30353 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. �O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
353
RUILDINGADDHESS: SANITARY NO. APPLICATION SUBMITTAL DATE
a- X34 �h �-l'�Ifb
OWNSAME: PHONI.: C TRA (lR' MC: LIC NO:
,iamlh IL %i — s-``,Tf ` t '��-+I "'1 NIC CONTROL#
RCHITECf/ENGINEER: LIC NO: A DRESS: " T i7`� 1 ❑
1 RArSCoL
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG E PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby arfimi mal I am Bnmaee ander pmvs;onx nl Chapmr 9(commencing JOB DESCRIPTION
lwo, with Scmion 9lNN))nl Dlvieinn3 oflhc Busineve and l'ndessinre CoJc.and my license 72�
F,�O in 1,[if ands(( , Ia� - fl� PERMIT ISSUANCE RESIDENTIAL
C F r']CJ� ❑SFDWI. ❑KITCHEN
F<U U License lass Lic,p
NGi Datc Contra LGf Ta .c APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECTS DECLARATION PANELS
F.Dtn MULTI-UNIT ❑STRUCTURAL
20rn IundcclnnJ my#loon shall he used as public rccnnls
MODIFICATION
024- UP TO 200 AMPS I^
F�F-W Licensed Professional ❑INTERIOR ❑CHIMNEY REPAIR
a 201-I(Nq AMPS IMPROVEMENT
C Ed J Oat I am exempt fr DECLARATION OVER IOOO AMPS ❑BATH RE.MODEIIREPAIR DEA�J.ITION
tX Q 1 hereby affirm that 1 am exempt from the Contractors License law for the ❑OTHER 2
?•O y V following reason.(Section?0315,Rusinen.and Professions Code,Any city nr county SIGNS ELECTRICAL
'1+33 a(: which requires a permit to construct,alter,improve.demolish,or repair any structure
t is issuance,also theapplicant for such tm file a signed menenem
-y prior of quiresin,opcnn; g SPECIAL GIRGGIT/MISG.
�p- tint he is licensed purxuanuothepmvisams of the Conlrannr's Licence Law(Chapmr)
=00 (commencing with Section 7")mf Division 3 of the Business and Professions Cale)ar TEMP.METER OR POLE INSL COMMERCIAL
tag.n C that he is exempt therefrom and the basis for the alleged exemption,Any violation of Ll NEW BLDG/ADDITION ❑DEMOLITION
'-„y Sectlor?031.5 by any applicant for a prruil subjects the applicant to a civil panahy'f POWER DEVICES
not more man Five hundred dollars(3500). ❑TENANT ❑FOODSERVICE
SSC ❑Las owner ofihe property.or my employees with wages as their sole conipenrnion, SWIMMING POOL ELECTRIC IMPROVEMENT
h will Jo the work,and the structure is not intended or uttered for mle(SeeJ044,Business ❑OTHER
W w anal professions Code:The Contractors License Law docs not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work hi mmlf ur th ugh
his own employees,provided that.such improvements ate not intended or offered for NEW RESIDENT LAL ELECTS SQ PT.
sale.If.however,the budding or improvement is sold within one year ofeompledmq the SQ.FL.FLOOR AREA S/SQ.FT.
owner-builder will have me burden of proving that he did not build or improve for pur- u
passe of role.).
❑I,as owner of the property,am exclusively contracting with licensed cnrumor,i- T a^yG 131996
consumer the es nail(Sec.911LL Business and ny who bus buildsor
i The es then ors Li- �a
whomlawdscsnmtapply man with
aofpmcenywhosedpurant toles thereon.ane QTY. PLUMBING PERMIT FF,E Y4
whosLaw, forsuch projewu withonmlramnKs)IiwenceJ pursuant mthe CunWemr's t-(�
0
License sca Law. PERMIT ISSUANCE
❑1 am exempt under Sec ,B&P C for this reason ��,,
ALTER-DRAIN&V ENT-WATER(EA)
Owner Date VALUATION
WORKERS COMPENSATION DECLARATION M
W PROTECT.DEVICE
I hereby affirm under penally of perjury one of the f Ilnwimg declarations:
[have and will maintain a Certificate of Conscnuoself-irour,for Wotkds Co.,.. FLOOR,ROOF.AREA,COND.
.tion,as pmvided for by Section 391)ofihe Labor GWe,for the perfcommum of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. -PER TRAP \� \\
❑1 have and will maintain Workers Compensation Insurance.as'required by Section
37W of the Luton Coda,for the performance of the work for which this permit is issued .SYSIIN-I INC.4 OUTLETS \� \� OCC.GROUP APN
My Worker's Compcwtion Insurance carrier and Policy number are:
Gorier Polley No.: .SYSTCM-OVI3R4fEA) �.,,CER'1'lhiCATf?OF E%EMPTION FROM WORKERSCOMPENSATION INSURANCE NDUSTRL WASTE INTERCEPTOR ��.\(This sailks and not hr wonipleted tithe permit iv future hundred dollar,(Sign BUILDINGDIVISUNFEPS
or less.) RAPPVsNCHECK FEEI certify Nat in the efommnce afthe work furwhich this permit is issued.I shall SANITARY-S)ORM IiA.21X1 FT. \nal employ any person in any manna sto M1Ty - v'rInthe Workers'Cnmlxry ENERGXFEEz salt..Laws art (ori Date X��Je� `-
Applicant -'S����C [�_=_�� ATER WNENODELF.CTR
z GRADING FEC
h NOTICE TO APPLICANT:If,after nicking this Cundicam of Exemption,you should WATER SYSTEM/TREATING
a ; become subje t to the Worker's Compensation provisions of the tabor Cade,you mum SOILS IEE
Lkl forthwith comply withsuch provisinm or this permit shall be JeemWlcvoked, WATER SERVICE
0. Q
7z CONSTRUCTION LENDING AGENCY NEW RESIDENT IAL BLAIR, SQ.FT PAID
U p Thereby nffnnihm there isacm.awnion lcnJing agav:y for the performance of Date Receipt#
W Fthe work far which this perrll is issued(Sec.3099.Civ.C.)
Lenders Name
WLender's Address TOTAL: T(1'TAL:
rZ. 1 certify that I have read this application and state mat the above fo m do is
(00 correct.I agree to comply with all city and county ordinances and state laws relatingui BUILDING FEE
U building construction.and hereby QTY. MECHANICAL PERMIT
6 yauttionz amork,emativec of this city as enter upon the FEE SEISMIC ER:E
abovemee)agreproperty far inspection keep harmless
(We)agree to save,indemnify and keep hnnnlns the City of Cu Wino against PP.HMR ISSUANCE Pc g ELECTRI
inconseq once ofihe granindofthis es permit.
may in anyway accrue against said City ALTERORADDTOMECH.
consequence of Ne granting of this penrdl. PLUMBINAPP NT UNDERSTAN WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10�jlie .000 CFM)OI RCE EGULATIONS. MECHANAIR HANDLING UNIT(OVER 10,(M CPM) CONSTR
Signature of A,licanUCunuacmr Data EXHAUST HOOD OVIDUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MI'I'ICATION FEE
Will the upplicam a,future building occupant door or handle hzenrdous maenol HEATING UNIT Fro 100.000 BTIII
as defined by the Cupertino Municipal Code,Chapter 9,12,and the Health and Safety
GWe,Section 25532(a)'l HEATING UNIT(OVER flE000 BTU)
C3 Vic, "19�10
' VENTILATION FAN(SINGLE RESID) PAID
Will the upplicanl or furore huilJing rcntpam use er,pourt m damea,which Date Rtteipt#
emit havmdous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP CRT OR I0RX0 BTU)
District? TO'T'AL:
❑Yes 10. BOILER-COMP(OVER 100.000 RTU)
1 have rew1 the hamNmus mmcrinls rcyuirement nnJer Chapmr 695 of Nw C:Ji- AIR CONDITIONER ISSUANCE DATE
Extra Health&Safety Cute.Sections 8505,25533 and 25534.1 understand Nal if the NEW RESIDENTIAL MECH. SQ.FT.
buildingdoes not cmready have i tenant,thus it is my mi,mumbility m siddy the s ecupenl
of the mi,mccmcas which marl Fn mel prinno isamnce of a Ccnllicale of Occupancy. !
Owner or unhunled agent Date TOTAL:
ISSUED BY:
OFFICE