29980 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. O
BUILDING DIVISION APPLICATIONMERMIT PLUMBING-MF.CRANICAL
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATIONSUBMITTALDA'I
a b/rers -1 ,0/-
Co �3
OWN E ' ME: y^�HONCON ACTOR'SNAME LIC NO:
O NIC CONTROL#
ARCHITECT/ENGINEER: r-NLIEN, ADD 1/O-$,SO �
'5 p`�� ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fists Paid by Applicant(Initial) BLDG TELT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATIONIDQTy ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
FW 0Z. with SectionMl(pofDivision 3afthe Bminessand Profession.CWe.andmylicenscis RF-'Ip
1O full force andc c � PERMIT ISSUANCE TIAL.
,U License Class G Lir.. r`I� ❑SFDWL ❑KITCHEN REMODEL
vFiQL Date dri ?� Contractor APPLIANCES-RESIDENTIAL
[]ADDITION El PLUMBING RE-PIPE
E'r=. IunJcrstand my Plans sell#used as-C public PANELS ❑MULTI-UNIT ❑STRUCTURAL
O Z=— Pu MODIFICATION
F4EC,W Lmeved Professional DPTD 2UTAMP$ ❑INTERIOR EI CHIMNEY REPAIR
G 201-1000AMPS IMPROVEMENT
S Q 1 hemby aftinn broth am exdmpF room the C n�IO oYs License law for the OVER ROB AMPS ❑OATH REMODEf/REPAIR 0 DEMOLITION
X 3 L V following reason.(Section OW L5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
41 W O UQ which reyuias n porous Io 031.5.n,nlmq improve,demolish,or repair any or
prier to its issuance,also requires the applicant for such pennitto Idea.signedstatemem SPECIAL CIRCUIT/MISC.
r�} that he is licensed pursuant to the provisions of the Contmnots License law(Chapter 9
I+ISOO (commencing with Section BOB of Division 3 afthe Business and Professions Codc)or TEMP,METER OR POL ST. COMM R IA
0. C Nat he is exempt therefrom and the basic for Ne alleged exemption.Any vialmion of
X Section 7031.5 by any applicant for a permit subjects the applicant to a civil [I NEW BLDG/ADDITION ❑DEMOLITION
�..y 1 pcwlty of POWER UEVIC S
notmurothan umerofthundred dolounnSSW). 11 TENANT ❑FOOD SERVICE
�=0
will
Lo the work,the propcnrun,is emntended with write,oredf r Nei(Sole 0n1,B Business
SWIMMING L IC IMPROVEMENT `
ad will Jothewons Code;The mumawrs License Law
of apply to an Business OTHER
3 and Professions Csde:The Contractors License Law does not apply m an owner of OUTLETS-SWITCHES I S
progeny who huiW,nr improves such
improvements
upr who mm.reach work intended
or offered
through
his own employees,provided the such mens is sold within am not intended ser pfnfor,for NE W RESIDEMIAL F.LEC3' SQ FT.
sole.ILhowev wll havelthe burng or en ofpemcnt;that hedoneyeor improve
the SQ.F7.FLOOR AREA EISQ.FT.
et'f vote will have Oto FUNcn of proving that he did not bull)or improve[m par-
youofsaleJ. - . i -•
I,as owner of the property,am exclusively contracting with licensed contmetms to
conswn the fill(Sea 7044,Business and Professions Code)She Comment's Li- Q JUN 13 1996
acese law does not apply to an ownerofpropeny who builds or improves thereon,and TY.EPERMIT
PLUMBING 2,CON
FEE
whoconvects forsuchpmjats withacontmeorod IiermsW pursuanttothe Com gimes
License Low.
❑1 and exempt under Sec. ,B&P C Unions reason UANCE n�^�f 1 Vi liUrLfYIHVI�AIN&VENT-Owner Uate VALUATIOY
WORKERS COMPENSATION DECLARATION PROTECT D1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate ofConsent mself-insure forWorker's Camper- OOR,ROOF,Asation,as provided for by Section 3700 of the Labor Cotte.for the Perfomunce of theSTORIES 'TYPE CONSTRUCTIO1,
work for which this permit is issued, FIXTURES_PER TRAP
❑1 have and will maintain Worker's Compensation Insutantt,as rcyuircA by Section
37s10�ofthc labor Code,for the performance of the k which Otis permit is issued. GAS-E SYSTEM-I INC.4 OUTLETS OCC GROUP APN
M u is r n s na n r onA tbcr arc:
tl ante: olio u GAS-EA.SYSTEM-OVER 4(EA)
ERTIPICATE OF-(E IP ON FROM WORKERS'
COMPENSATION INSURANCE: GRIiASE/rvDUSTRL WASTE INTERCEPTOR
(ffiis secfion tad not becomPle¢d if the permit is forme bundled dollars t$Iqq BUILDING DIVISION FEES
,it less.) GREASETRAP
Iccnify that inthe pert nnunwof the work for which thistis ixcued.lsMll PLANCHECK PEE
porton
not employ any person in any manner so as to become suhjat to the Workers'Compete SEWER-SANITARY-STORM EA.200 FT. ENERGY FEE
sZ sation laws of California.Date
WATER HEATER WNENTMLECTR
ZApplicant GRADING PER
NOTICE
y NOTICE TO APPLICANT.If,after making this Cisions of
Labor i hat you should WATER SYSTEM/TREATING
a ; become subjecttothe Worker's Coons or this provisions of thelabor Code,you must SOILS I'M
W fonhwiN comply with such provisions or this pcmm shall be Jamed revoked. WATER SERVICE
a Q
� z CONSTRUCTION LENDING AGENCY NEW RESIDEN FAL PLAM SQ.ET. PAID
V 0 Thereby affirm Bad there is a construction lend;.,agency for plc pcformance of Dat coign#
W F, the work fur which this permit is issued(See.31)7,Co.C.)
p L) Lender's Name
Lender's Address TOTAL:
a1 can ify that I have lead this application and state that the above information is BUILDI 1
Z) cancer 1 agree in comply with all city and county ordinances and state laws misting us QTY. MECHANICAL PERMIT
L) z building<onswction,and hereby authorize mprcwntaives ofthiscirymenter noon the FEE SEISMIC E
.hove-mentioned property for isnpection pure i
(We)agree m save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
liabilities,judgment,exosinl expenses which may many way accmc.gainnwid City
in consequence of Ne grunting of this permit' ALTER OR qUD TO MECH. PLUMBING E
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT 111,(X0 CPM)
SOU 'REGULATIONS. ^ �= MECHANIC LITE
y —Zs�/ AIR HANDLING UNIT(OVER to."CPM) CONSTRU TIONTAX
SlgnZmre of ApplicanaloCentractor Date EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSIN MITIGATION FEE
Will the applicant or future building accupantstore or handle hazaalous matched HEATING UNIT GO 100.000 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Cade,Section 25532(x)? HEATING UNIT(OVER 100,000 BTU)
❑Yes D Nu ( a
VENTILATION FAN(SINGLE RESID) PAID
Will flue
is applicant or furore definng by ue R use equipment or devices which Dan Receipt p
emitial' us air contaminants as defined by the Ray Arca pit'Quality Management BOLI-ER-COMP(JHP OR 100,11011 BTU)
niretde�?
Lbuildi.,d.,,..
(]No BOILER-COME(OVER 100,000 BTU) TDTAL:
ad the hzzuJous andends requirements under Chapter 6.95 of the Cali- AIR CONDITIONER h
Safety Code,Scetines 25505.25533 and 25534.1 understand that if the ISSUANCE DATE
currently have.tenant Na it ismyrespatsibilhy m notify the occupant NEW'RESIIIENTIAL MECH. SQ.Fnents which must be met poor to ismance of a Certifiate of(,ch,cm,.r¢ad ngeni Oate I ISSUED BY:
OFFICE