29365 APPL(CANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CIJPFSRTINO BUILDING-ELECTRICAL PERMIT NO.
RUII.DING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL, n C C
BUILDING PROJECT IDENTIFICATION G v J
BUILDING ADDRESS: sW u 0 SANITARY NO. APPLICATION SURMITTALDAT2
Via_Sapl
OW R'S AM /f CONTRACTOR'S NAME: LIC
-r" - Q /J•O/ylYf 7V �6 0 'l i- NIC CONTROL#
ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: _ PHONE - BUILDING PERMIT INFO
/t ElConsultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
tee-(_ ler 9 X �?
CENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
'1 hereby affirm that 1 am licensed under provisions of Chapter 9(cmnmencing JOB DESCRIPTION
O50 with Section]000)of Division 3 ofthe Business and Professions Code,and my license is
00 y PERMIT ISSUANCE RESIDENTIAL:
in full farce and effcc[
UU CSFDWL El KITCHEN REMODEL
HUw License Class Contractor—
APPLIANCES-RESIDENTIAL CADDITION El PLUMBING RE-PIPE
_ rF�ii are � Contractor
AR ARCHITECT'S DECLARATION � []MULTI-UNIT []STRUCTURAL
PANELS s
I understartd my plans shall be used as public records MODIFICATION
O,Z UPT02fIf1AMPS
G - ❑INTERIOR []CHIMNEY REPAIR
Licensed Professional - 201-IW0AMP5 IMPROVEMENT
F]pG' j OWNER-BUILDER DECLARATION
Fyyl C4 G I hereby affirm that 1 am exempt from the Contractor's License,Law for'Ihe OVER I"AMPS
3 6 F C BATH REMODEL/REPAIR C DEMOLITION
>( following reason(Sermon 7031.5,Business and Professions Cade:Any en,m county SIGNS ELHCTRICAI. C OTHER
f{tt77 LL y which'rea lres a permit to construct,alter,Improve,demolish,or repair any stmt
prior to its Issuance,also requiras the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
that he is licensed pursuannn lite provisions of the Contractor's License Law(Chapter 9
P60 (commencing with Section 7000)of Division 3 of Businessaad Prom"i.ts Code),, TEMP.METER OR POLE INST. COMMERCIAL:
d y o C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION ,
nXl Ix' Section 7031.5 by any applicant for a profit subjects the applicant to a civil penalty of POWER DEVICES a,, / 1 y'1
ZZZZ y, not more than five hundred dollars($500). TENANT. A � + ❑FOOD SERVICE
pl]I,as owner of the propeny,or myempioyees wilM1 wages as Ncir snlecnmpensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,..d the domain,is not inrended.,mlered for s.I.(Ser,7044.BusinessOTF(F
and Professions Code:The Contrac or,License Law dace not apply Ir an owner of OUTLETS-SWITCHES-FIXTURES /{ 18 q!q(gryl,
property who builds or improves thereon,and who does such work himself or throughhis own employees,provided that,pvh improvements arc not intended Or offered for NEW RESIDEM'IAL ELECTR SQ Ef.
sale.If,however,the building or improvement is sold within one Year,(if completion,the Ulf SQL".FLOORAREA1 JQ $/SQ.ET.
owner-builder will have the burden of proving that he did not build or improve for par-
posEl e of sale). /1� Bogy1,m owner of the propeny,em exclusively contracting with licensed contractorstoTOTAL: O-s/ •��ffVV/
crammer the project(Sec.]044,Business and Professions Code:)The Contractor's Li- -
cense Law does not apply to an owner of propeny who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who mourners for such projects with a eontmctor(s)licensed pursuant m the Commctor's
License Law. PERMIT ISSUANCE
❑1 am exempt under Sec. ,B&P C for this reason
Owner -
ALTER-DRAIN&VENT-WATER(EA) VALUATION
- Date
WORKER11 S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE A?
1 hereby affirm under penalty of perjury one of the following declarations: 0
❑Ihaveand will.,alumina CertificmeofC...cut tself-inmre tar Worker's Compton- DRAINS-FLOOR,ROOF,AREA,COND, STORIES TYPE CONSTRUCTION
submit,as provided far by Section 37M of the Labor Code,for the peffornmnce of the
work far which this permit is issued. FIXTURES-PER TRAP, -
[]1 have and will maintain Workers Compensation Insurance,as required by Section -
3700oftheLimmCcalfar the anformace.fthe work far which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Work ape ti p y(nr,E�,yrja,and Policy n hero - ,
Cartier: lltry Policy Na.: '�j�G�� 92Y GAS-EA.SYSTEM-OVER4(EA)
CERTIFICATE.OF EXEMFFION FROM WOR CERT 5'
COMPENSATION INSURANCE. CRGSPJINDUSTRL WASTF.INTERCEITOR BUILDING DIVISION FEES
(This section reactor be completed ifthe permit is forma,hundred d.11ars($100) GREASE TRAP O, '+
or less.) PLANCHECK FEE 0J
I certify that inth.performance of the work for wbicM1 Ibis permirisissuedlshall SEWER-SANITARY-STORM EA.2W FT.
not employ any person in any mann �s toms se Nc Workers'Compen- ENERGY FEE
,Z .firm Laws rfcali
I.
Date
O Applicant i WATER HEATER W/VENT/ELECTR
g 6 GRADING PEE.
y NOTICE TObj APPLICANT:If,after Compensation
g this Cisions of
Exemption,you should WATER SYSTEM?RFATING '
abecome subjecttothe Workers Compenr hisperount hal of the Lted resole,yom mat SOILS FEE' "
fila 1'oMwith comply with such provisions or this permit shvllbedremed revoked. WATER SERVICE
Q
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FI'. PAID
Ihetebyaffirmlhanhereisac.nsweti.nhemdingagencyfor Neperformanee of Date Receipt It
W- the work for which this permit Is Isxmd(Sec.3097,Civ.G) -
Q C.) Lender's Name TOTAL
Lender's Address TOTAL:- n
I certify that I have read this application and state that the above inhuman, is BUILDING FEE /Oa COQ
�! (4compel.I agree to comply with all city and county ordinances and stem laws reining to QTY, MECHANICAL PERMIT FEE
U G huildingemmhaction,and hereby authonzemprcsenlatives ofthis city tenterup.n the SEISMIC FE /e
above-mentioned Property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Criterion against ELECTRIC FEE
liabilities,judgments,costs and expenses whichmay in any way ameme against said City ALTER OR ADDTO nsMECH. PLUMBING FEE
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IT"CFM) MECHANICAL FEE D
SOURCE REGULATIONS.
'1 AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX •��
Sign.mreof ,pliam/Cmemormr Date EXHAUST HOOD(W/DUCT) - HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or building occupant store or handle hazardous material HEATING U NOT(TO I(XkW BTU)
as defined by,the Cupertino Municipal Cole,Chapter 9.12,and the Health and Safely
Code.Section Y532pd? HEATING UNIT(OVER 100,000 BTU)
❑Yes t ❑No PAID
r VENTILATION PAN(SINGLE RESID) Data Recept#
WIII the applicant or antra building occupant use equipment or devices which. BOILER-COMP QHP OR 100,OD0 BTU) [r•emit hazardous air contaminants as defined by the Bay Arca Air Quality Management TOTAL: /v
District?
F7 Yes ❑No BOILER-COMP(OVER 100,000BTU)
I have matter hazardous materials re,monnu ins under Chapter 6.95 of Ne Cali- - AIR CONDITIONER' - ISSUANCE DATE
forma Herdto&Safety Cade,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MEER. SQ.EL
Mbulhumid- no amyhas atenant,that it is my responslhllity to notify the occupant
ile rocs nn`ts whit he met prion.a,mnce.f.Cv ' tofO cops -
�r�tthoriud agent Date TOTAL: ISSUED BY:
OFFICE
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JUN - 5 1996
BLDG. INSPECTION DEPARTMENT
CITY OF CUPERTINO
LOT 1 CITATION HOMESTRACT No. 8687
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CUPERTINO CALIFORNIA SCALE:1"-20' DATE: 6/4/96 IJOB NO. 15236-4
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