S 0236 APPLI OF CUTP FILL IN
NO INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITYBUILDING.ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMHING-MECHANICAL S 0236
BUILDING PROJEcr IDENTIF'ICAI[ON
13UILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
rIPT Sz;2668 0WAer
PHONE
NIC CONTROLpNES
CONTRACTOR S NAME
Jl Ir nn 10106 C
�ARCHITECHENGINEER: LIC NO ADDRESS: ❑
CONTACT: / r PHONE: BUILDING PERMIT INFO
?g6_25 �I E] Consul[anl Fees Paid 6y Applicant(Initial) Oc F.IiC" P li
LICENSED CONI'RACfDIFS DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of chapter 9(commencing JOB DISC IPTION
�9Z0 with Section AXX)of Division 3 ofthe Bu.sinewand Professions Code.mainly license is PF.RMI'I'ISSUANCE RESIDENTIAL:
l�-0 nfull Inatome effect. ❑SFDWI. [I KITCHEN REMODELTUU Lion,,Clul, Lk.N APPLIANCES—RESIDENTIAL ❑AUDI TION 0 PLUMBING ItIiPIPE
h 7WDate Cochosea a ARCHITECTS DECLARATION
ARATION PANIMUI.TI-UNI'P ❑STRUM URAL
LDH :1S
MODIFICATION
Z bn?; I understand my plans shallM used as public records UPT02(MIAMI'S
02—� gA
TERIOR El CHIMNEY REPAIR
[- Licensed Professional 201-1000AMPS PR0 EMENT C]SWIMMING POOLS
Lq` OWNER-BUILDER DECLARATION Contractors
OVI7R 10B)AMPS TH REMODEUR1iPAIR ElDEMCHA I'[ON
LL 1 hercM1y u0irm thin 1 am exempt from the CnnOumnrs License Law fur bitebdOLU following reason(Section]0313,Iluxineas and Professins Code:Any city or emmry SIGNS ELIiC'IRICALf1EE 1
WW a
- which requires a permit m control she,improve,demolish,or repair any stmcmre
0 Morto its issuance,aiso requires the applicant forsuch Permitto file a signed statement SPECIAL CIRCUIT/M1SC. all
of,�y that he is licensed puremnuotheprovisions ofNeCommear'slicenseLaw(Chapters)
WypO (commencing with Satins 7")of Division 3nfthe Business and Nnfecsions Ctrk)ar TEMP MID ER OR POLF.INST. COMMERCIAL•
d c that he is exempt therefrom and the basis for the alleged exemption.Any emmion of pa ❑NEW BLDOIADDITION ❑DEMOLITION
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWI7R DEVICES ❑TENANT ❑FOOD SERVICE
not marc than five hundred dollars($500). - IMPROV�.rN�NT
t�O ❑I,as ownc,,,llhe proper,.r my entpinyecs with wages as thei r ole contpen.uaion, SW I M M I NG PME ELECT It IC 'C 4'�Yeow. Fi% �S
1F wi ll do the work,and the structure is not intended or offered for sale(Sec.]0,14,Business ❑OTHER 1 1
pW and Professions Cafe:The Co inctnr's License Law docs not apply to an ow nor of OU'D.ETS—SWITCHES—FIX'I URES F ur el�.�AeL•...+- q 'e t Eloj,
property who builds or improves thereon.and who does such work himself or through —gyp_---
his own employees,powided.that such improvements are me intended or offered fit, NEW RESIDENT IAL ELECIR SQ FI.
ad,.If,hmweveythe building mempowermm is sold within oneyemnfcompletion.the SQ FT A Sl P1'.
owner-builder will have the burden of proving that be did not build or improve for pur- p
prop of wale.). . V O
❑ I,as nwncr al the property,ata exclancely contmeting with fee oil cnnbumnrs nt TOTAL: { > ATV
construct the project(Sea44,]0Business and Professions Cod J The Contractor's Li- •a�C//
case law does not apply loan nwarrof propcnor y who build, improves thereon.and QTY.' PLUMBING PERMIT ll V 1,
aememtrl forsuch projects siblicracrands)licensed porsuannmhe Contractor's
Liana Law. PERMIT ISSUANCE NG
❑ l am exempt under Sec. .B&P C for this remnn 1
— ALI Ell—DRAIN&VENT—WA'I HR(EA) VALUATION
7
WOkKER'SCOMP; S TIONDECLA4A1'ION I
BACK FLOW I',GTEC,DIWIC, �X
I hereby affirm under penalty of perjury one of the Allowing decimations: 1B Oct)
❑ I base and will maintain a Cenificale of Comenuo self-insure for Worker's Canteen- DRAINS—FLOOR.ROOF,AREA,COND. STORIES TYPIi GONRTRUCA10t
ration,as provided felt by Section 3]00 of the labor Code,for the perlommnce,of the
work for which this permit is issued. FIXTURE S—PER TRAP
❑ 1 have and will maintain Workers Compensation Insurance,as required by Section
37110 ofthe Labor Cedc,for the performance ofthe work for which this permit is issued. GAS—IiA.SYSTEM-I INC.4()IH'I.ETS OCC.GROUP AI'N
My Worker's Compensation hemou ce carrier and Policy number ore:
Cartier: Plicy No, GAS—IiA.SYSTEM-OVER4(EAI
CERTIFICATE OFRXEMPTION FROM WORKERS' GREASIlIND115TN1.WASTI:INTIiRCEPII�R
COMPENSATION INSURANCE BUILDING DI VISION FIBS
(This.,am need ern he completed if the ponsit is(m one hundred dollan(I IBD) GREASHTRAP
or less.) I'LANCl1GCK PER
I certify that in the performance ofthe work for which this permit is issued,I.shall SEWER—SANITARY—STORM EA.200 FT.
41 not employ any Peron in any manner to as to become subject to tile Workers''Connam' ENERGY FEE
Z .him Lawsof California.Dam WATER HHAMR W/VHN'I'7111.IiC'IR y Q Applicant ) GRADING FEE
qI y NOTICE TO APPLICANT.If, Retooling this Ceri fico a of Exemption,you should WATER SYS'I'EMITREATING
h�•ff become subject m the Workers Compensation provinces of the Labor Gude,you must SOILS IEE
forthwith comply with such provisinnsor this permit shall bedeeed
tninvoked. WATER SERVICE
Q
rte CONSTRUCTION LENDING ng ageCV NEW RESIDEN'11A1.PCMB. SQ.FI. PAID
r`7 Z late Ree tX
I herebyahthis that them laami Ser.construction 30 lending agency lot'he perfnmmnce nl
U O too work rpt which this perms it ixsuul!Sac.309],civ.C.1 all
ploader's Name If TO'1'AI.:
WnJI< ers Address
y 1 certify thin I lime rwJ this applicmion and shim thin the above information is ifUILD1
FN correct.I agree b,comply with all city and county ordinances anal laws refusing it) QTY. MECHANICAL PERMIT FEE
U Z building consaamion.and hereby authonm representatives ofthis city to enter upemthe SETSMIL EE
above-mentioned prol for impemion purposes. PERMIT ISSUANCE
(We)agree In save,indemnify and keep humbles,the City of Cupeni nu against
fill jndgn®nts,cost and expenses whlehmay In any wayncernmtgmimtsald City ALTER Olt A DD TO M BAH. I'LIIMBINGF (
in mequerecof IIm grantingof this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NDN-POINT AIR HANDLING UNIT TO 1(0))CPM)
tRCE EGULATIONS. MIiCHAN1 FEIi
10,000C
�/ AIR HANDLING UNIT(OVER IO. XI CFM( (INSTRI1CIl0 TAX
Signatureof Applamuc Contractor 1V Date EXHAUST HOOD iVODUCq HOUSINGMITIGA'1 )NFI!I!
HAZARDOUS MA'ERIALS DISCLOSURE
Will the appllwtm or lbmrohuilding nanpam entre or handle haeardou,material HENIINGUNI'I'ITOI(X),0(X)If I'll)
as defined Cupertino
by the Municipal Cede,Chapter 912,and the Health and Sufdy
Cade,Section 255320)1 .1 HEATING UNIT(GVHR 100,000 BTIII
Yes pu No
El I� VENTILATION FAN(SINGLE RPSID) PAID Dme eceiptp
Will the upplicmm or future building acCupaal use equiptnent m devices which
emit homrdou.s air contaminants as defined by the Buy Area Air Quality Management BOILER—COMP TRP OR I W,IX)fl BTU) TOTAL:
D'utnml BOILER—COMP(OVER I NI,0110 BTIU
E]Yes No
I have re al the hamrdons mteemilsrequiremect,under Chapter 6.95 of the Cull- AIR CONDI'T'IONER ISSUANCE DATE
Gettig Health&Sa@ty Cade.Seshons 25505,M533 and 8534.1 understand that Rine NEW RESIDENTIAL MECH. SQ.rL
buildingdoes not currently have a tenant,that it is my responsibility to notify the oecup:mt
C m imntem It h mu mG p' r,,issuance of v Con ir v�¢}fo
O 7tl 94
n ut onood agent - Date _ TOTAL^ ISSUED BY:
OFFICE
\ /"Aev,s mw
i
Gehero.l NofeS �- Z
�• �etimo�e � YeeLaCe �
��. ZhSkQk1 IVe,�) 70 ��t
LG✓. C5
J7oor Lk),fk _Ne.W LG !a✓.
3°
1 .
�V.
� _ lrs�al� NR,.� 1 •It
Flooc a�� LJalls 2, °�.
To
1 � {�a CC��
�I A 1'JU(nlit ���t-C.
rilopy
/0100 tel g JUN 2 01997
&�IrjtIVAa
BLDG.INSPECTION DEPARTMENT
CITY OFCUPERTINO
i lev`5