29303I me last s onIMT DGM nUl V
APPLIGANI IU YILL IN IN-UIf INHAt lull mt nu. r.c- l n. --
CITY OF CUPERTINO
BUILDING DIVISION APPIACATION/PERMIT
....�. .�..__. _..... _.- _.._-
RIlILU1N(:- ELECTRICAL
PLUMBING - MECHANICAL
PERMIT NO,
K O
J
SANITARY NU. APPLICATION SUBMI'pl'AL DN'F.
nun,rvc raD,ulCp nR:NTIFICgre)N
BUILDING
BUILDINGADDRESS:
OWNER'SNAME: PHONE: 7vps�L
CONTRACTOR'S AMI ?: $ LIC
NO:
N/C
❑
CONTROL#
ARCHITECT/ENGI ' LIC NO:
i
CONTACT: PHOMi -:.
OESS:
�o DR
❑ CnnsulWnl F"S Paid by Applicant (Initial)
BUILDING PERMIT INFO
-BLDG ELECT PLUMB MGCH
l 1,Sb b O
❑ ❑ ❑
QTY,
ELECTRIC PERMIT
FEE
LICENSED CONTRACTORS DECLARATION
I hereby effort that I am hanged trader provisions of Chapter 9 (eommenelag
with Section 7NMBonf Division 3ofthe Business and Professions Cut and my license is
in full force and effect. 7J
Liven Cl ss Lic. #,
JOB DESCRIPTION
RESIDE LIAL:
❑SFDWI- ❑KITCHENREMODEL
❑ADDITION ❑PLUMBING RE -PIPIT
PERMIT ISSUANCE
gpPLIANCES - REIDENTIAL
1 Dam i•�_ 7 �—Commcmr
i ARCHITIECPS DECLARATION
❑MULTLUNIT []STRUCTURAL.
MODIFICATION
1'ANBIS
I rndemm�d my plans shall be umd as public reams
UP TO 200 AMP$
❑INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEIIREPAIR ❑DEMOLITION
❑ OTHER
Licensed Professional
OWNER - BUILDER DECLARATION
C I hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 7011 S, Business and Ismfessimss Code: Any city or comity
which requires a Permit m consumer, alter, improve. denmllsh. or repair any structure
priononits issuvnce,e6n requires Ne applicam for such pemtiun fileasignedatmement
!het he is licensed pmaram in 'he Provisions of the Contonom, Licanm Law (Cbaple,9
5 (commencing with Section 701)(B of Division 3 of the Business and Professions Csde)m
g that he is exempt themfrom and the basis for the alleged exemPtlnn. Any violation of
Section 7031.5 by any applicant fora permit o1bjecrs the applicant to a civil penalty of
not more Bran five hundred dollars (S500).
4 Fl 1. as owner of the property, or my employees with wages as their sole compcnmtion,
will do the work, and the saucmrc is not intended,), [fend for ode (See 7(94, 9usiness
a end Professions Cafe: The Contractors Liccm c Law does nor apply to an owner of
- •201-
IMOAMPS
OVER IO�I11 AMPS'
SIGNS ELECTRICAL
-
SPECIAL CIRCUIT /MISC.
^
TEMP. METER OR PO LE INST. {�
COMMERCIAL:
❑ NEW BLDG /ADDITION ❑ DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEME
11 OTHER —
POWER DEVICES
SWIMMINIPOOI.01 -11 IC
OUTLETS- SWITCHES- FIXTURES
property who builds or improves thereon, and who doea such work himself nnbrmgh
his own employees, provided that such impmvernme, ore me intended Or offered for
sale. If. however, the building or improvement is sold wirhm one yearofcompleriun. the
owner builder will have the human of proving that he did not build or improve for p o,
pnae rf sale.).
I, u owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sea. 7044. Brame,., and Professions code:) The contractors Li-
cense Law does not apply to an owner property who builds or improves thereon , and
wo comm@s for such projects rob a cenrmctor(s)licensed prmunen to the Contmctora
NEW ItESIDHNI'IALELIiCfR SQ FT.
Q FT. FL A '
�ry GF LU 996
fE�f(N
$ /SQ, FT.
QTY. PLUMBING PERMIT
P '
License Law.
❑ 1 ant exempt under Sec. . R & P C for this ran m0
PERMIT ISSUANCE
ALTER - DRAIN & VENT- WATER BIA)
U
VALUATION
Date
Owre,
WORKER'S COMPENSATION DECLARATION
RACK FLOW PROTECT. DEVICE
'1 hereby affirm under Finally of perjury one of the following declarations:
❑ I have and will teal main a Certificale of Consent o self-insore for Workers Compel-
action, res provided for by Section 3700 of the labor Code, far rho perfonneme of the
work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, its required by Section
of the LaboCnik. for the performumce of the work for which this parmir is issued,
DRAINS - FLOOR, ROOEAREA, COND,
RIBS
TYPE CONS9'RUI$
FIXTURES - PER TRAP
GAS - EA. SYSTEM-] INCA OU'T'LETS
OCGGROUP
APN
GAS - EA. SYSTEM -OVER 4(CA)
My War C mount"lnmmna cwrier and Policy number ere:
Carries , 'bay No.:
CERTIFICATE FE %EMPi'ION FROM WORKERS'
COMPENSATION INSURANCE
GREASEffNDUSTRL WASTE INTERCEPTOR
NUILDIN D S ZEES
GRP.ASETKAP
PLANCHHCK FEE
( fhissec tionnacrinmhccnmplctediftlic cmitlaforonehundreddollan($IM)
nr less.)
I certify that in the performance ofthe work for which this permit is issued, I shell
lwme soglecn to the Workers' Com te
not employ any person in any manner sit as m m pe
SEWER - SANITARY -STORM PA. 200 FT.
BNBRGY PER
WATER HEATER W/VENTIELECTR
GRADING E
satim laws Of California. Data
D Applicant -
yNOTICE. TO APPLICANT.[Lunt, making this Certificate of Exemption, you. should
httome subject, to the Worker's Compensation provisions of the labor Code, you must
fonnhwull comply with such provisions or this permit Shull he deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the it for which this permit is issued (Sec. 3097, Civ. CJ
WATER SYSTEmn REAL ING
SOILS FEE
WATER SERVICE -
PAI)
NEW RESIDENTIAL PLMB. SQ. rL
m Receipt#
TOTAL:
TOTAL:
Lenders Name
_
Lenders Address
y I ramify that 1 hove rend this appllation and stem !bulbs above information is
n contract. l agree to comply with all city and county ordinances and state laws relating to
building ammernalme, and hen by suthnrio, representatives Of this city m rym cm,, u the
above. mentioned property for Inspection purposes.
(We) agree mauve, bulemnify and keep harmless the City of Carideo against
Iiabilitle,tjoctonars, costs it expenses which may many way acme against said City
U1LDI G FEE
QTy, MECHANICAL PERMIT
FEE.
SEISM CFEE
PE RMIT ISSUANCE
ELh RIC FEE
,
ALTER OR ADD TO MECH.
PLU BINGFEE
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI .NON -POINT
AIR HANDLING UNIT (1010.(IOBCFM)
MECHA'ICALHH
CP. UL S.
: • %0 - w s 1
AIR HANDLING UNIT (OVER 10,000 GPM)
CONSTRII ION TA%
Signature of Applicant /C ut Dmo
HAZARDO S MATERIAL S DISCLOSURE
Willmeapplicam mfumrcbuildingoccupanI stnmorharelchammsmanslcriel
as dietitian by the Cupertino Municipal Code. Chapter 9.12, and the Hadth and Safety
Section 25532(a)'f
❑YeS )(No
E%HAUS'F GOOD(WNUCD
HOUSING MI ,ATION ITIE
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT LOVER 100.0g) BTU)
PAID
Dnlo Rcceipl#
VENT] IATION PAN (SINGLE RIiSID)
Will the applicam or future building Occupant use equipment or devices which
emit hammaus air contaminants as refract by the Bay Area Air Quality Management
BOILER -GDK1P (lHP OR IOO,gq BTU)
TOTAA
BOILER -COMP (OVER TOO,WII BTU)
District?
❑Yea a
the ht materials muin,ram¢amvE, Chapter 6.95 of the Cali-
I haveaad hare
AIR CONDITIONCR
ISSUANC DATE
NEW RESIDENTIAL MICH. SQ. FT.
fomin Health & Safety Cade, Sections 2550.5. 25533 arm 25534. I understand that if the
building does not currently have a tenant that it is my respnnsibilaym notify the occupant
..
of the requirements which must he met pdona is,aa aca ul'a Ceniliciec ol'Occupancy.
'TOTAL:'
ISSUED BY:�
Owner or authorized agent Data
OFFICE