30972 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 3O9 1 Q 7Z
CITY OF CUPERTINO BUILDING-ELECTRICAL - PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. J
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
I G" r� �/3-97
D ER'S NAME: PfIONF: r C RACTORS ME: /^ LIC NO: N/C 02 CON/3
i� . vS�C� 257-yoy! -B-0 /I ✓N 6.> 0,57
IM ARCHITECT/ENGINEER: LIC NO: ADDRESilh. - G p/1 ®/ / ❑
CONTACT: PHONE: / Ni,
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ . � ❑
LICENSEDCONTRACTOR'SDECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm Nat 1 am fthe Bu i order provisions of Chapter 9(commencing JOB DESCRIPTION
F-00 with Section DivisionJnfthc Business and RofessinnsCMe,and my license is RESIDENTIAL:
F O in full force and effect PERMIT ISSUANCE
W� ❑SFDWL ❑ CHEN REMODEL
m�J License Class Ii0.N APPLIANCES-RESIDFiM1AL
��tD Dam Comrwmr ❑ADDITION MB ING RE-PIPE
�' ARCHITECTS DECLARATION
g.7rn PANELS '
[I MULTI-UNIT ❑STRUCTURAL
z O ttg z I un lentwrd my plans shall be used as public remands MODIFICATION
oz--Q UP TO 200 AMPS
❑INTERIOR ❑CHIMNEY REPAIR
ri-gij Licensed Professional 201-10000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION
36 OVER UMAMPS El BATH REMODEUREPAIR [I DEMOLITION
yI hereby affirm that I em exempt from the Convacmr's License Law for the
sd F following msnm(Seldom]OJ 1.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
4S�1 LLO which requim a pemdt to construct,alter,Improve,demolish,or repair any structure
ern pnorm its issu4nce,4110 requires the applicant fnrsoch pennitfo file vsi,nedsmteme^t SPFCIALCIRCUIVMISC.
<7that he is licensed pursuant o the previsions of the Contractors License Law(Chapter 9
00 farmmmncing with Section]00%Onf UivisinnJ of the Business and lTofesninns Cade)or TEMP.METER OR POLE(NST. COMMERCIAL'
N
e Y at he is exempt mcrefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
^
Section 7031.1 by any applicant for a permit subjects the applicant to a civil Penalty of POWER DEVICES
} not mom then fve huMrcd dollars(5500). ❑TF.NAM ❑FOODSERVICE
❑1.asawnerof the property,or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
Q will da the work.and me structure is not intended oroffered for sale(Sm.J044,Business ❑OYTRER- {
L and Profic,i0ns Codi::The Cmmmmctore License Law dues not npply to ua owner of OUTLETS-SWITCHES-FIXTURES /;j
.. property who builds or improves thereon,and who docs such work himself or through q
his own employeea,provided that such improvements are not intended m offered for NEW RESIDENTIAL ELECTR SQ PT.
sale.If,however,the building or improvement is sold within one year of completion,the ASQ„l2,FLOOR AREA S/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for put- I'(w fL.71 3 REC g
pose of sale.).
❑I,es owner of the property,am exclusively convecting with licensed contractors to O' /y
convect the portion(See.7044,Business end Professions Code:)The Convacmr's Li-
cense Law does not apply to air owner of property
i-censeLawdoesnotapplytounownerofproperty who builds or impmves thereon,and QTY. PLUMBING PERMIT F UUr�H��NQ -
whocontmas for such po jots with n comrwtor(s)licensed part uanno the Contractor's
License Law. NIiRMI'T ISSUANCE '
❑lam exempt under Sec. ,B&PCfer Nisrcasun
Owner Date
ALTER-DRAIN&VCM-WATER(EA) VALUATION
-
WORKER'SCOMPENSATIONDECLARATION BACK I7LOW PROTECT.DEVICE
I hereby affnn under penalty of perjury one of the following dmlmtiom:
❑I have and will maintain a Certificate of Consent selGinsure for Workers Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES
TYPE CONSTRUCTION
cation,as provided for by Section 37W of the Labor Cale,fm the Performance of the
work for which this petwit is issued. FIXTURES-PER TRAP
❑I have and will maintain Workers Compensation Insurance,as required by Section
37W of the Labor Code, the performance of the work for which this permit is issued. GAS-F.A.SYSTEM-I INC.4 OUTLETS � OCC.GROUP AYN
My We, Compansmion � wrier t% Policy nytuber ye, ,
CuMe r S Policy Na.: f {Gf-/�Trf��G / GAS-EA.SYSTEM-OVER 4(EA)
CER FICATE O-EXEMPTION FROM WORKERS'
COMPENSA'HON INSURANCE. GREASF/INDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEIS
(Thio section need not be completed if the permit is for one hundred dadhum 1$100)
or less.) GREASE TRAP PLANCHECK FFM
I cenify that in the Performance of the work for which this permit is issued,I shall SEWER-SANITARY-STORM EA.200 FT.
e
not .ploy any person in any manner so m to hecome subject the Wmkefe'Crnnpen- ENERGY FEE
O z, s rtlon Wws of California.Dam WATER HEATER WNENT/ELECfR
Applicant - - GRADING FEE
NOTICE TO APPLICANT:If,after making this Cmtificntc of Exemption,you should WATER SYSTEMTREATING '
become subject to the Workers Compenmtion provisions of the Lehr Cash,you must SOILS FEE.
forthwith comply with such provisions or this Permit shall be deemed revoked. WATER SERVICE
O
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FT. PAID
V 0 (forhereby which
thi that name issued( ect 3097.Cis,agency for the Performance of Dam Receipt It
C)U.'+ the work for which Nis permit is issued(Sec.JO9],Civ.CJ
Q i~ Lenders Nome TOTAL:
Wfo
Under' Address TOTAL:
Ira certify that I have rcaJ this application and state that the above information is BUILDING FEE
'F IAA correct.l agree to comply withal]city and county ordinances and state laws reining to QTY, MECHANICAL PERMIT FEE
L) building construction,and hereby authorize represcnmtives of this city to enter upon the SEISMIC FEE
ahove-mentioned properly 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 wNch may in anyway accrue against said City ALTER OR ADD TO MECH.
in conugmnce of the granting of Nis� - PLUMBING FE
SOPir RCERLGU RSyANJ� {7D �LL MPLYW HALL NON-POINT AIR HANDLING UNIT 71D 10,0010 CFM) MECHANICAL
NN �13 AIR HANDI.MG UNIT(OVER 10,005 CFM) CONSTRUCf10NTAX
J
Signatureof plica rat 0 Dam F.%HA UST HOOD OVIDUCT)
//� AZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
II�W the 4pplicam orfuture building occupant store or handle muMous mournful HEATING UNIT ITO 100.000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU)
E3 Yes ❑No VENTILATION FAN(SINGLE RESID) PAID
Will thea applicant or future building acv nt use t m devices which Date ,Receiptg
Pp d P° Area
Aire^ BOILER-COMP(3HP OR 100,000 BTU)
emit rtzwdous air comuminunte us defined by the pay Arca Air Quality Manugemcnt TOTAL:
Distort?
[I Yes ❑Nn BOILER-COMP(OVER 100,00p BTU)
7 AIR CONDITIONER
I hnvere the mutenals uiremcnts under Chepmr 6.95 of the Cali- ISS CE DA
famia Healds Safe ndens 255 ,25533 and 2S5J4.I understand that if he NEW RESIDENTIAL MECH. SQ.FT.
'Idingd notcu rely haves tenant, itismsihilitymnotify theracupum
ern Fremem hick n(u�bc metp'z t ssu ^fa 'v:am of upwsy.
O e rauth dagcn Data TOTAL:I ISSUED It .
OFFICE