29760 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALLPOINT PEN ONLY '
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 9 2 7 6 0
BUILDING PROJF.CI IDENTIFICATION T-V-•
4 BUI LNG ADDRESS:, - SANITARY NO. APPLICATION SUBMITTAL DATE
NER' NAME: PHONE: CONTRACTOR'S NAME: LIC NO.
g IS I L .e, 11jkv C•� N/C CON'1'ROLb
R HITEC`UENGINEFR: 'LIC NO: ADDRESS: ^ ❑
CONTACT PTiONF.: BUILDING PERMIT INFO
" ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT , PLUMB MECH
/❑ ❑ ❑
ucehat I CONTRACTOR'S provisions
of'I QTY. (ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under pmvisinus of Cha 9(commencing JOB DESCRIPTION
0WZ wiN Section]IXM)ofDivixion 3.fthe Husinexsn ons Cale,u mylicense is
00 to } PF.RMRISSUANCE RESIDENTIALr
full fnree anA elfect. e 1
�U� ` - ❑SPDWI. 1:1 KITCHEN REMODEL.
�aUU License Class Cone
4 Data Gmwmnr APPLIANCES-RLSIDLNTIAL ❑ADDITION' ,OPLHMBING RE-PIPE '•
ARCHITECTS DECLARATION PANELS _ El MULTI-UNIT ❑STRUCfURAI.
y p H Z 1 undersand my plans shall be used as puhhe meoNs MODIFICATION
OZ�O I/PTO 300 AMPS El INTERIOR CHIMNEY REPAIR
A.p{,fpp'41 LlccmW Professional is 201-1NIBAMPS IMPROVEMENT
pp��2d 2,....11 has I..HUILDIIR DECLARATION O I"AMP5
g,,d'�6 1 hereby affirm that 1 am exempt Taus the Comncmr's Lic<nse Law for the ❑BATH kEMODEI/REPAIR El DEMOLITION
W a LL U following reason.(Section 703 .5,Business and Professions Code:Any city or county .ECTRICAL [)OTHERLLl 4, which requires u permit to construct,alter,improve,demolish,or repair any sWemre
ChSAI�LLO prion.its issuance,also requites the applicant untimely pemlino file a signed satemem S CUIT/MISC r
y that he is licensed pursuant to the provisions offee Cnmmor's License Law lChapta')
p0 (commencing with Section 7000)of Division 3 of the Business and Profeseituns Qwle)or TEM )R POLE INST. COMMERCIAL;
Q. myy (hot he is exempt Beaman.and the basis for the alleged exemption.AnY vinlaitun tuf
ms,µ Section]OJLS by any applicant fnral'erdit suhjecu the applicanunacivii penalty of POWER - ❑NEW BLDG/AUDITION ❑DEMOLITION
I-„Z} notimre than five hundred dolly,($500), ❑TENANT ❑I'OOD$ERVICii
p6 D Las.wnerofNe properly.or my employees with wages as their ale compensation, 'SWIMMING LECTRIC 'IMPROVEMENT
�+O will do the work,and Instiumurc is not intended oroffced forsale(Sec.7004,Business ❑OTHER
and Pmfessinns Cdde:'I he Cmamelm's License Law dues not apply toanowner nl' OUTLETS-S 'Cl�FIXTURES
progeny who builds or improves thereon,and who does such work himself or through _
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIA E SQ ET.
sale.IL however,the no liing or iluprovenumt iss.ld'withinn feyewof complction;thc SQ.FT FLOOR ARI7A $/SQ.Fr
owner-builder will have the burden of proving that he did not build or improve for par. U
pose of mwni n )?
❑sus owner fiect(See 7 y,,B sines ad commuting with:)The l csaneum's i. TOTAL: „�.J 2 7
nserva the es not (Sec.]00Q Business and Professions Cale:)The Conlmmon,and
cense law docs not apply a an owner M property cords who builds or improves Contra,or's TY. PLO n {r {n,/, 99
who con¢acu for such pmjecw with aconvocmr(s)Ilunscd pnrsuynnnthe Cnmmaa'y Q °e (SEE "�r(� 1"`a6 ,
License Law. I'ERMI'1'ISSUAN /, Guj
0 l am exempt under Sec. ,B&P C for this reason in M t1 GTI/
ALTER-DRAIN Owner Dare ° -WA':R IL ) VALUATION
.s
WORKER'S COMPENSA'TIONDECLARATION saaVIIIAM"VI NIL
BACK FLOWPROT[CT.DEVICE . . U/0pf MceptCO,fYIp!ete
II hereby affirm under penalty of perjury one of the following declarations
d(have and will meinluin aCenificate of ConsenlmselLimure for Workers Cooper. DRAINS-FLOOI R A L ""f
salon,as Pmvidcd for by Section 37M of the Labor Code,for the performance of the B STUMPS TYPE CONSTRUCTION
work for which this permit is issued FIXTURES-PER I '
❑1 haveand will maintain Worker's Cmnpemsmion Imsummce.as required by Section '
37W ofthe lasur Code,for the performance ofthe work for whit t spennitisissueI. GAS-EA.SYST� OCC.GROUP APN
M War ,vG�m�, t uranE�carticrunAPnlic , 1 J .4s e
Combe\ cnxm )A1tU • Policy GAS-CA.SYST. - ( I pys
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE' GREASMNDUS TEI ERC. R
(This section need not he eompletel iOhe permit is fora.hundred dollars(Slap BUILDING DIVISION fTF;S
or lexsJ GREASIi TRA(' NCHF.CK FEE -
I certify that in the pefform+mce of the work for which this permit is issued,I shad l
not employ any person in any nanner so as to became subject to the Workers'Compen- SEWER-SAN
I'T
aZ cation Law:.f Coldomia.Date
C C Applicant WATER HEATER WNENT/ELE Of ADING FEE
NOTICE TO APPLICANT:IL seller making this Cmificmc n1'Exemption;you should WATER SYS,TLS� G
a ; home subject o the Workers Compensation provisions of the Labor Code,you must - SOI FEE
G1J forthwith comply with such provisions or this pennitshall be deemed revoked WATER SERVICE
1 Q
CONSTRUCTION LENDING AGENCY
.'7 NEW RESIDENTIAL P1.1,111. SQ.FT. PAID'
U0 l for
anther Nem issued(See.3nlending agency fonhe peRormunce of are Receipt
W F the wmk for whlcM1 this permit is issued(Sat.309],Civ.C)
U Lundcrs Name TOTAL:
Lenders Addr<sn TOTAL:
Iy 1 certify Lha 1 have reed this epplicmiorand state thin the above infnrinminn is BUILDING FEE
E� ,V) correct l agree mutuality with all city add county ordinances and state liws relating o QTY. MECHANICAL PERMIT FEE
V 7- building construction.and hereby authorize representatives ofthis city a emerupod the SEISMIC FEE
above.memimad pmpeny for inapeminn purposes. PF.RMI'1'ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in anyway scene against said City ALTER OR ADD TO MECH.
in cor se,onme,of the goaling of this permit. PLUMBING EEE
ev-ZLICANT U ERSTAN S AND Wild,COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TIO IO.UIIfI CFM)
OU REGUL TIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CPM) -
�-/✓ ry I CONSTRUCTION TAX
SignatureofA,Iic.VCommnnr pmt- EXHAUST HOOD(WOUCf) HOUSING MITIGATION FEE
HA7ARDOUS MATERIALS DISCLOSURE
Will the applicaml or future building«cupam some or handle hazardous material HEATING ON]'1'(TO 100,000 BTU)
ax defined by the Cupertino Municipal Crile,Chapter 9.12 and the Health and Safety
Code,Section 25532(0)'1 I - _ HEAT]NO UNIT(OVER 100,000 BTU)
FI yes ❑No
VENTILATION FAN(SINGLE RE,SID) PAID
Date Receipt
Will the air contaminant,
a defirng nccup:ntuseea Air enlnrdeviceswhich BOILER-COMP(3HP OR 1011,000 BTU)
bet hazardous air cnnlyminants us JefinW by the Hoy Area Air Quality Managemcnl•
strict? TOTAL:
❑Yes No BOILER-COME(OVER 100,000,BTU) ,
I have must(be hazardous materials AIR CONDITIONER
"movements an 2513Chapterrstaof the if
lull,
mia Health n Safety Calc,e a teras t.that,25571 and 25571 I to notify
the
that if the NEW RESIDENTIAL MECH. SQ.FF..
building resPire mens rrentlywhich have be mon p that it is my responsibility fy Nc cccupam
the requirenxna which mon be met prion.issuenre of a Certificate of Odvpamy.
necmmohnimil agem Deo - TOTAL: ISSUED BY.-
OFFICE,
Y:OFFICE,
Inspection Query for a Specfic Permit 4/7/97
1
M U$ $ TRE ro S<3fS 1 s UESI e o 1#1
9760 20301 STEVENS CRE LATH L.O. 4/25/95
9760 20301 STEVENS CRE FRAMEL.O. 4/19/96 4/19/96JB 2 N
9760 20301 STEVENS CRE SHEAR L.O. 4/19/96 4/19/96JB 2 N
9760 20301 STEVENS CRE ELECT 4/23/96 4/23/96JB 2 P
9760 20301 STEVENS CRE PLYWOOD 4/23/96 4/23/96 JB 2 P