S 0975 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - - -I BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL _ 0975 A.7I C
BUILDING PROJECT IDENTIFICATION 5
BUILDING ADDRESS: . SANITARY NO. APPLICATION SUBMITTAL DATE
1 of VhihO I S I..f-G1
OWNERS NAME: PHONE: CONTRACTOR'S NAME: LIC NO: ..
5 H I \ . � 6 NIC CON TROL#
A CH TECT/F.NGINEER: LIC NO. A DR• S. l.�la O ❑
✓� oZ 0 Y
coNTACT PxorvC: BUILDINGP RMIT INFO
_O / ❑ Consultant Fees Paid by Applicant(Initial) .D F.hF; M Mecx
LICENSED CONTRACTOR'S DECLARATION QTY, ELECTRIC PERMIT FEE
L hereby affirm that I am licensed under provisions of Chapter 9(commencing _ JOH DESCRIPTION
IIyl 00 with Section 7000)-f Divison i3oftho Businessvnd Professions Code,and my license is
Fw� nfull force and effect, 11�� PERMITISSUANCE
DIFNTIAL-
U License Class 9 Lia.# l� 3 x 21 S3 DWL ❑KITCHEN REMODEL
yZW Dale--I IT— Continuum APPLIANCES-RESIDENTIAL []ADDITION Ll PLUMBING RE-PIPE
ARCHITECT'S DECLARA IO VSO' s ''-- PANELS
'pan El MULTI-UNIT ❑STRUCTURAL
�zOnq 1understand myplans shall heused aspublic records MODIFICATION
I- Iz UP TO 200 AMPS ❑INTERIOR El CHIMNEY REPAIR
fG.2,Ip•.:W Licensed Professional 201-IW(IAMPS IMPROVEMENT
,y k.Lj OWNER-BUILDERDECLARATIONthe ❑SWIMMINGPOOLS
I:G OOGGGOVER ION) L1 BATH REMOUEUREPAIR D1,,�.OLITION
W 6 1 hereby a0irm that 11. exempt from the Computer's C License Law for the (.+�"'
3 a F following reason(Section]0.91.5,Buxiness and Professions Cale:Any city or county SIGNS ELECTRICAL. ❑OTHER
W which requires a permit to construct,alter,improve,demolish,or repair any avaemre
F F,'�an Prior to its tssaxnas,alsoregmorsthe up,lannit forsuch permit to file a signed statement
an SPECIAL CIRCUIT/MISC.
W>' that he is licensed pursuant to the provisions of the Commmors License Lew(Chopter9
d (commencing with Section of Division 3 of the Business and Professions Code) R AL:
W g q O TEMP.METER OR POLE INST.
tY q m es that he is exempt therefrom and the basis for the subjects
the exemption.a civil
violation of ❑NEW BLDG/ADDITION El DEMOLITION
YXl-„fyL Section 7031.5 than five
any hundrelleantforapermit subjects Ne applicant tovcivil penalty of POWER DEVICES
FEF... nonnore than five hundm0 dollars(5500). ❑TENANT El FOOD SERVICE
CyQ ElI.a-caner-flue Property.in my employees with wages as theirsole compensation. SWIMMING POOL ELECTRIC- - IMPROVEMENT
52p.e will do the work,and thestrucmre is not intended or offered forsale(Sao 7044.1ainess ❑OTHER
W�•ao and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
63-' properly who builds or improves thereon,and who does.such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR
sale.If.however,the building orimprovement is sold within one year ofcompletion,theS FB
- Q AREA,I I $/SQ.ET,
owner-builder will have the burden ofpmving that he did not build or improve for per- `JL—U
❑p0ve of side), N V 18 1997
T.as owner of the Sce.70property,um exclusively and Pommels,with licensed contractors.. T� 'ILO y
-nswcl the project(Sec]U44,Business and Professions Codoq TTe Cnntrxcmr's LI-
seLaw doesnot apply to an owner of property who huilds-r improves(hereon.and ,QTY PLUMBING PERMIT
who contracts for such projects with a commemgs)licensed pursuant to the Contractor's PEC
rIR M�
Owner
License Law.
❑ QTY ION
ECTION DEPAR
1 ate exempt under Sea ,B&P C for this rexsnn PERMIT ISSUANCE I
ALTER-DRAIN&VENT-WATER IEA)
Date y A V
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE r M
L hereby affirm under penalty of perjury one of the following declinations:
❑ I have and will maintain a Certificate of Courant to self-insure for Worker's Compen- DRAINS-FLOOR,RUDE AREA,CONI].
,.tion,as provided for by Section 3700 of the Labor Code,fon he performance of rho RI ITYPE CONSTRUCTION
work far which this permit is issued. - FIXTURES-PER TRAP
❑I have and will maintain Worker's Compensation Insurance,us acquired by Section _
37M of the Labor Code,for performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS APN
My Workers Compensation Insurance carrier and Policy number are: VIl
Popsy No.: '+ G 2 is / i GAS-EA.SYSTEM-OVER 4(EA)
ERTIFICATE OF EXEMPTION FROM WORKER-S' _ 3
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR _ BUIL LNG DIVISION PE•S _
(This section need not be completed ifthe permit is for one handrail dullaa(5100) GREASE TRAP
or less.) PLANCk K-CE/
I�
Icertify that in the performance orthe work f-rwhich this permit is issued.I shall SEWER-SANITARY-STORM EA
not FT.
not employ any Person in any manner so as m become subject m the Workers'C-open- ENERGY FE.
7i smion Laws of C.Iifomia.Date
O O Applies.[ WATER HEATER W/VENT/GLGCTR
PP GRADING PG
ay NOTICE TO APPLICANT:If,atom making this Certificate of Exemption,aboCode,you u midst WgTF,R SYSTEMITRLATING
; become subject y the W-rkw's Compensation provisions of the Lvbom -loyou must SOILS NEB
{L)
forthwith comply with such pnvisions-r this permit sM1all be deemed revokeJ. WATER SERVICE.
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,FT. PAID
UO ' 'I hereby them issue (Sec.3097, agency for Performance of Dam Receipt#
(Jt N Ua work for which this permit is issued(Sec 3p9],Co.Civ.CJ
O h Lender's Name - TOTAL:
W Lender's Address TOTAL:
LLt 1 certify that 1 have read this application and state that the above information is s BUILDING FEE
rpt correct.l agree to comply with all city and county ordinances and spire laws relating to QTY, MECHANICAL PERMIT PEE
U
building construction,and hereby authorize representatives-Rhis city to enter upon the 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,costs and expenses which may in anyway accurate againsixed City' ALTER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO Blood CFM)
SOURCE REGULATIONS. ///19 MECHANICAL.FEE
�z / / / AIR HANDLING UNIT(OVER IO,lN1aCFM) - CONSTRUCTION TAX
MI'llum
of Ap agd]mrmaamr Dao I EXHAUST HOOD ONMUCT)
HAZARDOUS MATERIALS DISCLOSURE. ' HOUSING MITIGATION FEE
W the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Sufety
Code,Section 25532(x)7 HEATING UNIT(OVER I OffO00 BTU) ,
Fl yea ❑No -
VENTILATIONFAN(SINGLERESID) PAID Data Receipt#
Will the applicant building by
Area
AirQnt-tdManaementes which BOILER-COME LIHP OR I Of"BTU) _
emit District,
us air cnmxminante as Defined by the day Area Air Quality Management TOTAL:
_ District? -
❑Yes E]No BOILER-COME(OVER 100.000 BTU)
I have read The harzm car,mmernls requirements under Chapter 6.95 of the Cad- AIR CONDITIONER ISSUANCE DATE
E-mia Health&Sol Code,Sections 25505,25533 and 25534.1 and ervunit That if the NEW RESIDENTIAL SUCH. SQ.Pp. -
buildingdoesnot currently have a tenant,that it is my responsibility to notify the occupant
of the requirements which must IN met prior o issuance of a Conferee or Occupancy.
Owner or authorized agent Dam TOTAL: ISSUED BY:
OFFICE