28678 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL 28678
BUILDING PROJECT IDENTIFICATION
JJWLDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
br.
I NAME: 1 L )N'TRACTOR'S NAMIE LIC NO:
T l� / N/C COM ROLN
RCHI'fECD.NGINHER: LIC NO: DURESS: KJ r
1
CONTACR - PHONE: '- BUILDING PERMIT INFO
❑ Consultant Fees Pairs by Applicant(Initial) BLD a.LEcg' PLUMB IAFCH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE JOB DESCRIPTION RIPTIONDN
I hereby affirm that 1 am licensed under previsions of Chapter 9(commencing
WCz with Svctinn]IXIO)of Division]of the lluxinenx end Pndessiona CnJe.and my licenscix RESIDENTIAL
� fllforeeande c �j PERMIT ISSUANCE'
tJ U^U License Cl ss Lic.p 3 56- CSFDWL C PLUMBIKITCHENREMODEL
W Date '� Cementer APPLIANCES-R[SIDLNTIAL CADDITION CPLUMBING RE-PITT,
Fly ' AR ITECTS DECLAR 'Ili PANELS CMULTI-UNIT []STRUCTURAL
ypF12� st my pia shall he used as public records MODIFICATION
Oz n UPTO200AMPS RIOR El CHIMNEY REPAIR
�� sl 201-1000AMPS 1, IMPROVEMENT
OWNER-BUILDER DECLARATION OVER HIMAMPS ♦ BATH RFMODEUREPAIR 0DEMOLITION
y 1 hereby Affirm that 1 am exempt from the Contractor's License law for the
RpU (allowingreusnn.(Scc'ien]031 S,Business and l'rofeavione Cole Mycity or county SIGNSELECIRIC CGTHER
Yl 4. which rtquirta a permit m construct,alma improve,demolish,ar repair any swnum '
prior In its issuance,also requires the epplicam for ouch penninn 0leo signed aummem SPECIALCIRCUIT/MISC. all
i+ that he is l icenaed pursuant m the provisions of Ne C.sibuctots License,Law(Cbapte9
e C� leommencing with Section 70m)of Di.ision 3 of the Business and Protestants Code)or 'I L'MP.SIM 17'H OR I4JL COMMERCIAL:
d b y that he is exempt therefrom and the basis far the alleged exemption.Any violation of -1 NEW BLDG/ADDITION ❑DEMOLITION
^ Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of POWER DhVICIS
"m IMTRNAPROVEMENT El FOOD SEEVICI?
FZx< 0L.e lbanfive hnnoted
y,ocount,
....l. ,
FA C Lo the work,the propenyl cis ram pleyeeswith wagessatheir(See compensation. SWIMMING POOL ELECTRIC
IMPROVEMENT
QQa and Jo Newark,and C.1c: he Comusnm,Lirxmor.tfictud.a,do for ot apply to an Ouxinees ❑OTHER
4�� and Professions Calc:The Cnnwctnre License Law dace not apply m an owner of OUTLETS-SWITCHES-FIXTURES essits,
progeny who builds or improves thereon,and who docs such work himself or through ,
his awn enrpleyaea,pmv ided that such improvemcrttx are not intended or offered for NEW RESIDENTIAL FLECTR SQ FT.
sale,If,however,the building or improvement is sold within our yearofmmplicam,the \ SQ.FT.FLOOR AREA S/SQ.PT.
owner-builder will have the burden of Ineving dist he did not build or improve tragal- ,Ll qq pp
Pose of sale.). bi L
C 1,as owner of the pmpety,am exclusively contracting with licensed contractors to I{��'� 1, [
construct the project(Sex.7044,Business and Proflnre oseCol,The Conuactolx 7 199i�
cense Law does net apply to an owner of property who builds or improves re
theon,and QTY. PLUMBING PERMIT FEE INOIJ
who contracts for such projects with a aantmnor(x)licensed pursmrm m the Connector's
License Law. PERMIT ISSUANCE `
❑I on exempt under Sec. ,B&P C for this reason k, 1�' u+- Lu�st�l'�
ALTER-DRAIN&VF,NT-WATER(EA) VALUATION
Own Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under,penally of perjury one of the following declarations:
I have col will maintains CenifcatcofConscm tnxelf-insure for Workers Comp:n- DRAINS-FLOOR,ROOV,,AREA,COND, STORIES TYPE CONSTRUCTION
sarion,as provided for by Section 3700 of the Labor Cale,for the perfomrance of the
work for which this pereal is issued. FiX3'ORES-PER TRAP
1 have and will maintain Worker's Compensminn Insurance,as require it by Section
J700of Ne Lalror Codefortheperfamuses.ft J work for which Nis pe mat is issued. GAS-EA.SYSTEM-1 INC.40U TITS
OCC.GROUP APN
My Worker's Compensutinn Insurance carrierol Policy number are:
Caries Policy No.: OAS-EA.SYSTEMOVER 4(NA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPBNSATION INSURANCE. GRF.ASEIIIDUSTRL WASTE INTERCEPTOR
BUILDING (VISION FEI'S
Obis section reed not bennnNdeJ ifthc permit is for onehundred dollars(SIM) GRP.ASE'I'RAP
or less.) PLANC IECK
Ic<nify that lathe perfnrmancmfthe wmkforwhic/his Permit issuN.l shall SEWER-SANITARY-STORM FA.200 FT.
not nn ploy any person in any manner so as he'sal cnothe Workers'Compen- ENERGY FEE
cation Laws of Califnmia.D' 7
Q — 9: WATER HEATER W/VCNTflA.ECIR
Applicant GRADING FET.410
I5A NOTICETOAPPLICA LAIN aP gh a u.'c -Exemption,you should WATER SYSTEN17RF,ATING
It
F_ Fo become subject m the W er's Compensation previsions of Ne Lahr Code,you must SOILS FCE
Ltl forthwith comply wird such provisions or this Penin'shall he deemed revoked. WATERSERVICE
tCONSTRUCTIONLENDINGAGENCY NF,WRESLDENTIALPI.MB. SQ.IT. PAID
I hereby affirm that there is acensuuction lending agency fon heperformance.( ale Receipt%
the work for which this permit is issued(Sec.3097,Civ.CJ
Q U lenders Name TOTAL.,
110 TOTAL:
W LenJerAddress
rectify Nat I have reed this application and ata¢that the above information is OUI1.131 F'IiC
V3 eLingreemco.and herebyldbon7 repecomsinanoesand store enter
Q'py, MECHANICAL PERMIT FF:E
V build i�nstmmion,eel hereby euNome mpremnmtives of this city mrnmr upon the SEISMIC FEE
thnvemening rlttedgtmpcny far inspection purryrscs. PERMIT ISSIIANCB
(We)agree to cave,indemnify and kc harnlesa the City of Cupertino against ELECTRIC FI? ix
liebdibr,judgmems,costsand expensesw may in any weymeruengainsr sato City ALTERORADD'IOMECH.
in consequence of the granting of thispe PLUMPING Ft
APPLICANT 'NDE [jf AND ILL COMPLY WITH ALL NON801NT AIR HANDLING UNIT(TD IOTM CPM)
MECHANICA FEE
SOURCE sfL O 7) ^7
Lil J,!s' AIR HANDLING UNIT Ig0o0 CFM) CONSTRUCTIINTAX
Signa'ureof Appl UCommctor Date HXHAUSTHOOD(W/DUCO HOUSING MI NFEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hamolous material HEATING ON 0101111I1X1BTU)
as defined by the Capetian Municipal Cale,Chapter 9.12,and the Health and Safety
Cade.Section 25532(m7 1 HEATING UNIT(OVER 100,000 BTU)
E3 Yes ON.
VENTILATION FAN(SINGLE RCSID) PAID
Will the applicant or future building occupant use equipment or devices which Dace Receipt
ren hazardous air contaminants as defined by the Ray Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU)
�• unit'^ TO
❑Yen CNe BOILER-COMP(OVER 100.000 BTU)
1 have read the havtNous nmmr all re uirements under Cha ter 695 of the Cali. NR CONDITIONER
q p ISSUANCE DAT
forma Health&Safety Cale Sections 25505,75533 and 255]4.I undersand'bat if the NEW RESIDENTIAL A1ECH. SQ.PT.
hulloing Jae no'currently have Is brand.Wm it Ix my responsibility¢t nosily the occupant
of the rtquiremenu which matt be met prim m issuance of a Cenificate of Occupancy.
im
Owner or authorized agent One L \ ISSUED BY:
OFFICE — aM_
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U NOV 71995
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BLDG. INSPECTION DEPACTMEXI
O CITY OF CUPERTINO
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OFFICE COPY