31276 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMrpnO. 31 nL 7 C
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL v
BUILDING PROJECT IDENT'IFICA'TION
BUILDINGADDRCSS. SANITARY NO. APPLICATION SUBMITTAL[)ATE
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ACHITTENGINER: LC NO: ADtMO
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CONTACT: PHONE: BUILDING PERMIT INFO
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Consultant Fces Paid by Applicant(Initial) Epp. EIEC PLUMB MECH
LICENSED CONTRACTO`R'S DECLARATION ` 'y�•7`/` El 1:1I herehy affirm that 1 ao licensed ander provisions of Chapter 9( QTY ELECTRIC PERMIT cammm�cing JOB DESCRIPTION
woz0
PERMIT ISSUANCE RFVIDENTIAL
I full force and effec _
�UU License Cluxs 1.ic.a 6 6257 ❑SFDWL ❑KITCHEN REMODEL
l,ZW Dam Conuannr APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
a,pr� ARCHITECTS DECLARATION PANELS ❑MUI.TI-UNIT []STRUCTURAL
z O y 7J. I understand my plans shall housed an public reernds I MODIFICATION
Oz—, UP TO NNI AMPS ❑INTERIOR ❑CHIMNEY REPAIR'
Licensed Professional 201-1000AMPS IMPROVEMENT
-{ OWNBR-BUILDER DECLARATION
g0K a 1 hereby affirm Nal I um exempt from the Contractor',License Law far the OVER 10!10 AMPS- ❑BATH RP.MODEIIREPAIR ❑DEMOLITION
3 6U following reamm(Section]WLS.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
Fma' which requires a perntit to com,m,et.ager.improve,demolish.or repair any structure
prior to its issuance,also requires de applicant for such permino file a signed statement SPECIAL CIRCUUDMISC. -
fy�y that he is licensed pursuant to the provisions of the ContmctoesLicense Law(Chapter 9
I+E�C�O (commencing with Secti�n]INIp)af Division the Business and Pmfcsnions G>ve7 or 'TEMP.METER OR POLE INS'I'. COMMERCIAL:
a q M y Nm he is exmpt Nerefmm and the basis for the alleged exemption.Any violation of [INC
BLDG/ADDITION L1 DEMOLITIONiC 4th, Section 703 t.5 by any applicant for.permitsubjems the applicant to a civil Pon uhy of (OWER DEVICESt
ty not more Nw five hundred dollars($500). El TENANT ❑FOOD SERVICE
ml
Las owner of the rt.orm bees with woes as their sole cum nsation, SWIMMING POOL ELECTRIC IMPROVEME
¢Q ❑ property. romp > e a K1r N INCAV( 110tl
will dothe work,and the structure is Datintended orow do for al¢(Sec,]014, circ,of OTHER
L•' and Professions Code The eves theme License law does not apply s if owner of OUTLET'S-SWITCIIES-FIST'URES
properly who hyees.or impedes thereon,and who does such workhimself
or or though
_i/
his own employees,provided that such impmvcmcros ore nm imendW or offered for NEW RESIDENTIAL ELP.CTR
sale.If.however.the building of improvement is sold within one yearof completion,the - SQ.IT.PL AREA VSQ.PL
ownenbuilder will have the burden of proving that he did not build or impose for put.
Ease of aown, • OCT 171996
❑1,as owner of the property,em exclusively convening with licensed camunnrs m TOTAL:
construct the project(Sec.7044,Business and Professions Code:)The Ciampi Li. (�7�y
c se Law dna,mxrpplym annwnafof property who lmddsae improvers thereon,and QTY. PLUMBING PL'RMIT PET: a1/11 /�f,
who conhanc for such projects withacnnunnorts)Iicensnd pursuanun the Commdors M VUY[11I IIvu
License Law' PERMIT ISSUANCE
❑Iamexemptunder Se, ,B&PChr1h600,mi
Owner Date
ALTER-DRAIN&VENT-WATER(PA) VALUATION
WORKER'S COMPUNSATION DBCLARAS'ION BACK FLOW PROTECP.DEVICE AOoO o0
Thereby affirm under p5naltyof perjury one ofthe following chelandsom s: `t a I
❑ I have and will maintain a Cedificac of Consentro self-insure for Worker's Compen. DRAINS-FLOOR,ROOF,AREA,GOND. STORIES TYPE CONSTRUCTION
w
nation,as provided for by Section 3700 of the Lobar Code,for the performance of me
for which this permit is im od. FIXTURES-PER TRAP
1 have and will maintain Worker's Compensation Insurance•as required by Section
J Inf the Lnhor Ctrle,teethe performance of the work for which thin permit is issued. GAS-BA.SYSTEM-I INC.4 OUTLET'S OCC.GROUT' APN
My Worre�Q nytion nsur a carie,and Policy n
I'll
a1If II 'i„eo Policy Na, GAS-EA.SYSTEM-OVER4(EA)
CERTIFI TIIOPEXI:MPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEnNDUSTRL WASTE INTERCEPTOR
('phis section need nm bcwmpletedFthe permit is foram hundred dollars(SIW) BUILDING DIVISION 11,6S
m less) GREASE TRAP
PLANCIIECK FEE
Loy any Nat in the any mane of the hisconork r which this themitisipp col ICou hall SEWER-SANITARY-STORM EA.200 FT.
urn employ any person in any nmvnw en as m buame subject o the Workers'Cnntpan- ENERGY FEE
,Z 4 . cation Laws of California.Dam
�C) Applicant WAT6RHEATIiRWNPNT/ELECER GRADING FEE
A NO'HCE TO APPLICANT:IL after makin this Certificate of'Exem don,you should
VI 6 P WATER SYSTI?M!1'RP.q'fINO
abantam subject to Ne Worker's Compensation provisions of the labor Code,you must SOILS FEE
kkl forthwith comply with such provisions or this permit shall be deemed tesokedWgTEµSERVICE.
Q .
.7. Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PL.MB. SQ.FL PAID
U Q I hereby affirm that them is a construction lending agency for the perfoomnce of eceipp
INF he work for which this penni i is issued(Sec.3097,Civ,C.)
C U Dundee,Name - TOTAL:
Lender's Address TOTAL:
GI cenlfy that I have read this application and state that the abase information is BUILDING VCH
Z) correct.L agree to comply withal]city and county ordinances and nate laws mlating to QTY. MECHANICAL PERMIT PEE
U building construction,and hereby andraire representatives of this city to enter upon the SEISMIC FEE
above-memloned popery for impectiun purposes. PERMIT ISSUANCE'
(We)agree m use,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
Iiabilities.judgmenrs,cons and expen,es which may in any way aceme aguinst said City ALTER OR ADD TO MECH. PLUMBING FEE
in mequenee ofthe glinting of this permit. -
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT ALR HANDLING UNIT(TO 1(L000 CFM)
SOURCER60U 11 NS. MECHANICAL FEE'
IOIIQ�¢I AIR HANDLING UNIT(OVF.N 10.000 CFM) CONSTRUCIONTAX
Signature of Appllcant/Contractnr I Dte EXHAUSFHOOD W/DUCT) HOU91N0 MI'1'IOATION PEE
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant or future building occupant store or handle haranlous material HEATING UNIT(TO 110,000 BTU)
as defined by the Cupertino Manlnlpal Code,Chupmr 9.12.and the Health and Samiy
Coda,Section 25532(x)] HEATING UNIT(OVER 100,000 BTU)
E]Ye., XNo VENfI LAHON PANS I NGLE RESID) - PAID
Dam Receipt a
Will the air comntarfunto building by the nt use BayAry Air ent or Quality
Management
BOILER COMP(JHP OR 100,(1110 BTU)
mit huzuNous air nmmminams a,defined by the Bay Area Air Quality Manngemem
D¢trmt]
*a
a BOILER-COMP(OVER 100,1X0 BTU)
❑Yes ^b1wl '
I have read the haurdnus camdalsmmoment,under Chapmr6.95of the Cni- AIRCONDUIONER ISSUANCE DATE/1
fornix Health&Safety Code,Sections 15105,25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.FT. ` 1
building docs not eurtently have a tenant,that it is daVespmnsihility to notify the occupant
ofthe requiomcnB{�iq�musl be nttetyuio�u+issuance ofa Certificate t'Oce
SOIney.
c
Owner or authonmd vgem I- — lam TOTAL: ISSUED BY:
OFFICE