S 2006 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HUI LDINC-ELECTRICAL TEST NO. 2006
BUILDING DIVISION APPLICATIONIPERMIT rLunuHSIG-siF.CHANICAI. \J
BUILDING PROJECT IDENTIFICATION
BUILDINGAIIIIRF.SX SANITARY NO. APPLICATION SUBMITTAL DATI
/0370sfel(% 94
�IWNIiR'S NAME: 4Rr'T ell 110 E: CONTRACfOR'9 NAME' �S l• •LIC NO:� NIC CONTROLN
�ARCIi1TF,C 2NGINEER: G.a Loll-
NO: A ESS: 16Ae. 'SA3,;Yv ?S-
CONTACT: PHONE:/ BUILDING PERMIT INFO
Yj� o ❑ Consultant Pcea Paid by Applicant(Initial) BLDG / BLOT PLUMB MOH
LICENSEDlCCONTRACTOR'S DECLARATION f!' Q'I'Y. ELECTRIC PERMIT FEE
1 hereby of ion that I am license under provisions of Chronic 9(cammendns JOB DESCRIPTION
OaZ whir Seetinn7000)ofDtvtsi 3o le Businevsand Prof cions Co ,and n,y lltxnse ie RESIDENTIAL'
W O PERMIT ISSUANCE.
Fol- in full force and Beer, C Swim. ❑KITCHEN REMODEL
�UV Limnso Cl Lic.M APPLIANCES-RESIDENTIAL El ADDITION ❑PLUMBING RE-PIPE
F-Z W Dam Cnnwcmr
mQp, ❑MULITUNIT ❑STRUCTURAL
ARCHITECT'S DECLARATION
F v Z I ordelrl'nnd my plan.shall be nseJ es public rerorda PANELS MODINICAHON
UP AMPS
O Z El INTERIOR ❑CHIMNEY REPAIR
[,000�l'i_ Licensed Nonessential 201-1000AMPS IMPROVEMENT SWIMMING POOLS
,6y .•]] OWNER-BUILDER DECLARATION
G < 1 hereby affirm that 1 am exempt form the Conb edn',License Law for the OVER❑XIII AMPS El BATH REMODELIREI'AIR OLITION
O G U hollering reason.(Section 7031.5,Business and Professions Code:Any city or camty SIGNS ELECTRICAL C OTHER
get W y which re,mov,a permit m wnshma.alley improve,derrolLah.or repair any no cture
(:'v�Q prinrm its issuonur,nlu�reyuircslhr applicant fnrsucb ponnit to lileasigned aotenmm SPECIALCIRCUCOMISC.
C G
but he is licensed puratint to the provisions of he Connector',License Law(Craapmr9
W Q� (commencing with Section 9000)of Division 3 of the Business and Pmfevsines Code)or TEM It METER OR POLE I NST OMM L'
d G e that he is exempt the,
and the Mavis for the alleged exemption.Any violation of C NEW BLDG/AD C DE fOLITION
W m., Scctien 90315 by any applicant far a permit subjers the applicant m a visit penally of POWER DEVICES �
t more than five birthed dallnn f&500). CTENANT ❑FOODSERVICE
F¢Q ❑ 1.re—orrof the nemarty,ar my mapleyess with wage,us theirrale eomprenaion, SWIMMING POOL ELECTRIC IMPROVEMENT w
F CO'I'HEk
will dothe work,and thcstrucmre is no ludedcdoroffered forsulr(Sec.7l Bip,mcss
and Professions Code:The Contractor's License Law does not apply In an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or impmses thereon,and who docs such work hitmulf or through
his we employers,provided that arch improvcmerm ere nal intended reoffered for NEW RESIDENTIAL ELFCTR SQ tH'.
sallf,however the M1ullding dr improvenenl is sold within one yearnfcounpletidn.the SQ.FT.FLOOR ARRA SISQ.fT
c
owner will have the burden of proving that he dirt not build or improve for pur-
pos corsair.) .FCfI'AI..
[] L as owner ofpropertycut IY tTswith 1' Icontractorsm
can in,p w,S j t 7044 R . and P f:. C d )TI r ve y s U-
come L �d t applyl f property who b 'Id'or nmervesth .,d QTY PLUMBING PERMIT FEB ,; 7
whocrschprdu-0withvvdn¢acmHv)I un.vdp rsuanuotheGn tars
LicenseeLaw.Law PERMIT ISSUANCE
❑ Iant exempt under Sec. ,B&PCfor this mason
AUFER-DRAIN&VENT'-WATER CA)
Owner Date ..
Wm under:SCOMPf VrjorI m DECLARATION BACK PLOW YIt01 F.CT.DEVICE Q
I hcreM1y oilier under lxnuhy of perjury one of the following declensions:
0 [have and wIfcondition a Certificate of Consul(to self-insure for Worker's Cmnpen- DRAINS-FLOOR,ROOP,AREA.COND. STORIES :ONSTRUCPIOh
snion,as provided for by Section 3700 of the Labor Core,tor the performance of the
work for which this permit is issue. FIXTURE-PER TRAP AUG 21 199
❑ I have tend will mmi
ainn Worker's Compensation Insurance,as required by Section
3700 of the Labor Cee,for the performance of the work for which Ibis permit is lssucd. GAS-P.A.SYSTEM-I INC.4 OUTLETS OCC.GROUP Lj APN
My Work "Compe1sal nn corm eharrani old Policy No: =67i nCary Iky/ 671�a/p CAS, SYS'TE.N-OVf?K 41P.A) -
CF.RTIFIC 'TG OF SXP.MPOON FROM WOR-KERS' Y Lf[tlRy
COMPENSM ION INSURANCE GREASEIINUUSTkI.WASTF.INTERCIiPI'OR SIGN FESS' '
(Thi,section need not be completed ifthe permit is furore hundred dollms XI W) GREASE'I'RAP
or IcxoJ PLANCHECK FEE
I certifythal ionic performance oDhc work lot which this pd ilia issued,I shall SEWER-SANITARY-STORM P.A.20X1 PC
not employ any person in any manner sn as m become alejed in the W Fees'Contact- ENERGY FEE
Z salon LavenfCalifomin.Done WATER HEATER W/VENT'/HI.P.CTR
Q A,darm ' GRADING FEE
NOTICE TO APPLICANT:fl,afternaakin,this Certificate of Exemption,you should WATER SYSTENUTREATINC
become subject to the Workers Compensation provisions of the Labor Code,you muN SOILS FEE
LTI forthwith comply with such provisioner this peamit shall be decided resided. WATER SERVICE
Q
Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.PT. PAID pale -r Receipt iY
I haffirm rrAy arm that there Is a conxwc0on lending agency Turbo perfnmmnm of
U O me wad: r wbmh tmsce m .cam(sec.3B9d,civ.c.)
LTt H Lenders Name TOTAL:
C' WLenders Adders TOTAL' BUILDING PEE
1 vend,that I have mad this application and stake that the above infomtahon Is
�i 0a/ correct.I agree m comply with all city and county ordinances and slake laws rotating to QTY MECHANICAL PERMIT PEE 4.
U z building construction,rand hereby authorize representatives ofthis city to enrupme the SEISMIC FEH
above-mentioned pmperry for inspired..purposes.
PERMIT ISSUANCE ELECTRIC PSE
OVOa6ree to save,indemnify and keep families the City ol'Cupcrdnoagainst
linhilitiea,judgments,costs and expanses whichmay in any way awmragaimisaid City ALTER OR ADD TO MECH.
in consequence of the graeding of this permit. PLUMBING FP.F,
APPLICANT UNDERSTANDS AND WILL COMPLY WITHA.LN -POINT AIR HANDLING UNIT('1010,000CFM) MECHANICAL FEE
SOURCP.REGI FLAGONS 8 �� AIR HANDLING UNIT(OVER IO,IHXI CFM) CONSTRUCTION TAX
Xnathrrcoil
pp v IConme'., End EXHAUST HOOD OV/DUCT) HOUSING MITIGATION P'
AZARDOUS MATERIALS DISCLOSURE
Will[I a licant or fuwrc M1uild ng occnPnnl store or bundle hnzmdoun mamdal HHATINGUNIT('rOK0fifXIBTU)
as defined by the Cupertino Municipal Calc,Chapter 9.12,and tiro health and Safety
Cade,Section 25532(x)'! HEATING UNIT(OVER 100IXX)11 FU)
E]Yes E]No VENTILATION CAN(SINGLE RESID) PAID -
Dne Receipt%
Will the applicant 9r future building occupied use equipment ordevices which BOILER-COMP(3HP OR]FROM BTU)
mit hazardous air containments as defined by the Buy Area Air Quality Manageman TOTAL:
DisvimP BOILER-COME(OVER 100,000 BUT)
❑Yes E]No
I have orad the hazardous materials requirements under Chapter 6,95 of the Cnli- AIR CONDITIONER ISSUANCE DATE
Admin Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MFCL SQ.EF
building deco not curremly have a tenant.Iran it is it,rcxponamiiity m reify the rmcupam
of(tie nanimmems which must do met prior m issuance of Cenificate of Occapnncy.
'Owner or autM1orizenl agent Dam TOTAL ISSUED 6Y:
OFFICE