29492 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY s -
CITYOFCUPERTINO - BUILDING-ELECTRICAL' PERMIT'INf�(] /1 /�
BUILDING DIVISION APPLICATION/PERMIT PLUMBING,-MECHANICAL - �, - 2 J Lf G
" BUILDING PROJECT IDF"F'ICATION
Il�AI�O t/ I/7rF r SANITARY NO, APPLICATION SUBMITTAL DATE
N2$'S. IwOVwH: 'I'RACT'UR'1� LIC NO:
I/' '04NIC CONTROL#
N ❑
00,
CONTACT. PPHHHOONvE,: �7 S BUI G PERMIT INFO
ION.R /14 ❑ Consultant Fees Paid by Applicant(Initial) BLD ELECT PLUNTE MECH .
LICENSED CONTRAC'TOR'S DECLARRTION QTY. ELECTRIC PERMIT FEE
1 hereby alarm That I an licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
PCZO with Seaion]gp)of DivisionJofthe Businesi anJ lsrafessinns Cade,mttl my License ix pERMITISSUANCE RESIDENTIAL
�UK I.full forceand affect)License Class Lic.0 0SFDWL OKITGI{EN RI3MODE
Ut;zDate Commctor APPLIANCES—RESIDENTIAL ❑ADDITION .0 PLUMBING RE-PIPE
F.Pw ARCHITECT'S DECLARATION ❑MULTI-UNIT 'G STRUCTURAL.
1 understand m lens shall be used as public records PANELS
Z O'-a Y P Pu MODIFICATION
02— - UPT021p AMPS 100001NTERIOR' ❑CHIMNEY REPAIR
x,'13 Licensed ProPesnionaI 201-1000AMPS IMPROVEMENT
0 W I Thereby uffirm that 1 am exempt from the ConOWNER-BUILDER DECLARATION tmnm's License Law fur The OVER](=AMPS _ 0 RATH REMODEURF.PAIR 0 DEMOLITION
aas U following reason.(Section 7031.5,13usiness and Professions Cale:Any city or countySIGNS ELECTRICAL
as(� which requires o permit m construct,char,mini demolish,m repair any aructme
F.aO Jct prior To its issuance,also requires the applicant for such Permit o file a signed statement SPECIAL CIRCUITIMISC.
jr That he is licensed pursuant to the prostanns of The Contractor'%License Law(Chapter 9
(anmmcncing with Section 7001Bof Division Sof thc Bnsineseand Professions Code)or TEMP.MEI'ER OLET. COMMERCIAL:
d n q that he is exempt Therefrom and the basis for The alleged exemption.Any violation of [I NEW BLDGIADDITION 0 DEMOLITION
Section III IS by any applicant fill a lumou subject,In,applicunt to a civil Pcnupy of POWER DEV '
fzGnot more Nan five hundred dollars(S500), - .#ANT ElFOOD SERVICE
O Laaownerofthepropenyormyemployces with wages as their sole compensation, SWIM O •LECfRIC IMPROVEMENT
will do The work,and the structure isnot intendadmoffcmd forsale(Sec.1044,Business 00THER
Land Professions Code i the Conuucmrs License Low docs not apply to an owner ill0 T. S 'TCHES—FIXTURES,
property who builds or improves Hereon,and who does such work himself or through
his own employees,provided the such improvements arc not intended or offered for N :.5 #TIAL ELT:CfIt SQ PT.
sale.If.Novireal.the building.,improvement issold withinonayea,ill an6pletion.the SQ.IT FLOOR AREA $/SQ.FP.
twoof-builder will have the burden 'ng That he ad not build or improve for pin,
-
as owner of The any,tan exolraive cnnmeti.g wish Ilcemul eontnmro,s m - "TOTAL:met n the pnsje (Sce.]044,Boxiness d PmfNxinns Code:)The Conwmoes U-
censeLavedoe apply to an owner of m,my who builds or improves thereon,and PLUMBING PERMIT FEE
whoramtmet nth prnjects with a nuneor(s)licensed pumuont to the Contest/n/.s
0Tam�empr ,B&Is C for dr, Z,
PERMIT ISSUANCELicense I
AIITER—DRAIN&VENT—WATER(EA).
Aw. DaT VALUA'T'ION
dalOMPENSATION DECLARATI0 BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of pegiuiy oneof the follnwin
0 l hmveand will maintain¢Certificam.IConsenuoaa,Inrc ft cr's Grm n DRAINS—FLOOR,ROOK AREA,COND, STORIES TYPE•CONST'RUCTION
roti..,as provided for by Section JAM of the Labor Code,in r ance the
work for which This permit is issued FIXTURES—PER TRAP
0•I have and will maintain W.rkcrs Compen,iron InsomI uPumd b ,action
3700 ofthe Labor Code,for the performance ofthe work is'. sia'am. GAS—E,%.SYSTBM-IINC.40UIT.LTS
My Worker's Compensation Insurance carrier and Polic M are: OCC.GROUP APN
Carrier: PolieyN C —EA.SYS'I'HM-OV ER 4(EA)
CERTIFICATE OF LXEMPTIONI )RKERS'
COMPENSATION INS E U ASOR BUILDING DIVISION MES
(This seatior need not be completed ifthe pe monsoon •ddollus($100) �—..
s .r less.) PLANCHECKI'M
(certify thm in Nc performance of The work for which this it is issucd,ishall �ltan LV
not employ any persortmanymunuersoasmhea,in subjecuo eWo Is Compete TA �_A(��fT ENERGY MI?
Z sari-.Lows of California.Data
O Applicant INn G DING FEE
q y NOTICE TO APPLICANT:If,after onsi this CertlOa w, E?xnnpdon,you should '
become subject to The Worker's Compensation provisions o e Lahr Code,you must CYST A B cR� eorre - E
forthwith comply with such provisionsorthis permit shall decmedrevoked. B revision.,; Wuflulls
5z CONSTRUCTION I.ENDINGA CY SI p
V � Thereby affirm that Theeisuconst,.etion lemdi agInsyforthaperformareeof r'aa SQ.PT. PAID Data Receipt#
O V the work for which this permit is issued(Sre,309],C' .C.) - -
LenderIV, O TOTAL
R7 Lenders Address F T TAC:
a 1 certify that 1 have read this application an state that The above information is BUILDING FCB
% coraco.l agree,.comply with all city and county rdinomcea rand state laws relating to y. M f
L) z building maxi union,and hcrebyauthodze rcpre nmtivesof Nis city,.over upon the / FEE SEISMIC FEE
above-mentioned property for inspection panic.
(WB)agree to save,indemnify and kee sonless the City of Cupimin,against re ELECTRIC FET?
Iiabilitiesjudgments,costs and expenses whic ayinanywayeccme........said City
consequencein of the granting of this permit. TER OR EC PLUMB ING FEE s -
APPLICANT UNDERSTANpS AND WI COMPLY WITH ALL NON-POINT
SOURCE REGULATIONS. AIR 4; MECHANICAL FEE
AIR HANDLING UNIT(OV 10,010, NSTRUCTION TAX
Sigoamrenf An,licant/Conuanor Dam EXHAUST HOOD ONMUCI') HOUSING MITIGATION FEF,
HAZARDOUS MATERIALS DISCLOSURE
Will The applicant m home building occuparn sore or handle h i,ard..x m renal I117AI'INC,UNIT('TO)00,000 BTU)
as defiled by the Colman Municipal Cale,Chapter 9.12,and the Health and Safety
Cade,Section 25532(x)? HEATING UNIT(OVER 100,000 BTU) .
El Yes' 0No
VENTILATION PAN(SINGLE RESID) PAID
Will The applicant or future building occupant use equipment or devices which Data Receipt p
•emit hazallous air conmminums is defined by the Bay Arco Air Quality Management BOILER—COMP LHP OR I W."BTU)
Dianat? TOTAL:
❑Yes EINo BOILER—COMP(OVER 100.000,BTU)
I have rand The baiardous ma¢tials AIRCONDITIONER .� ISSUANCE DATE
rry25533 an under Chapter 6.95 of the Cali-'
hard.grice,Health&Safety tlymCode.Sabots 25505,25573 and 25534.I ranch ydi that Ease NEW RESIDENTIAL MECH. SQ.FT.
of
regoe,nent rtech have be at prior
iorohai it isuaceoftsCediytgno0fOccupa.pram'
of the reyuircrnents which must be ntd poor Tu issuance oft Certifcam of Occupancy,
Owner or authorized agent I, - Data.. TOTAL: - ISSUED BY.
OFFICE
Inspection Query for a Specfic Permit 4/7/97
O' 2030�1 SSTITEUV$ESNTS CRE t►o UNDESRt3GF_SR(E�BFIAFR — E4S4//t11R//996
1 1
UNDGR PLBG
20301 6
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STEVENS CRE REBAR 4/4/96 4/4/96 CC 2 P