30036APPLICANTTO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
FEE
CITY OF CUPERTINO
BUILDING DIVISION
APPLICATION/PERMIT
BUILDING - ELECTRICAL -
PLUMBING - MECHANICAL.
BUILDING PROJECT IDENTIFICATION
•
PERAIn'N030036
'
BUILDING ADDRESS:
LIO
-
� L<�
SANITARY NO.
BUILDING DIVISION FIEFS
APPLICATION SUBMITTAL DATE
OWNERSN ME .�
PHONE'. '
l D
`
CONTRACTOR'S NAME: 1
G 1 C J-G
LIC NO:
'� r
NlC
1-1 '
CONTROL#
RCHITECUEN INFER: LIC NO:
ADDRESS. I _ ^ T _
IPA
❑ Consultant Fees Paid by Applicant (Initial)
LICENSED CONTRACTOR'S DECLARA )N
I hereby affirm Net 1 am licensed under provisions of Ch ter 9 (commencing
with Section 700inufDivision 3.f ,ha Businessand professions C and my license is
in full force and effect.
License Cate Lic.#
Con
ARCHITECTS DECLA A 1 N n
I understand my plans shall he used as public records N
PEI— OWNER - BUILDER DECLARATION ' I hereby ufflrm that I um exempt fnm the Contractors License Law ad following reason. (Section 7031.5. Business and Pridaviuns CWe: Any city or which eximme a permit ,, consumer, alter, improve, demolish, or repair any inecmre
I, Charm insistocurce. also requires theapplicmn breach permiuo file.0ined swmmert "
6� thmhe is license) Pursuant m the provisionanfthe Contractors License Laa(Chapmr9
DO icammcrecingwiN Section 700dpof Diviwon3 ofthe Busimessnmd Professions GlalC]oI
6 that he is exempt uherefmm and the basis for the alleged exemption. Any violation of
YX1 ub Sation 7031,5 by any applicant fora permit sabjats Ne applicatn rte a civil penalty of
1F.. rn t mom than five hundred dollars ($500).
'J-� 01, as owner of the properly, or my employees with wages as Neir sole compensminn,
•CC�� will do the week, and Neswcmre is not intended m offered for sale (See 7044, Business
4'3 $ and Professions Code: The Contractors License Law does not apply to an owner of
property who holds or improves uhereun, and who does such work hinsxclf or through
his own employees, provided that such improvements are nm intended or offered for
sale. If. however, the building or improvement is sold within one year of completion, the
po�er-huilder'will have the harden of proving flat he did not build or improve for pur-
nfsale).
0 I, as owner of the property, am eseloswely ...has with licensed continuous to
coustmct the project (Sec, 7044, Business and Profession, Crew) The Contractors Li-
estate law does rot apply to an owner bf property who builds or improves thereon, and QTY
who convects for such projects with a commucmrts) licensed pursuant o the Conmeors
License law,
0 1 am exempt tinder Sec, , B & P C lot this reason
Owner Doc
WORKER'S COMPENSATION DUCLARA'I'[ON
1 hereby affirm under penalty of perjury one of one following declimetiom:
0 I have and will maintain a Cmificare ofConsem to sclf-insure for Workers Compen-
sation, as provided for by Section 37101 of the Labni Code, for the performance of the
work for which this permit is iseuel.
0 1 have and will maintain Workers Commandos Insurance, as required by Section VJ
3700 of the Labor Code, for the performance of the work for which this permit is issued
Worker's opens faint tree 'nand Palicynue. ��
artier._ Policy No:
R PICA MPE SATIONIONpRAN WORK,
COMPENSATION INSURANCE
(This saoion need not bemntpleoed Ban, permit is for one hundred dollerx ($100)
orl cast I -
I employ my That in in my anmmoe o as i work bra which this fee Workers is issued, rCol shell
not employ any Cason in any manner so m nn home subject m Ne Worken%Compcn-
• O Z Appe Laws of California. Ume
7 O NOTICE ^� H NOTICE TO APPLICANT, IL atom making this Certificate.( Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
m
� Q forthwith comply with such provisions or this permit shall he deemed rovnkeJ.
CONSTRUCTION LENDING AGENCY
U O 1 hereby afford that hem is a construction lending agency for the performance of
O.9 the work l or which this permit is issued (See. 3097, Civ, C.)
U Isnders Name
U Lenders Address
G I certify that I huvc read this appleakin and.mo thal Ito ubmc information is
V) comet. ) agree m comply with all city and county ordiand.a and seem laws totaling to QTY
U building contraction, and hereby outhorize representatives of this city to enter uptsnthe
„ above - mentioned property for inspection purposes. PERMIT ISSUANCE
(We) agree 10 save, indemnify and keep homeless the C le
'City of Coleman. against
liabilities, judgments, cuss and expenses which may in any way a.., against said City ALTER OR ADD TO MECH.
in nsexp ence of his, great in, of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITHAL]. NON -POINT AIR HANDLING UNIT(TO If000 CFM)
SOURCE REGULATIONS. / • -
A]R HANDLING UNIT (OVER 10,000 CF
EXHAUST HOOD(W /DUCT)
HEATING UNIT (TO 100.000 BTU)
HEATING UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER- COMP IMP OR 1110,000 BTU)
HOILER -COMP (OVER 100.000 BTU)'
AIR CONDI'f10NER
NEW RESIDENTIAL MUCH,
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES- RESIDENTIAL
PANELS
UPT02MAMPS
201- If00AMPS
OVER 1000AMPS
SIGNS ELECTRICAL
,SPECIAL CIRCUITIMISC.
TER METER OR I' L•E I
POW Of:VICEs
SWPvl POOL TEL IC
OUTLETS -S ITCHES- DXT.9tES
NEW RMIDIBI ELECTR SQ FT,
TOI I
PLUMBING
YL• MIT
PERMIT ISSUANCE
ALTER - DRAIN & VENT - WATER ( )
MECHANICAL PERMIT
`HAZARODUS MATERIALS DISCLOSURE
Will me applicant or future building accupano store or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.11, and the Health and Safety
Code, Section 25532(mit,
❑Yes 0 N
Will me applicant or fuorc huili ing mention, use e9uilmenl nr devices which
1:mit hazardous air commairsels as defined by the Buy Area Air Quality Management
isticl?
❑Yea E] No
1 have read me hmartlous shouts requirements under Chapter 6.95 of me Can-
Room Ifealth & Safety Code. Sections 25505, 25533 and 25531 I understand Nat if the
building does not currently have a ¢rent, that it is my re.sponsibilihy to notify the recnpnnt
of No requirements which most be met prior m invance of a Certificate of Occupancy.
Dam- TOTAL:- TOTAL:
OFFICE
BLDG /ADDITION -' ODIEMOLITION,
NT ❑FOOD SERVICE
SQ, FT. FLUOR AREA
JUN 11 1996
ut-
FEE
JOB DESCRIPTION
RESIDENTIAL
❑SFDWI. ❑ KITCHEN REMODT:I,
❑ADDITION [I PLUMBING RE -PIPIT
❑MULTI -UNIT ❑STRUCTURAL
., MODIFICATION
OINTERIOR ❑ CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEUREPAIR 0DEMOLI']ION
❑OTHER '
TYPECONSTRI
'
OCC GROUT'
APN
BLDG /ADDITION -' ODIEMOLITION,
NT ❑FOOD SERVICE
SQ, FT. FLUOR AREA
JUN 11 1996
ut-
PAID
Date Receipt is
TOTAL:
tlon
STORIES
to
TYPECONSTRI
Torn !
OCC GROUT'
APN
BUILDING DIVISION FIEFS
PLANCHECK FEE.
ENER Y FEE
U
A GME
OILS FEE
PAI
Date Receipt#
TOTAL:
BUILDING FEE'
-
FEE
SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MCCHANICALF'EE
'
CONSTRUCTION TAX '
HOUSING MITIGATION FEE
PAID
Date Receipt is
TOTAL:
Inspection Query for a Specfic Permit Print
10/23/96
PERMIT#
ISITUS STI
SITUS STREET AVE,CT,ST,RD
Lot# INSDESCRIPT
]n,lXee
DATEDESIRED
DateDone Ins actor
30036
19110
STEVENS CREEK
RGH PLMBG
7/10/96
7/10/96 AD
30036
19110
STEVENS CREEK
RGH ELEC
7/10/96
7/10/96 AD
30036
119110
ISTEVENS CREEK
I JFRAME
7/10/96
7/10/96 AD
Page 1
Units Pass /Fail
1P
1P
1P
Inspection Query for a Specfic Permit Print
Page 2
10/23/96