S 0489 (2) Arl'LILMN I 1 O FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUILDING-ELECTRICAL PERMIT NO.
HUILE) ODI VISION APPIACATIONIPERMIT PLUMBING.MRcxnNICAI.
BUILDING PROJECT IDENFIF'ICATION
BUILDING MORESS: SANITARY NO. APPIACA'I'[ON SUBMITTAL DATE
Gat o. ''J.- /5-97
OW rR'S NAME: PHONECOW CONT CT(IR'S NAME: / I�O
fs9'`72 1 NIC CONTROL
ARCHITECTMISGINEER: LIC NO: AU ESS:V n IDS Qafdnz,i I 5
CONTAC`F, PHONE: BUILDING PERMIT INFO,
❑ Consultant Fres Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ Q-- ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affect that I am licensed under previsions of Chapter 9(commencing JOB DESCRIPTION
DAX with Section Axx))of Divisinn3ofthe Business and Professions Code.anA my license is RESIDENTIAL
0p in full fore.mal effect. PERMITISSUANCE
y.N[ ❑SFUWL ❑KITCHEN REMODEL
QUtt License Class-Lis.
X Dam Contractor APPLIANCES-RESIDENTIAL ❑ADDITION YSPLUMBING RE-PIPE
F
fDy ARCHITECTSS DECLARATION PANELS ❑MULTI-UNIT EJ STRUCTURAL
X O r�'� I understand my plans shall ba used as public records MODIFICATION
J UPTU 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
Licensed Professional 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
S y y OWNER-BUILDER DECLARATION
I hereby N
hy afflt at 1 am exemptN
from e Co License Law for Ne OVER 1000AMPS [I BATH REMODEUREPAIR 0 DEMOLITION
p(06a
V following name. 70)1.5,Business and Professionsssions Code:Any oily or ttnmYSIGNS ELECTRICAL ❑GTHER
{titll W OI'2 which requires a pennil to construct,uheq intpmvq demolish,nr rcpnir unY ntmctvre
��+y}7 prionoi¢isxuance,11x0 requires Nc applicanrtnr such permiuo fleasigned stvmmem SPECIAL CIRCUIT/h115C
,>. Nat he is licensed pursuanuothe previsions of NC ConwnOrs License Low lChnpmr9
la)�p0
that
he
exempt
therefrom
refrand basis
for oftheR ed exem,tm..Any
Code)or TEMP.METER OR POLL INST COMMERCIAL:
a C pt that he is exempt Iany ,di and the basis for the alleged the exemption.Any violation of ❑NEW BLDG/ADDITION ❑FOOD SERVICE,^„N Sectinn90JlSby hundred
dollooWall.it mbjerts the sufficient to civil pewlry of POWER DEVICES ❑IMPROV El FOOD SIiRVICE
F Z is not ntnro than Ove hundred Jnllurx(&SIIIB.
�p0 ❑Lasownerd Ne propenyor is..,moyeeswiN wugesssale(Sele compensiness SWIMMING POOL ELECTRIC OTHER IiMFN1'
will Professions
r Newons and the he nareCont is..,not s License Law doesed rot apply to an teener of � 11 OTHER
63 and any who builds Calc:The Cntnmctm's Liceme Law dces mrt apply to if owner of (IUTLIiTl-SW I'CHIiS-FIXTURES
property who oyes.or improves Neuron,and who dice smch work dad or or through
his own employees.provided that such mens is old were not intended or alined for NEW RESIDENTIAL 1i1.ECTR SQ FT.
sale.If however the building or improvement is sold within one your(if completion,the SQ.FI'.FLOOR AREA ASQ.IT.
r will have the burden of proving that he did not build or improve for pun-
po,eer-buildeofs.E.) f g�
A 1 D
❑ 1,as owner of the properly,am exclusively contracting with licensed contractors to TOTAL:
emetracl the project(Sec.70,14,Business and Pmfcs.xions CWt:)The Conuanors Li-
cerise m se Law does not apply an owner of property who builds or ImproN
ves emon.and QTY, PLUMBING PERMIT FEE 1 t
whoc,i..Iafn...ehprnjaels wilhuconlracmr(s)licensed mrsuamlolha Gmarnams
License Taw. PERMIT ISSUANCE
❑l am exempt under Sec. ,11&PC for this reason _ yr
Owner Date ALTER-DRAIN&VENT-WATER fI?A)
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE �V
1 hereby affirm under penalty of Perjury one of the following declarationsi.
]have and will maintain a Certificate ofConsertl to self-insure for Workers Contain- DRAINS-FLOOR,ROOF.AREA,COND. STORIES TYPE CONSTRUCTION
mtim,in Provided far by Seen..3700 of the[..he,Code,for the scrforacrav of the
work for which this permit is issued. FIXTURES-PER TRAP
❑ 1 have and will maintain Work<rs Compensation Insurance,as required by Section CS
39W ofthe Labor Code,for the parforamnce of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCCGROUP APN
My WakeCom pe anon tre. ' d Policy numbervre: GAS-EA.SYSTEM-OVER'4(EA)
Carver �.R Policy FROM
,, CERTIFICATEOFEXE PTION FRAM WORKERS'
COMPENSATION INSURANCE GREASPIINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
fDtis section need not be completed if the parous is for me hundred dollar gled) GREASI?TRAP
or less.) PLANCIIF.CK FEE
Iccnifythmimlheperf0rmavicenRhe wmrkrorwhich Nispermit iskned.Lvhall SEWER-SANITARY-STORM FA.2W FT.
not employ any person in any comm r so as to beemmc suhje,t m the Workers' mp
Coen- ENERGY FEE
Z ration Law.of z California.Date WATER HEATER WNENT/F.LECTR 12 Applicant ` GRADING FEE
trNOTICE TO APPLICANT.IL after making this Certifcute of Exemption,you should WATER SYSTI?MG`REATING
a? become subject to the Workers Compenwttion previsions of the Labor Cede,you must SOILS FEE
UJ0 forthwith comply wiNsuch provisions.,,his permit shall he deemed rtvnkod. WATER SERVICE
tCONSTRUCHON LENDINGAGENCY NEW RESIDENTIAL PCMB. SQ.14. PAID
U O Date RccciPt N
I herchy which
that theta is s sed(See i30 lending agency for Ne performance of
the work for which phis permh Is issued(Sec.31199,Civ.CJ
OI'" Lender's Name TOTAL:e
W Lenders emyt TOTAL:
I certify that 1 have reuA thi,application and xwm Nm the abrvo information is WELDING Flil?
Val correct.l agree to comply with all city and county ordinances and slate laws reining to QTY, MECHANICAL PERMIT FF.F:
Ll Z trabbngconmuction,and hereby authorize representatives of this city memar upnnthe SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,casts and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit PLUMBING HE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IB000 CFM) MECHANICAL FEE
SOU."RCE RE�GUL�A/DONS. (
��/ ;f AIR HANDLING UNIT(OVER 10.00()CFM) CONSTRUCTION TAX
Signe�f Cnntrecmr 7 J Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE.
Will she applicant or future Wilding occupant smremferanle hazardous material HEATING UNIT(TO IW.000 BTU]
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
GNB.Section 25532(.)1 HEATING UNIT(OVER IOQLYN BTU)
El Yes FI No VENTILATION FAN(SINGLE RESID) PAID
Dam ReceiptN
Will the applicant or furore Wilding use equipment or devices which
Broil hvzardoun air mmaminantsadcfnN by by the the Bay Area Air Quality Management BOILER—COMP(3HP OR I00,1100 BTU)
TOTAL:
Dismial
❑Yea ❑No BORER—COMP(OVER I W.000 BTU)
I have read Nehazurdous material,requirements under Chapter 6.95 of the Calm AIR CONDITIONER ISSUANCE DATE
main Health&Safety Code.Sections 25505.25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building dies not currently have a tenant,that it is my responsibility to notify the resolution
of the nex,ireniona which must he mel poor to issuance of a Cmilierce of Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
IaiaalF
OFFICE