S 0209 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO- - BUILDING-ELECTRICAL PERMI'TNO.
BUILDING DIVISION APPLICATION/PERMIT ' PLUMBING-MECHANICAL Q O n O(�
BUILDING PROJECT IDENTIFICATION, l7 G 9
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMI'FfAI.DA'Z'E
OWN 'S NAME: PHONE: CONTRACTOR'S NAME:
I LIC NO:
3 N/C CO 'ROU#
AR F. I GINGER: � ' LIC NO: ADDRESS: ❑
/ G S
CONTACT: - PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) B ELECT PLUMB MFCH
❑ ❑ ❑
'LICENSED CONTRACTOR'S DECLARATION QTY.- ELECTRIC PERMIT - FEE
I hereby affirm that 1 am fthneed under provisions of Chapter 9(commencing JOB DESCRIPTION
o�z wllh5«tion]BnpofDivisionJofihoBusinessendPmfesslonCode,andmyiicwseie PERMIT O O RESIDENTIAL
Ed in full farce and exec r•
�U'`r License Cl cs LIC.# y - L1 STEAL ❑KITCHEN REMODEL
`Z Dale Connaaor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
RCHITECTS DECLARATI pgNELs, ❑MULTI-UNIT ❑STRUCTURAL
z 0 r�z I undersand my plans shall be used as public records MODIFICATION
OZ- - UPT02MAMPS El INTERIOR El CHIMNEY REPAIR
Ultimata Prof esxtons[
OWNER BUILDER DECLARATION 201-I000 ❑AMPS IMPROVEMENT SWIMMING POOLS
�G I hereby affirm that I am exempt from the Comorclnr's License Law for the OVER 1000 AMPS ❑BATH RE 'I REP IIf`�DEMOLITION
y U, following reason.(Section]031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER '-T1
WO I"' which requires a permit to concoct,alter,improve,demelish,or repair any structure
G-uy116
prior to its issuance,also requires the applicant for such permit to the a signed summand gp14C1ALCIRCUIT/MISC.
`n that be is licensed pursuant mile provltioms of the COnhactors License Law(CIquer9
C) (commencing with Section]0W)of Dlvlsion 3 ofthe Business and Professions Curt)Or TEMP.METER OR POLE INST. COMMERCIAL'
1 Oo W Out he is exempt therefrom and The basis for the alleged exemption.Any violation of - - ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES El TENANT ❑FOOD SERVICE
not more than five hundred dollars(3500). IMPROVEMENT
G
11 Las Owner ofthe property,or my employers with wages as their sole compensation, SWIMMING POOL ELECTRIC
will do the work,and the mandate is not intended proffered forsale(Sm.7044,Business - [-]OTHER
til3� and Professlora Code:The Contractor's License Law does nor apply to as owner of OUTLETS-SWITCHES-FIXTURES
6 ,mi who builds or improves thereon,and who does such work himself or though
his own employees,provided that such improvements are not intended or Offered for NEW RESIDENTIAL ELECTR SQ ET.
sale.If.however,the building or i mprovemem is sold within one year or complaint,the SQ.FT.FLOOR AREA WSQ.FT.
caner-builder will have the harden of proving Nat he did not build or improve for pur-
pose of sale.). AID l�
F11,as owner of the property,am exclusively contracting with licensed contractors m TOTAL: W ry
constructhe poj«r(Sec 7041 Briameas and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of properly who builds or improves thereon,and QTY PLUMBING PERMIT FEE � r �r/I[IfD
who contracts for such projects with a commmor(s)rceuxd pursuant in the Contractors JUN
III�I Imo{!
License Law. PERMIT ISSUANCE''
❑1 am exempt under Sec. ,B&P C for bars renaon
ALTER-DRAIN&VENT-WATER TA) QTYup
Owner + - Date � V A ITIx
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
!hereby u0irm undo penally of perjury one of baa following dalnmtions;
Orheve andwill maintain a Cendeate of Consen[m self-insure for Worker's Compact- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
,mien,as provided for by Section 37M of the Labor Code,far the perfnmmarn of oho
work for which this permit is issued. FI STU RES-PER TRAP
tI have and will maintain Worker's Compensation Insurance,as required by Section
of the Labor Code,for the performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCCGROUP APN
My Workers Co pensarion l ranee ca rand policy number
arc_ ya „-�
Carrier: Policy No.— GAS-EA.SYSTEM-OVER 4(EA)
C IGC
ATE OF EXEMPTION FROM WOR ERS'
COMPENSATION INSURANCE GREASEMSDUSTRL WASTE INTERCEPTOR y -p )IVISION PEGS
(Thissecdom reactor ba completediftha permit is future hundred dollar,($100) GREASETRAP Or tc,s.)
PLANCHECKF
(certifyN in he many ncersoias work fnrwhich th is permi[is issued.I shall SEWER-SANITARY-STORM EA.200 FT.
mationLwany Canon in any erso ask ore 'Gyri IbTSWnrkerF Compen- ENERGYF
Oz Armon Laws
Cal Due-Dnre WATER HEATER WNENVELECTR
z ACPlicant_ �� 0' C GRADIN
w-t fn NOTICE TO !I,e er making this nitica¢of Exemption,you should WATER SYSTEM/TREATING
1" become subject to the Worker's Compensation Provisions of the Labor Code,you must SOILS FE
NJ
forthwith comply with such pnviskmism this permit shallM deemed revoked WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
aI
thereby Off.that isocons[mction nudingageney for the performance of to ReceipiN
I,& the work for which this permit is issued(Seo.3097,Civ.C.)
Caider'a Name TOTAL:
der's Address TOTAL: _
1avidly that 1 have read this application and nate that the abase information ix BUILDING FEE
corzer)Sm}6.II agree to comply with all city and county ordinances and sate laws reining to QTY, MECHANICAL PERMIT FEE
buildm cnnslmction,and hereby authmiu representmives of this city renter upon the SEISMIC FEE
above,qqq������tinned properly for inspection purposes. PERMIT ISSUANCE
(ye)agree to save,indemnify and keep harmless the City of Cupertino against - ELECTRIC PEE
Iiebilities,1ltjudgmeats,costs and expenses which may in any way accme against said CityALTER OR'ADD TO MECH. PLUMBING FEE
in consequence of the granting of this permit, -
APPLICAVTUNDERSTANDSANDWILLCOMPLYWITHALLNON-POINT AIR HANDLING UNIT(TO 11,000 CFM) MECHANICAL FEE
SOURCE 9EGULATIONS.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of ApPlicam/Conuector Dale EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEEm. HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building Overpaid store or handle hazaNuus material HEATING UNIT(TO 100,000 BTU)
as defined by the t_uper ino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 255/2001 - HEATING UNIT(OVER 100.000 BTU)
❑Yes No PAID --
VENTILATION PAN(SINGLE RESID) Data Receipt#
Will the tin exanar i future building bycupant use equipment or devices which
count limitations air n,nmminanb sdefined by the Bay Arca Air Quality Management BOILER-COMP(3HP OR IW,WO BTU)
District?
TOTAL.:
El Yea f - BOILER-CONE(OVER 100.1100 BTU)
I have man the hezmdous materials requimmems under Chapter 6.95 of the Cali- AIR CONDITIONER - ISSUANCE DATE
fomia Health&Safety Code,Sections 25505,25533 and 2.5534.1 understand Nm if the NEW RESIDENTIAL MECH. SQ.FT
buildingd nw currently heveatenant nit is myresponsihility ro naify the«cupant
of there ms I]Y came =-r In isinymnfnCerti/llfine �DC�}`'�/ '
f, ��/l /
O mete minced ager I^ Uside TOTAL: ISSUED BV:
OFFICE
64
cup
t
'JUN 2 51997
'. BLDG. INSPECTION DEPARTMENT yLAlrS
CITY OFCUPERTINO PLU'C
CHECKED BY
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CUSTIMER 6115 CONTRACTnR'S LIrFtAF d .fil_17917 :
ADDRESSCITY/OR CQHNTV
CITY cls 5D [BUSINESS LICENSE P
SAV - AWN" ALUMINUM PRODUCTS
850 ALDO AVE. . SANTA CLARA, CA 95050 . (408) 988-4444 - 988-4445
RESIDENTIAL PLOT PLAN
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