: � n�._ GAS-EA.SYS'fEM-OVER 4IEA)
CERTIFICATE FEXEMP`TONFROMWORKERS'
COMPENSAUON INSURANCE GREASPIINDUSTRLWASTE INTERCEPTOR
Clbissection need not be completed if the permit is fore ne hundred dollars(SI(N)) BUILDING DIVISION FEES
or Lem) GREASE TRAP PLANCHECK FEE
Loy myths in Nc any manner
w ash.
work far subjedt tto the W ikes'Com re.all SEWER-SANITARY-STORM EA.200 FT
not employ any Califon in any manner m as to become subject nr the Workers'Cnmpen- ENERGY FEE
2 vilApplicant
nt of California.Date O O Applicant WATER NEATER WNENT/LLECTR GRADING FEE
y NO I become
Ebj APPLICANT.It,after making this visamcate of Exemption.you should WATER SYSTEMITREATING
F ; become subject, the Worker's Coons or
it provisions of the Lubar Cade,you must
forthwith comply with such provisions nr Nis permit shall he d«recd rnaked. SOILS FEE
� O WATER SERVICE.
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
U O T hereby of rat ho t mere is a construction lending agency for me perfmmance of Data Receipt it
lk.P the work for which this permit is issued(Sec.3007,Civ.C.)
p U Lender's Name TOTAL.:
F yLanders Addre.a TOTAL:
I amity that 1 have read of,application amt state rhm me above information is BUILDING FEE
or) correct.I agree to comply with all city and county ordinances and nom laws rioting to QTY, MECHANICAL PERMIT FEE
U Z building convection,and hereby authorizempresentatives ofrhiscitym enterupn the SEISMIC FEE
idave-mentioned property for inspection purpssn.
(We)agree to ave,indemnify and keep hrnnlaas thc City of Cupen inn againstMTOMECIL
UANCE ELECTRIC FEE
liabilities,judgments.costs andespentts which maymany wayzecmeagainst mid City ADD TO MECH.in consequence of the granting of this permit. yPLUMBING FEEAPPLICANT UND RSTANDS AND WI LY WITH ALL NON-POINTING UNIT TTY)1(,00)CFM) h1ECHANICAL PGE
ING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
Signamrc Appmemm Contractor Data HOOD(W/DUC)HAZARDOUS MATERIALS DISCLOSUREWill the applicant or future building occupant stere or handle hazardous materialNIT LTO 100.000 BTU)
as defined by me Cupcnino Municipal Code,Chapter 9,12,and the Health and Safety
Cole,Section 25532(.)'1 HEATING UNIT(OVER 110,00(t BTU)
❑Yes ❑No
VENTILATION FAN(SINGLE R[SIU) PAID
Will the applicant(it famine defitred occupanty Aequipmentardevices which Dam Rtteiptp
emit iwl? s oit contaminants as Defined by the Nay Area Air Quality Management BOILER-GO.MP(JHP OR 100,000 BTU)
Ui.vtrinP TOTAL:
❑Yes ❑No BOIhER-COMP(OVER IW.WI)BIG)
I have mad the hazaNmw materials requirements under Chapter 6.95 of the Cali AIR CONDITIONER
forma Health&Safety Core,Sation 25505,25533 and 25534.1 undersand that if fie ISSUANCE DATE
building docs not currently have a tenant,Per it in my responsibility to notify the occupant NEW RESIDENTIAL MSCI{. SQ.FT.
of Ne requiu menti which mus he met prior to issoams,of a Camoseare of Occupancy.
Owner or authorized agent - Date TOTAL:
ISSUED BY:
OFFICE