30795APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF�iIJPF.RTINO BUILDING - ELECTRICAL I+IiRMI T NO. O
BUIhI]ING IIIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL 9
BUILDING PRO.IECT' IDENTIFICATION
21111 Stevens Creek Blvd.
lncoulF
— 150th Ave., San Leandro,
❑ Consultant Fees Paid by Applicant (Initial)
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I hereby alHrm thus Ian, licensed under provl.ione of Chapter 9 (ronunenciag
yl[cenia
e B.,insaod Profexxionseale.and ma
with Somon70hkFufni1x4m3 ofthm
full force and affect.m--l- L,een,e j 6/q/C20 C4Ae.,, 189874
or ( 11• 4--
Dam �o", Camran�`a
QTY ELECTRIC PERMIT
PERMIT ISSUANCE
APPhIANCLS- RESIDENTIAL.
ARCH ECI':S DEC LA RATION
I undecaand my plans shall be used as public records
PANELS
UPT0200AMPS
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OWNER -BUILDER DECLARATION
1 herebyaffirm that I um exempt Imre the Cnnuars Co License Law for the
70.11.5. Business and improve. h, or Any city or roomy
whnwing resin. Permit de i demolish, repair ed .uucmrc
which requires n permit m cores the. al¢e improve, h permit t file
prinnu it, iso;utec.d,a rc4ttirc, the applicant for such permit BleasignrJ statement
that he is licensed pursuant o the provisions ofthe Conmcroh License Law (Chapter9
201-1000AMPS
OVER I00E AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE. INST.
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lcommcncing with SacI....1010)ofDiv bion 3ofthc business and P..1 iota Co let nr
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a Permit subject, the applicant in a civil penalty of
POWER DEVICES
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W 3ceand
n more than live hundred dollars (5500).
C] 1, as owner of the property, or employees with wages as their sole compensation.
will do the work. and the luchoei,nmlmcndedornffemil fe,,ule[Sec. 7194. Bmineu,
Professions Gde: The Connector's License Low does not apply m an owner of
who builds or improves thereon, and who dies such work himself or through
SWIMMING POOL ELEC'I'R IC
OUT TLETS - SWITCHES - FIX 'I'URIS
Property
his own employees, poo ded that such improvcmen¢ arc nm intended or offered for
NEW RESIDEN'T'IAL ELECTR SQ Ef.
sale, If, however, the building or improvement is sold within one year of completion, the
oviver-milder will have the burden of proving that be did not build (ir in+provefor pur-
,,a of talc.).
h m owner of the property, am exclusively crammed, with Messed emamehn e
TOTAL:
nstrum the protect (Sm. 7014. Imsincs, and Professions Csde:) The Contractors Lt.
cane Low dace not apply in an owner of parts, who builds or improves thereon.and
QTY. PLUMBING PERMIT
who summit, he such p ices whh u contractors) licensed pursuant too ho Comrns7or',
PERMIT ISSUANCE
License Law.
I ore exempt under Sec. .B& P C for this reason
ALTER - DRAIN & VENT- WATER (EA)
BACK PLOW PROTECT. DEVICE
Owner Date
WOR KER'S COMPEN SATION DECLA RATION
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Cenificite of Conant luoil item. for Worker,Cnmlvan.
DRAINS- FLOOR. ROUP. A REA, COND.
sailor, i , provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is small.
](1 1 have and will maintain Worker', Compensation Inwumec, ax required by Scctian
3700 ofine LaborGale, fon he performance of he work for which this permit a. issued.
FIXTURES - PER TRAP
GAS- EA. SYSTEM. I INC. 4 OUT TLIHS
GAS - EA. SYSTEM -OVER 4(EA)
My Walker's C mi Iyya cc cgrt' and Policy nou �rr�
Cnrticr: mR i f ki (,DaOry No.: wr/ 4961 S
GREASEIINDUSTRL WASTEINTERCEPTOR
CERTIFICATE OF E%EMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP
Cnissemlon need not he completed ifthe permit ieforonehundreddollan(SHp)
mlass.)
SEWER -SANITARY -STORM EA. 200 FT.
[cattily that in Oe l+erfnomnce of the work finwhich thispermit isissued, l shall
not employ any pe.n in an, monmr so as to become subject 1. the Worker' Compen-
WATER HEAT'IIR WNFNDELECTR
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.Scion Lawaof Cnlifumis. Data
Applicant
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NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
WXIER SYSTIEIn REAIING
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Lamm, subject m the Warkcrs Compnmmion 11.1 liom of she LuMr Cut you must
forthwith comply withsuch powai...... his mo on shalt be deemed revoked.
CONSTRUCTION LENDING AGENCY
Iheebyafftnn that (he. construction lending agency lin the perliinurecof
the wofk for which this 1a"1111J l3rc.1X7, Ctv. C.)
'done
WATER SERVICE
NEW RESIDENT IAL PLMH. SQ ET.
0ULeniName
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gTvan
TOTAL
Lender's Address
1 cenify ohm 1 have read this apglict for and slam that the aMve information is
correct. I agree to comply with all city and county ordinances and state law, palming m
building constructiogand hereby authorire mpreeenm0ves of thi> city n+ enter upon the
QTY. MECHANICAL PERMIT
PERMIT ISSUANCE
above-mentioned progeny for inspection purlmses.
(We) agree to save, indemnify and keep harmless the City of CuMriao ., ins1
ALTERORADDTOMECH. 4— rllleE
[abilities.judgments. costs and expenses which may in any way accrue against said City
in consequence of tM granting of this permit.
AIR HANDLING UNIT TO to." CFM)
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
AIR I IANDLIN. UNIT (OVER ff.fi hCFM)
/
3/6/97
Signature mApplicanVContncmr Data
EXHAUST' 11001)(W/DUCT)
I IA9dRDOUS MAIERIALS DISCLOSURE,
Will the applicant or future building occupant store or handle hamrdous material
HEATING UNIT'(' 1'0 100,000 BT U)
as dc[ined by the Cupertino Municipal Code. Chapter 9. 12. and ilia I health unit Satiny
Code, Section 25532e)T
HEATING UNIT (OVER HXI.000 BTU)
VENTILATION FAN (SINGLE RESIT»
E3 Yes 0 N
Will the applicant or Tatars building by the Bt use equipment or devices which
emit hamrdous air contaminants m defined by the Hay Arca Air Quality Munugnncnt
BOILER -COMP fJHI' OR 100.11(X1 RTU)
BOILER - COMP (OVER 11X),0110 B'IT)
District?
E] yes ❑Nm
AIR CONDI"I'IONER
I have read the hwurdous materials rcgaimmumae under Chapter 6.95 of the Cali-
NEW RP_SIDENT[AL MECIL SQ, FT.
(rota Health & Safety Ctde, Sections 25505.25533 and 25534. 1 understand abut if the
huilel ng docs not currently have a emm6 than it is my res,r nsihiliy to notify the mcupont
of the requimments which must be met pass u+issuance of a Ceriricate of O Vupancy.
FEE
n
❑ ❑ ❑
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL
❑ KITCHEN REMODEL
❑ADDITION
❑ PLUMBING RE -PIPE
[]MULTI -UNIT
❑STRUCTURAL
air cnnditi OT
MODIFICATION
❑ INTERIOR
❑ CHIMNEY REPAIR
IMPROVEMENT
9.50
❑ BATH REMODEL REPAIR C DEMOLH'[ON
[]OTHER
MIiCHANICAL FEE
COMMERCIAL:
❑ NEW BLDG/ADDI'I'[ON
❑DEMOLITIPON
[]TENANT
FOOD SERVICE
IMPROVEMENT
❑OTHER Pxtpnti
air cnnditi OT
ing duct distribution
sys,
SQ. ET. ELOQR AREA
A , O
EEE cit MqR j1 te
4e, 000.00117
TYpe
PLANCHECK FE -E
ENERGY FM
GRADING REE
SOILS FEM
PAID
Date Receipt X
TOTAL] 155.00 ISsuEDHY:2S
OFFICE I
ISSUANCE DATE,
155,00
PAID
Date Receipt p
TOTAL:
BUILDING FEE
FEE
SEISMIC FEE
5.50
ELECTRICFEB
9.50
PLUMBING FEE
MIiCHANICAL FEE
CONSTRUCTION TAX
HOUSING MITIGATION PEE
PAID
Date Receipt X
TOTAL] 155.00 ISsuEDHY:2S
OFFICE I
ISSUANCE DATE,
155,00