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29242L_ 1,44 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING -ELECTRICAL PERMIT NO. ^ ^ A� rs BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL L 9 L L _ BALDING PROJECT IDEN'P 'IOATION LDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE 02el (-16-96 O NER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO: NIC ❑ CONTROL. /V AR ITE'TIENGINEER:LIC NO: ADDRESS: i ¢9 CONy�TT��sAC�T. PHONE. - BUILDING PERMIT INFO QT/ ❑ Consultant Fees Paid by Applicant (Initial) BLDG ELECT PLUMB MECH av 99S3Y9 ;K A ❑ ❑ LICENSED CONTRACTOR S DECLARATIONw QTY. ELECTRIC PERMIT FEE JOB DESCRIPTION I hereby affim 1 aunder provisions of Chapter 9 (mnc Nm ]trend comeing with Secam,7000)of Division 3 ofthe Booressand Pnfasimns Code,and all iicenseis RESIDENTIAL: In full fame and effect. PERMIT ISSUANCE ❑SFDWL ❑ KITCHEN REMODEL License Class Lica Dute Contractor APPLIANCES—RESIDENTIAL ❑ADDITION [I PLUMBING RE -PIPE ❑MULTI -UNIT []STRUCTURAL ARCHITECCS DECLARATION PANELS T understand my plans shall be used as public records MODIFICATION UP TO 2W AMPS ❑INTERIOR ❑CHIMNEY REPAIR IMPROVEMENT Licensed Professional 301-IWOAMPS OWNER -BUILDER DECLARATION OVER ION AMPS ❑BATH'REMODEVREPAIR ❑DEMOLITION I hereby affirm that I am exempt from the Contractor's License Low for the Following reason. (Scotto. 7031.5, Business and Pu fesaions Cade: Any city nr v my SIGNS ELECTRICAL. []OTHER which require, a pewit to consimct, alter, improve, demolish, or repair any structure prior to its issuance, also requires the applicant for such Permit o file a signed statement SPECIAL CIRCUEDMISC. that he is licensed pursuant to the provisions of Ne Commences License Law (Chapter 9 COMMERCIAL: (commencing with Semina 7(Xp)af Division3 tithe Businan asd Professions Code)nr TEMP. MITER OR POLE INST. Nat he is exempt therefrom and Ne basis for the alleges) exemption. Any viohnin. of ❑NEW BLDG/ADDITION ❑ DEMOLITION Section 7031.5 by any applicant for a permit subjects the applicant to a civil peoulty of POWER DEVICES TENANT ❑FOODSERVICE not more than five humbaddollms (5500), IMPROVEMENT ,F]1, an ownerofthe pmpeny, army employees wiN wages astheirxole compensation. SWIMMING POOL ELECTRIC will do the work, and Ne swcture is not intended oroffered for sale (Sec. 7044. Business ❑ OTHER and Professions Code: The Connector's License Law'does not apply to an owner of OUTLETS — SWITCHES — FIXTURE 74 property who builds or Improvos thereon, and who does such work himself or through his awn employees, Provided that such improvements bre not intended or offered ter NEW RESIDENTIAL HLECTR SQ PT. SQ. FT. MOOR AREA $JSQ. IT. aide .If. h..sa,, NC Wilylingorimp rovement is sold withillmayeat ofrompintiogtbe owner -builder will have the burden of proving Nat he did not build or improve for put- set ^/ 1�/' I ff I, a owner of the PropenY, am exclusively contmging with licensed a,mmnars It L , !/� I ` cons project (Sec. 7014, Business and Professions Code:) The Connector's Li- Li - R�T p B ® cerise Law does not apply to an owner of pmpeny who builds or improves thereon.end QTY. PLUMBING PERMIT FEE I(' p, who eommets for such Projects with a contraclor(s) licensed pursuant to the Contractor's t License ❑ 1u xet Pt .der Seo D PC for his .,.a PERMIT ISSUANCE �,J n t) .7 JANr - ALTER—DRAIN&VF, WATHR(HA) VALUATION Owne Dam ER:S OMPENSA'TION DECLARATION BACK FLOW PROTECT. DE // sown. 11 WI �V}��a7� ,, .•LL 1 hereby affirm under penxhy of i cipi-y one of the following declarations: Ibavc anJ will nminwin aCenificate nfConnem to xelf-insure for Werke/s Compen- DRAINS — FLOOR, Rw ,STORIES TYPECONSTRUCUON notion, as provided for by Section 3701 of the Labor Cade, for rise performance of the' work far which Nis pcmail is issued. FIXTURES — PER TRAP ❑ I have and will mainmin Worker's Compensation Insurance. as required by Section 3700 of the labor Code, for the perforamice of the work for which this permit is issued. GAS—EA, SYSTEM -I INC.4 OUTLETS OCC. GROUP APN My Worker', Compensation Insurance carrier and Policy marts, me: - Carrier: Policy N., GAS — BA. SYSTEM -OVER 4(EA) CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEI'S (Th'n section need be, he n,mpletedif the permit is for one hundred dollars ($100)) PLANCHECK FEB or IcssJ GRIiASE TRAP Icenify ohminthe teeth,ersC,I shalloner- SEWER—SANITARY—STORM EA. 300 FT. in..in....eofto bakforwhichNto not employ any Carton in any manner son, to hcome,ubjen to the Workers Coroner- ENERGY FEE I JAI W3 satin. Laws of California. Dote Applicant WATER HEATER WIVENT/ELECI'R WATER PEE ' NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you shout, WATER SYSTEMNREATING SOILS FEE become subject to the Workers Compensation provisions of the Labor Code, you mum fonhwith comply with such provisions or this feat. hall be decmedrevoked. WAI'ERS17RVICE CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ, FT. PAID (hereby affimt ohm there isnconswctinn lending agency f0rthe pedowantt of Date Raeipta the work for which this Permit is issued (Sea 3097, Civ. C.) L.eni Name TOTAL: lender's Address TOTAL: BUILDING FEE 372 1 evnify that 1 have reed this application and stem Be,, the above information is correci. l agree to comply with all city and county ordinances and state laws relining to QTY. MECHANICAL PERMIT FEE buildingconstruction. and hereby audience representatives of this city to enter upon the SEISMIC FEE .Mve-mentioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE (We) agree to save, indemnify and keep harmlea the City of Cupertino against PLUMBING FEE liabilities.judgments, costs and expenses which may in any way accme alpinsuaid City ALTER OR ADD TO MECH. in nacquence of te hgranting of this permit MECHANICAL FEE APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT AIR HANDLING UNIT (TO 10,000 CPM) SOURCE, REGULATIONS, CONSTRUCTION TAX AIR HANDLING UNIT (OVER 10,000 CFM) Signature of ApplicanVContmmor Data EXHAUST HOOD(W/DUCD HOUSING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occapail store or handle heamdous mmeriul HEATING UNIT (TO 100,010 BTU) as defined by the Cupertino Municipal Coca, Chapter 9,12, and the Heahh and Safety Code. Section 255320)'! HEATING UNIT (OVER IN," BTU) ❑Yes ❑ No VENTILATION FAN (SINGLE RESID) PAID Date Receipt a Will the applicant or future building occupant use equipment or devices which ICTAL BOILER t hazardous air contnminams as defined by N=e Bay Area Air Quality Management COMP (3HP OR 100,000 BTU) Disvia^ El yes []NoBOILER— COMP (OVER 100,00) BTU) ,7 I have readthe haaatdousmaterials rcquiremems undo Chapter 6.95 of the Cut, AIRCONDITIONER ISSUANCEDATE_ heroin Health & Safety Code, Satorste 2505, 25533 anal 25531. I understand that if Ne NEW RESIDENTIAL MECH. SQ building ax nes a t, Net it is my rto notifyoccupant of Nm e recareenu which a,ast be.tet prim, a, wounce of x Cor ifiate of Occupancy. - 1 ISSUED BY: MZA Owner or authon7ed agent Data TOTAL: OFFICE