30103APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PENONLY
CI'T'Y OF CUPERTINO BUILDING- ELECTRICALI PERMIT NO. 1 /(�
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -ME HANICAT, O1OV
)111 uislG Punwi-I'I mocr 4'ICAi'ION
03& ,> S
VERS NAME it
..I_
CONTACT.
Q�if 7 L.7
1 hemhy umrm that 1 um liaenud under pmvisions of Chupter 9 (commencing
with Sermon Division 3 of the Rosiness and/ Professions GW¢, and my license is
in full force andnd effect. 6
Lace az
Lie A
' ARCHITECTS DECLARATION
l andmsmnd my plan. shall homed as public mcmds
Licensed Pmfe ousal
OWNER-HUILDER DECLARATION
I hereby affirm Lein 1 am I.Pt firma the Comma mrs Licence Law for the
following reason. (Section 7031.5, nosiness and Professions Gnle: Any city or county
which requires o permit to construct, alter, improve, demolish, or repair uny structure
Town) its issuance, also requires the applicant for such permit to filen signed stntemem
that heis licensed pursuant to the previsions of the Commetoes License law(Chapmr9
(commencing with Section 1000) of Division 3 of the Business and Professions Cade) or
that he is esempl therefrom and the basis fur Ila )Based exmnpfmn. Any violar)n of
Section 7031.5 by any applicant for a permit subpn the applicant to a civil penalty of
not mom than five hundred dollars ($500).
❑ Las)wnerrofthe Pmpeny, mnry employees with wages as their sole compensation,
will dothe work, and the structure is not intended croffcred for sale (See 9144, Business
end Professions Cole: The Contractor's License Law does not apply m an owner of
property who builds or improves Ihemon, amt who does such work himself or through
his own employees, provided Nm such improvemenu are not intended or offered for
sale. If, ho lover, the building or improvement is sold within one year ofcnmpletion, the
onvow-builder will have the burden of proving that he did not build or improve for pur-
,see cfs:de). '
❑ 1, as owner of the properly, am culmively commcting with licensed contractors in
construct the project (Seo. 7044, Bus and Professions Code:) The Comoor's raLi.
ams Law does not apply m an owner of properly who builds or improves thereon, and
who contracts for such projects with a contmctons) licensed pursuant to the Contramnrs
License law.
❑ I am exempt under Sec. ,B& P C for this reason
LIC NO:
❑ Consultant Fees Paid by Applicant (Initial)
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES-RESIDIENTIAL
PANELS
UPI 0200 AMPS
SIGNS ELECTRICAL.
SPECIAL CIRCUIT/MISC.
TEMP, METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECPRIC
OUTLETS - SWITCHES - FIXTU R FS
NEW RESIDENTIAL ELECPR SQ FT.
PLUMBING PERMIT
FEE
FEE
COMMERCIAL
❑ NEW BLDG/ADDITION El DEMOLITION -
CTIENANT ❑ FOOD SERVICE
IMPROVEMENT -
C OTHER
SQ. IT. FLOOR AREA $/SQ. PP.
JUN 2 01996
lK#1SIits
PLANCHECK EE
ENERGY PEE
GRADING FEE
SOILS FEE _
PAID
BUILDING FEE Pit �—
SEISMIC FEB
ELECTRIC FEE
PLUMBING FEE
H
ANICAI. PEERUCI'IONTAXNG MITIGATION FE.
PAID
Date
IRFYkiakm.1v
TOTAL:
Date
ALPER - U146fiNA, 9FNT-WATER (EA)
.Owner
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penally of perjury one of the following declarations:
BACK FLOW P EVICE
DRAINS -FLO ,N IEA, COND,
I have and w ill maintain a Cenificam ofConswn msclf-inure for Worker's Compete
BUILDING PERMINFO
cation, as provided for by Section 37W of the Labor Cole, for the performance of the
FV7 ES- �R AT
work for which This permit is issued,
JOB DESCRIPTION -
RESIDENTIAL'
❑SFDWI, C KITCHEN REMODEL
CADDITION ❑PLUMBING R&PIPE
❑MULTI -UNIT []STRUCTURAL
MODIFICATION
C INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
C BATH REMODEUREPAIIi EMOLITION
C OTHER
C 1 have and will maintain Worker's Compensation Insumnim as required by Section
37M of the Labor Cole, for the perfauhance of the work for which this permit is issued.
GAS -EA. YST 40U S
it i/
My WuCarler:rke(CyaP ry'linnl r:uhoeparriel'ol Y ll
�
�cnum
cy Nn yi-�_
__dEERTI
GAS -EA. SY. MOV (EA)
-
EOFE 'TION FROM WORK RS'
COMPENSATION INSURANCE
GREASE/INDUSTR ASTEI RCEPTOR
(This section need nm be completed lithe person is furore hundred drift. p$ Bell
or less.)
GRIEASETRAP
0 Z
I sciify that in the perfmmanceofhhe work for which this permit is issued, l shall
nor employ any person in any manner w u
was to become subject the Workers' Compon-
sasion Laws of California. Date
Applicant
SEWER-SANITANV-STORM EA. 21X1 FP.
WATER HEATER WNENT/ELECIR
ftp
Wforthwith
NOTICETO APPLICAN'1:If, w1malaking this Cerlifiaateol' Exempt i, you should
become subject to the Worker's Compensation provisions of Ne Labor Code, you must
comply with such provisions or this Permit shad l bo deemed revoked.
WATER SYSTEM/TREATING
WATER SERVICE
Q
U
CONSTRUCTION LENDING AGENCY
NEW RLSID[NTIALI'LMB. SQ. PI'.
CoQ
0
Lks F
lhauhereissued(eaconstmc;ion 0lending agency Touter Performance of
l herebywhich
the work far which this permit is issued (gee, 3097, Civ. CJ
Lenders Name
Q
r J
9L.1
IFi V)
G z
Lenders Address-
cenify that have rend this application and stun that the above information is
corse]. l agree to comply with all city and county ordinances and state laws reading to
Luildingconmoron, And herehy.whous,repreumbuivesoRhihcityme..nrupsnthe
TOTAL.
Q'IY. MECHANICAL PERMIT
PERMIT ISSUANCE
above-mentioned property for inspection purposes
(We) agree manse. indemnify and kap harmless the City of CupeNno against
ALTER OR ADD TO MECH.
liabilities, judgments, ' costs and expenses which may in unywayaceme against said City
in nuq.amo of the granting of this permit.
Alit HANDLING UNIT CPO 10.000 CFM)
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
[-ILS% fj Z� �9'V
AIR HANDLING UNIT(OVER IO,000CFM)
Signature of Applicam/Contrnctor Daut
EXHAUST HOOD OVIDUCT)
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Will the upplieuntnrfuture huilcing oauparloore or hmdleh... Nous material
as defined by the Cupeninn Municipal Code, Chapter 9.12, and the He,dth and Safety
Codd Section 25532(e)7
HEATING UNIT (OVER 1000)) BTU)
❑Yes C] No
VENTILATION I-AN(SINGLE RIESID)
Will the applicant or future building occupant use equipment or devices which
:mit hazardous air contaminants as defined by the Bay Area Air Quality Management
BOILER -COMP (3HP OR 100.000 BTU)
District?
❑Yes ❑No
BOILER- COM P( OV ER 100,0011 BTU)
AIR CONDITIONER
I have rend the hmaolous materials mquirements under Chapter 6.95 or she Cul i-
NEW RESIDENTIAL MECH. SQ. PP.
four. Health & Safety Code, Sections 25505, 25533 end 25534. I uaderstnnd that if the
building does no currently have a Anneal Nut it is my respmsibility to notify the occupem
of she requirements which must be mel India 10 issuance of a Certificate of Occupancy.
,
Owner or amharized an, Date
TOTAL',
OFFICE
FEE
FEE
COMMERCIAL
❑ NEW BLDG/ADDITION El DEMOLITION -
CTIENANT ❑ FOOD SERVICE
IMPROVEMENT -
C OTHER
SQ. IT. FLOOR AREA $/SQ. PP.
JUN 2 01996
lK#1SIits
PLANCHECK EE
ENERGY PEE
GRADING FEE
SOILS FEE _
PAID
BUILDING FEE Pit �—
SEISMIC FEB
ELECTRIC FEE
PLUMBING FEE
H
ANICAI. PEERUCI'IONTAXNG MITIGATION FE.
PAID
Date
IRFYkiakm.1v
TOTAL:
N/C
❑
O/NNIROL#
C�j`
V I l
BUILDING PERMINFO
BLDG (ELECT PLUMB MIECH
CT
FEE'.
JOB DESCRIPTION -
RESIDENTIAL'
❑SFDWI, C KITCHEN REMODEL
CADDITION ❑PLUMBING R&PIPE
❑MULTI -UNIT []STRUCTURAL
MODIFICATION
C INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
C BATH REMODEUREPAIIi EMOLITION
C OTHER
FEE
FEE
COMMERCIAL
❑ NEW BLDG/ADDITION El DEMOLITION -
CTIENANT ❑ FOOD SERVICE
IMPROVEMENT -
C OTHER
SQ. IT. FLOOR AREA $/SQ. PP.
JUN 2 01996
lK#1SIits
PLANCHECK EE
ENERGY PEE
GRADING FEE
SOILS FEE _
PAID
BUILDING FEE Pit �—
SEISMIC FEB
ELECTRIC FEE
PLUMBING FEE
H
ANICAI. PEERUCI'IONTAXNG MITIGATION FE.
PAID
Date
IRFYkiakm.1v
TOTAL: