S 0194 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
(CITY OF CUPF,RTINO BUILDING.ELECTRICAL P.F§IT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-A1F,CIIANICAI, F§
019.4
BUILDING PROJECT IDENTIFICATION
RJR-DING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
O BR'S NAME: # + `� CO C'IG SNAME: h'} / as NIC CONTROL#
�ARCHITFCT/ENGINEIER, LIG ncr -(J ADDR S (��L O�I ❑
1 PHONE: Ir - - BUILDING PERMIT INFO
CONTACT -
❑ Consultant Fres Paid by Applicant(Initial) BLD-IGIiLECI' PLUMB MECH
LIC ❑ ❑ ❑
LICENSED CONTRA(CTOR'S DECLARATION QTy, (ELECTRIC PERMIT FEE
1 hcrehy surmount,I am licensed under p wkwas or Chapter 9 RnmmuneNg _- JOB DESCRIPTION
O04Z with Section of Division 3 ofue Business and Professions Cale,and my license is RESIDENTIAL
WOO in p,
F-
F-ly full force and efleci I S ❑SFDWL ❑KITCHEN REMODEL.
�V License Clus. Lic.# s APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
F Dam Commcmr
y ❑ ❑MULTI-UNIT ❑MODCfURAL
7y Aoxhall use DECLARATION PANELS
F MODIFICATION
ZOy- 1undemmnd my plans shall adused as public records
O Z.-q 11PTD 210 AMPS El INTERIOR ❑CHIMNI?Y REPAIR
rot; Licensed Pmfeseiond 201-1100AMPS IMPROVEMENT ElSWIMMING POOLS
G � OWNER-BUILDER DECLARATION OVER I(100AMI'S ❑BATH RI?#ODIiLIREPAIR ❑UIiMOLIJION
I hereby affirm th
that I ren exempt from the Cmdonno's License Low for e
x06V following....(Scene.7031.5.Business and Pmfevow.s Code:Any city or countySIGNS ELECTRICAL
a, prior
{F O which requires a pennn m conmm�,ober.lmpmvq demolish,or repair any wouclure LGA/M9Q(P/
prior to it issuance,alsorequtres the applicant bowel permiuo file actgnedstammmou SPECIAL CIRCUTUMISC.
Nat he is licensed pursuant to the previsions of the Contractors License Law Chapter
00 (commencing with Section90Ut)ofDivirkm 3 of the Business and Professions Codchu TEMP.MET ER OR MILE INST. GOMMERGIAI:
a q m C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
uXl I+y Section]0315 by any applicant for a permit.subjects the applicant m a civil penalty of POWER DEVICES ❑TENANT El FOOD SERVICE
t more than five hundred dollars($5 0). IMPROVEMENT
=Z0 ❑I,z owner of the pmpcny.ormyemplOyces wiNwagesas their snlecompensation, SWIMMING POOL ELECTRIC
will If.the work,and theobucmre is not intended ofoffered farsale(See 904q Business ❑OTHER
3 and Prafexamas Cade:The Contractors License Law does not apply to an o mar of OUTLETS-SWITCHES-FIXTURES
property who builds or impmvec durenn,and who does such work himself or through
his own employees,provided that such impowemems are not intended or offered for NIEW RESIDENTIAL ELEC'I'R SQ R'.
sale.If,however,the building or improvement is sold within one yearofcomplmion.tehSQ.Fr.FLOOR AREA SISQ.FI'.
nsocr bolder will have the burden of proving ilial he did not build or improve torpor- .4`
prose
orpor-
pose create).
I,as owner of the pmperty,nm excb¢Ively contracting with licensed cnm
mmms to TAI"
construct he project(Sec.9144,nosiness and Pforesslons Calc:)'11re Contractor's LI-
cense Low does not apply m on owner of propcny who builds or improves thereon,and QTY, PLUMBING P I FEE
who amtmcts Tarsuch project with.cnntmm...o)licensed purcuom wthe Cnmmcmr'e
License Tnw. pERMrr ISSUANCE.
I um exempt under Sec. .B&P C far this reason
ALTER-DRAIN&VIENT-WATER(EA) VALUATION
owner Date 0
WORKER'S COMPENSATION DECLARATION HACK FLOW PROTECT.UEVICIi U1 2 .^x a U
Ihereby nl mom under a malty or e perjury one of thefollowingdcrlaruWorker
snna: O� V
0Ehavc and will mountain aCenircam of Gm.mnnoself-insure for Worker's Contpcn- pRAINti-Fl.00R,ROOF,AREA,COND. S'I'ORHES 'TYI'Ii GONS'1$GG'1'TGt
cutins,as provided for by Section 3900 of the Lulmr Cade,lir the performance OIthe
w kfor whichthislabornI,issued. FI STORES-PIER TRAP S N
have and will maintain Workers Compensation Insurance.as required by Section
(Nl of the Labor Code,for the performance of the work for which this pennn is inucJ, GAS-IEA.SYSTEM-I INC.4OWLETS OCC.GROUT' APN
My Worker's Ali mentation Insurance carrier and Policy numher am:
Carrier. IZ(/�! Policy No.: GAS-IEA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GIt GA51%INDUS'TRI.WASTE INTEItCLPEOk ••J
COMI'ENSA'fION INSURANCE BUILDING DIVISION FEES
(ThissectionneednotbeeompletedifNe pemth istmonehundrcddollurs(EIND GREASE TRAP
mle".) PLANCHECKIEE too(
certify that in the performmuce nllhe work for which this permitis issued,lsh°ll SIEWF.R-SANITARY-STORM F.A.3101T.
nm employ any person in any manner ur nx m become wbjecun the Workers Contpcn- (ENERGY FF.IE
Z ration Lows of California,Date WATER HEATIiR VINENT/BLL'CTR
z O Applicant ) - GRADING lili
y NOrICETO APPLICANT:If,after making this Certifiwm of Exemption,you should WATER SYSTI?MfFREATING SOILS FEE
al'� become subject to the Workers Cnmprowtion previsions of the Labor Cale,you muss
Lkl i� feflawiNmmply with such previsions or this permit shell be deemedresoked. WATER SERVICE
Q
7z CONSTRUCTION LENDlNGng agent NEW RGSIDENI'IALI'LMB. SQ,F. ('AID Date Receipt#
C.) p I for
roe that then i isacd(Ser.ion lending agency for performance of
Le work for which this permit is issued(Sec 31)99,Civ.C)
Lenders Nome TOTAL:
{Utl Lenders Address IYYfAI.,
Lit I certify that 1 have read this application and state that the above information is BUILDING hEE a
N coned l agree m comply with all city and county ominarectarimme laws odmingm QTY. MECHANICAL PERMIT; FEE
V z mildingcunstniennuond herebyouthoriza represemmlvesof this city In emerupon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)u%rec m save,indemnify and keep harmless the City of Cupertino agourea IELECJ'I FA
'
liabilities,judgments,cuss and expenses which may in any way uceme against said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERS'T'ANDS AND WILL COMPLY WITH AL1,NON-POINT AIR HANDLING ON IT(TO 10,000 CFM) M PCeUs Fi
SOURCE
/n.f /py AIR HANDLING UNI'I'IOVHR 10,1NXICFM) CONS`I'RUC'1'ION :
Signature ofAppli JConlmctor Date L/O EXHAUtiYl HOOD(W/DUCq •j .IN.MI6�AI'ION PI?li
HAZARDOUS MA'T'ERIALS DISCLOSURE
Will the applicant or future building occupant.aore or handle hmmedoesmarerial HEATING UNIT rI'0 I Ont"11110as darned by Ne Cupertino Municipal Cade,Chapter 4.12,and the Health:red Safety
Cale.Section 25532(a)'? HEATING UNI'('(OVER 100.1000 BTU)
Dyes ❑NO VIENTILA'r10N1'AN(SINGLEREMDE PAID 4887
Date Receipt#
_
Will the applicant or future building occupant use equipment or devices which tlOILER-COMP(311P OR IINk01H1 B'fU)
emit hazardous air contamiumu uc defined by the Bay Area Air Quality Management DUAL: Q
District? BOILER-COMP(OVIiR 100.000 BTU)
C3 Yea No
1 have read the harnNous materials requirements under Chapter 6,95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Cade,Sections 25505,25533 and 25534.1 understand thatif thin NEW RIESIDEN'I'IAL MFCH. SQ.F-L r
building does not currently have a tenant,that it is my respmsihility to notify the occupant
of the rquircmenu which man be ren pnnnoissuance ora Cenircam of Occupancy. !J /kms
Ownerornithanced agent Dole TOTAL: ISSUED BY:TOe
OFFICE
FROM CABINET CRAFT PHONE NO. May. 22 1998 0t 42PM P4
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MAY 27 1998
• BLDG.INSPECTION DEPAR4mcivl
I CITY OF CUPERTINO
COR
'08 39vi SlIWN3d AVS Hi6ON C99LO LOLT 6b:68 866T/9d/99
FROM.: CAP114ET CRF*T PHONE NO. MSy. 22 1998 2141PM P3
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j MAY 2 7 1998
ULUU. INSPECTION DEPgn r"r
CITY OF CUPERTINO
L0 3DVJ SlIWH3d AVE HINON E9919ZGLOLI EV:60 866I/9Z/90