30564 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF C+PERTJNO 'BUILDING-ELECTRICAL - PERMITNO, O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL r
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
OWNER'S NA(,3E: PHONR: C CTOR:S NAME: LIC NO:
.Uot�I af0 2Sz- sib 4U�-U/! Q_IEP_ So3418 NIC CONTROLS
AR CIIITELR/ENGIM?ER: LIC NO: ADORN: ED ^�-
5 �.Ir., LI Lar,
COSTpA�T�: \ -s•2-�p p -71-16inc,PHONE:
v� BUILDING PERMIT INFO
i�' l Y/V�L.•pis J 1 +� ❑ Consultant F¢¢e Paid by Applicant(Initial) BLDG ELECT PLUMB MF.CII
❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT PEE
ZI hereby offlon that Iran hernia t order p...mons of Chapter 9(commencing ]OE DESCRIPTION
with Section]000)of Division 3 of the Business and Professions Code,end my license i
�0O s PERMIT ISSUANCE RESIDENTIAL:
fome and eBec
aVUr Licenin full.va Clu Lfc.«—��0 Wile T ❑SFDWL ❑KITCHEN REMODEL
Oil, Dam Coal. �. �jL�sti A(I��s APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
N�N ` ARCHITECTS DECLARATION - ❑MULTI-UNIT EI1,
Z82.4 I understand my plans,hull be uwJ as puhlic records PANELS MODIFICATION
OZ%J, UP TO 2W AMPS ❑INTERIOR ❑CHIMNEY REPAIR
r�� Licensed Professional 201.1"AMPS IMPROVEMENT
e�++� OI am exempt
from
RNPION
Comment's
OVER 1000 AMPS ❑BATH REM P.I4R DEMOLITION
q C a� I herchy affirm that 1 em exempt from tt Contractnl6 Licenm Law for the fes, II
k3 per.V fallowing reason.(Section T03L5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ,IpvTHER
fsl {y which requires o permit to onamo el,after,improve,demolisher repair any avnnure
priermits issuance,almrequires teapPlicant forauch penniuo BleasignW statement SPECIAL CIRCUIT/MISC.
G� that he is licensW puromnuons,provisim,Af the Conronnr's License Law(Chos.,9
Qp (commencing with Scadnn Mrs))tef Division 3nflha Business and Professions CmIt)or IEMP.METER OR POLE INST. COMMERCIAL•
CL c C
that he is exempt Nercfmm and the basis for the alleged exemption.Any violation of ❑NEW BLDG/AUDITION []DEMOLITION
1+• Section)031.5hyanyapplicanifor.,,nti,subjenstheapplicanttoocivilpenalt
�y yf POWER DEVICES° ❑TENANT ❑FOOD SERVICE
y not marc than 0 f dr,proed perty,
dollars,y Sap.
❑Lothe owner k,the propeny,mmyemployees d wltwages artei(Sec.compensation, SWIMMING POOL ELECTRIC
IMPROVEMENT
will do the work,and to stmcontre ra rots License Law eed does a.,le Illy
1.no ouvract of ❑OTHER
3 and Professions C°Jou iflo,mp oyes otthave License Law s such
nm apply In if owner of OUTUTI:S-SWIT ES-FIXTURES
hpropertyis own who builds or improve,Hereon,and who nts a such wet himself or through
his own employees,provided that such improvements ere not intended or offered fur NEW RE IAL ELF.Crk SQ Ff.
sale.IL however,the huilding nr impntvenmmia znld within one ywruf nnnpletian,the � SQ.R.FLUOR AREA 9SQ,FT.
owner-builder will have to burden of proving that he did not build or improve for pur-
pose of sale.).
El I,as owner of the pmpery,oro exclusively contracting suit licensed comraams to TOTAL:
construct the project(Sec.7044.Business and Professions Code:)The—amem/ — _g
camic Law does not apply to an owner of propsirty,Who Infilds Or improves thereon,and QTY. PLUMBING`V RMIT FEE
who eoWracts 1'or such pmjectswith a cnntramnrfs)licensed purmam m the Cnnwmnr'a
License law' PERMIT ISSU E
❑ Iamesensptunder Sec. ,B&PChrtisamwn
Owr
ALTER-'RAI &
Dam ER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION HACK FLOW PRO'fE .13EV /a�[3�
1 hereby affirm m
antler Penalty of perjury one of the following dedmutio : 1�
(hove andwildfar y eCenificam of the Lahr Coalenstsrefm Worker'sce of the DRAINS-ILOTBR,EDGE AREA,COND, STORIES TYPE CONSTRUCTION
se k f r pmvidcd fpr by Section 3](gl of the Lahr Coale,for the performance of the
work for whichthis
rtineris ascan FIXTURES-PEft'1'RAP
❑ I have and will ode,fon Workeh Compensation Insurance,h required n i Section
37011°1 the L:Iror Code,for the performance of the work for which this permit is iseuad. GAS-EA.SYSTEM-1 INC.4OUT'LETS OCC.GROUP APN
My War Co smm ha ce 2 at and Policy @f9 lft p 7
Carrier: 'try Ory Na.:—�T S�i(.��1 GAS-HA.SYSTEM OVER 4(EA)
s CERTIFICAI'BOFF,%EMP IONFROMWORKERS'
COMPENSATION INSURANCE OREASPJINDUSTRL WASTE INTERCEI-MR
(This sectian n« m
d not he caplemd tithe perout is feature th ndtcddollars(BIW) BUILDING DIVISION FRMS
or less.) GRF.ASF.TRAP PLANCHECKFEE
(certify tatinthe perl,,,...a uftework far which this Permit is isauW.l shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner / g5ub3 a the Workers'Campen- ENERGY FEE
zzi satian Laws.(California.Date7� ec o WATER IIGATE2 WNCNT/ELLCI'R
O Applicant GRADING FEE
rp NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTEMfUlEATING
abecome subject to the Worker's Compensation provisions of the labor Code,you must SOILS FEET
L>J forthwith comply with such pmvisipnsm this permit shill bedeemed rcvukW. WATER SERVICE
Q
CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PLMN. SQ.Pf. PAID
UQ (herebyeffttm that them is unswctiun lending agency for the Performance of Dare Receiptp
W. H the work for which this permit is issued(Sec.3097,Civ.C.)
O U Lenders Name TOTAL: .
W Lender's Address TOTAL:
1 certify that 1 have mad this application and state that the above information is BUILDING FEE Q r
rtirA correct.I agree to comply with all city and county ordinances and state law,,relatingm QTY. MECHANICAL PERMIT FEE
U z building construction,and hereby authorize representatives oflhis city to enter upon the SEISMIC THE v
above-mentioned pmpcny for inspection purposes.
(We)ugae In save,indemnify and keep no.]...the CII,of Cupertino against PERMIT ISSUANCE ELECTRIC FEE '
habit ILIlggments,costs andexpames which mtoy irony wayaccme...instsaid City ALTER OR ADD TO MECIL
nnsequence�(te graining of this permit. PLUMBING FEE
A`PLICANT UNIT ERSTANDS AND WILL COMPLY WITH ALI,NON-POINT AIR HANDLING UNIT('1'T)10,001)CFM)
SO' EREGUL r10NS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10T00 C M) CONSTRUCTION'rAX
s Sigwtumof AppliranUCo ter I Dam EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEEHAZA DOUS MATERIALS DISCLOSURE
W01 the applicant or future building occupant store or handle hazardous material I IEA'rING UNIT(TO 100.0(6)BTU)
as dehril by the Cupertino Municipal Code,Chapter 9.12,and to Health and Safety
Code,Sermon 25532(u)? HEATING UNIT(OVER IW."BTU)
❑YesS'o VENTILATION PAN(SINGLE RESIU) PAID
Date Rcccipt«
Will the rdousair licant or contaminants a building occupaBayat Area Air ntmtdManaemes ent BOILER-COMPDHPOR 100,(I(I(IBTU)
emit hazardous air contaminants as delinW by the Boy Arca Air Quality Management TOTAL:
L�DZno? BOILER-COMP(OVER IOO,WO RTU)
the hazardous mmeriWs requirements under Chapter fr.95 of to Cali. AIRCONDITIONER ISSUANCE DATE
a y Cola Bertin.,25505,25533 and 25534.1 onderemnd thm if to NEW RESIDENTIAL MECH. SQ.Irl'.rten0yhavee¢ myer,ptmbiflywrmily theexerprat
¢ asst be t r' issuavtt of Ce m p x/edagentRi Date TOTAL: ISSUBOBY:
OFFICE
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(Nor 1v 6F <-L-T) __ _ _ � S16 Set oT P xn ^{ a x;t T, of �,�at� SEP 17 1996
jhis tpe j afs 00
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eou yw a� t pe;Uno BLDG. INSPECTION DEP
-•� ton Same w pePt., od sP 1 CITY OF CUPERTINRIMtivi
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T.
DATE.
REVISED
I AUL- INC.
1 L-'(�' �F��I - DRAW WO NUMBfiR
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