30970APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN'ONLY Q 7
CITY OF CUPERTINO BUILDING ELECTRICAL. PERMIT NO. O O V 1 O
BUILDING DIVISION - APPLICATION/PERMIT. PLUMBING - MECHANICAL - J
A CHITECT/ I EER:.
t G_LIC NO: i
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CONTACT: PHONE:
BUILDING PERMIT INFO
T04'e SIL �,JMyL�D -7 /_ 1wag
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COONTRACTOR'S/D_E'CLARATIOfNa e/ I
❑ Consultant Fees Paid by Applicant (Initial)
BLDG r� PL� M.
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LLICCEENSE(D
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
wit Semina nala1fT�cl cD1VLsIon3of the Business and Professions Code. and mylicense is
fall farce anal aq
Licetre QI,ass ql''% G�rl- giLic,#->� Z�3
Dote- (= ��Col.,... _ - _ ash-
QTY. IiLECTRIC PERMIT PEE
JOB DESCRIPTION
RESIDENTIAL:
CSFDWL C KITCHEN REMODEL
[]ADDITION ❑PLUMBING RE -PIPE
CMUI.TI-UNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR EJ CHIMNEY REPAIR
IMPROVEMENT
[I BATH RLMODELIRF.PAIR El DEMOLITION
❑ OTHIiN
I'IiRMIT ISSUANCE _
APPLIANCES -RESIDENTIAL
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ARCHITECT'S DECLARAI[ON
dnnyplrao he ublicre Ns
Law ofessional
OWNER -BUILDER I am enl,' a a one CrATLON
I hereby affirm that 1 am exempt fent tl¢ Cantrumor'e License Luw'for me
following feaumf(Section 7031.5, Business and 1'mfessions Coda: Any city or county
which teymace a #o.it m sonswcl, direr, improve, demolish, or repair any swcwrc
prior to it issuance, also requires the applicant forxach permit an file a signed statement
thin he is licensed pursmun to Chepawisimaofthe Canoed.,', License Low (Chapter 9
PANELS -
UPTO 2f10 AMPS
201-1000 AMPS
OVER 1000AMPS
SIGNS E CAL
-
SPE .1#4)"C IT SC.
?R POLE INST.
WE )
COMMERCIAL
LDG/ADDITION C DEMOLITION
- FOOD SERVICE
IMPROVEMENT
R
'a!d
O00
=G
p.0
L
(commeneingwhh Section](If10)of DivisionJofthe Busmessand Profesxinns Coae)mr
Ibar he is exempt themfmm and no basis for the alleged exemption. Any violation Of
Section 7031.5 byany applicant fora pe.ii,x.bjerame applicant to s civil penellyof
not more than live hundred dollars ($51n)
❑ I, es owncrof me property army employees with wages as, their sole compensation,
will do me w.'1= the sudcmm is not intended orolTezed hassle(See. IIW4, Business
and Professional Code: The Contractor's License Law does not apply to an owner of
property who build, or improves petition, and who docs suchwork himself nr thmu
1 , GPOOL LEC'I]iIC
FYI ArAyS
I
his own employees, provided that such improvements are ant intended ar offered
Call M4"Ilul GC=t
RE. R Q
unsgQFT. FLOOR AREA
$ISQ. PE
sale. If,however. the buildingm impmvemem is sold within0neyear ofconShmon,t
0111.11HILY I VI 1,1611 1 16 11211.1%
owner -builder will have the bode. of proving that he did Out build or improve for par.
pose of role.).
❑La owner ofthetetany, am exclusively contracting with licensed en In
cansbuct Be project (Sa,9044, Business and Pria ..in. Cale:) no C t . Li -
F U1111
mas, Law does not apply to an owner Of pm,mY who builds or improv res
who trommels finswi,politick wile. enntm Ynr(s) licensed pm, anll 'lltn
QTY. L le N P
'
License Law.
❑lamexempt tinea Sm. ,B CN
PERMITISSUANCE
'
ALTER- VENT -WA ) VF
Owner �
VALUATION
WORKER'SCOMPENSATIONDECL
I hereby germ under penalty of perjury one of in i mg deal '
BACK FLOW PROTECT .D E
DRAINS
FIX'I'URES-PEETRAP
'
C I hteelod will maintain. CennicieafConsent ms 1.rt W ex Compem
a stion. m provided for by Section ]AIB of the Labor p mane. of the
Work for which this permit is issued
C 1 have and will maintain Worker's Crops, nsulion 1 ce, o mired by Sectio
e
TYPE CONSTRUCTION
39Wofine Laken Cede,for the perfsmance ofthe walk I hi is permit is issued.
My Workers Comps,psation Insurance carrier and Policy a M1 a.-
Carrier + Policy No.: - - Y_
GAS -
UP
-
APN
GAS- EA. SYSTEM -OVER 4(EA)
CEIiTIFICATF. FEXEMPTION PROM RKERS'
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Li 0
COMPENSATION INSURANGREASFDNDUSTRL
Miissectiun need mol be completed lithe permit i role bundleddollars($,(#)
Or less,)
I certify that in the performance ofthe work lot ahthispermitisioaed,Ishull
not employ any person in any manner us 0 ro bjut a the Wmkcn' Compem.
audio laws nig. Dee
Applicant -
WASTE INTI?RCEPTOR
BUILDING DIVISION Fr..IS
GREASETRAP
PLANCHECKFEE
SEWER-SANITANY-STORM EA. 200 fT.
ENERGY FEE
. WATER HEATER WNENTIELECTR
GRADING FEE
NOfICE TO APPLICANT. If, aft inking tb' erliftcme of Exemption, you should
became subject m the Workers Compensatio nwW,m' of the labor Q.Jc. you must
.nit shall he deemed invoked.
forthwith Comply with such pmvisiol/Xion
1, CONSTRUCT '0' ING AGBNCY
Iherebyaffilm thanhereis ac lending agency fame perfomlmom of
WATER SySTEMITREATING
SOILS FEE
WATER SERVICE
PAID
Date Receipt#
NEW RESIDENTIAL. PLMB. SQ. HI'.
0 U
0.
the work far which this permit is issu99, Civ. CJ
Nam-
TOTAL:
ers timers
LendAddress "
TOTAL:
I certify that I have read application and xtate that he above information is
BUILDING FEE
QTY MECHANICAL PERMIT FEE
fq
V
corrcct.l agree to comply with cityandeminlyoNiw."send state laws«lating to
building constriction, and hart callemzereprexnmtives Of this cit, it, enter upon the
SEISMIC PEE
above-mentioned pap, fn lopeelin l purposes.
(We) agree to save, indemnify and keep harmless the City Of Cupertino against
PERMIT ISSUANCE
ELECT RIC ME
liabilities,judgments, eau and expenses which may in any way accoe agnirrnsaid City
in consequence of the granting of this permit.
ALTER OR ADD TO MECH.
PLUMBING FEE
AIR HANDLING UNIT 1'IO,IO', N) CFM)
-
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI, NON -POINT
SOURCE REGULATION
MECHANICAL FET?
AIR HANDLING UNIT (OVER 10,000 CENT)
A7;�
CONSTRUCOONTAX '
Signature Of AppbcanuConoa Dare
HAP OUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DI1CT)
HOUSING MITIGATION FEE
HEATING UNIT (TO 100.000 BTU)
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Cattle, Section 25532(.)1
CYce, No
HEATING UNL'f (OVER im," BTU, '
VENTILATION FAN (SINGLE RESID)
Will the applicant or u ore building occupant use equipment or devices which
mit hazardous air connotations as defined by the Bay Arco Air Quality Management
DlsldctO yes �
J
PAID Date Rasipt#
BOILER-COMP(3HP OR Ifp,(NIO BTU )
TOTAL:
BOILER- COME (OVER IM.W0 BTU)
AIR CONDITIONER
1 have mail the hazardous materials requirements under Chapter 695 of the Cali-
fonds Health & Safety Axle, Sections 25505, 25533 and 25534. 1 undersand that if the
building does not currently base a tenant, mat it is my responsibility to notify m -occupant
mr�as(ten�tprionoissuattce of yEYyifc .(gcupancy.
c J 77
ISSUANCE DATE
'
ISSUED By:
NEW RESIDENTIAL MECH. SQ. FT.
O n eumonsmagent DJim
TOTAL:
OFFICE
Inspection Query for a Specfic Permit
P 1
4/7/97