S 1377 (3) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL, PE ITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 1377
BUILDING PROJECT IDEN'r FI"Oole
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAD
`I i gg4q Lop bile-: broa L ^�
LO _�
OWNER'S AME: - PHONE: CONTRACTOR'S NAME: LIC NO'. 31 �
Almik Ion -f 1y'e- 10 0 •f�,/1 J / L NIC CONTROL#
t RCHITEPTNGINEER: LIC NO: ADDRESS; l 1 E:1
I 6!E
CONTACT: 't,, ` PHONEILDING PERMIT INFO
/1 ❑ C....Itart Fees Paid by Applicant(initial)� BLDG ELECT PLUMB MECH❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT PEE
I hereby affirm that 1 am licensed under provisions of Chapter 9 mommeneng SOB DESCRIPTION
Q P+Z with Section?010)of0ivision 3 ofthe Business and Professions Code,md my license's
POO O PERMIT ISSUANCE RESIDENTIAL:
�UVfull force and 9gCfoqt�
License Class.S.�^ Lic.N ❑ADWL ❑PLUMBIN RE-PIPE
FZW Dare Contrnemr - ,.APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
Nan' IW ARCHITECTS DGCLAR 1 / ❑MULTI-UNIT ❑STRUCTURAL
PANELS
C m',� I un erste d my plans shall be used as public records M IFICATION
Z`4 UP TO 200 AMPS
y F,O ,__ El INTERIOR HIMNEY REPAIR
Licensed Professional 201-IOW AMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECOVER WDDAMPS ❑BATH REMODELn EPAIR DEMOLITION
Q 1 hereby affirm that I em exempt from[h
Or
Character's Licence Law for the
onnn
O Or U following reason.(Section 7031 S.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
Oy which requires a permit to construct,alter,improve,demolish,or repair any structure
prior to its issuance,also requires lheapplicant for such permit o file a.signed statement SPECIAL CIRCUIT/MISC.
�} that he is licensed Director to the provisions ofthe Contractor's License Low(Chapter 9
(emnmevaing with Spun..7000).f Division 3.Rhe BthreSted Professions Cade)., TEMP.METER OR POLE INST. COMMERCIAL:
p eL mat he is exempt therefrom and the basis for the alleged exemption,Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
^6v. Section 70315 by any applicant fora permit subjects the applicant to a civil penalty of POWER DEVICES
as,
El ❑FOOD SERVICE
>>Cnot more than five hundred dollars($500),GQ ❑ I,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
H2it[do the work,and the traction is a.,initiation or offered (S
for saleec.](144,Business []OTHERTHER
ru
m and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
.. property who builds or Improves thereon,and who does such work himself or through
his own employees,provided mot such improvements are nor pleaded m offered for NEW RESIDENTIAL ELECtB SQ PT.
sale.IL however the building or improvement is sold within eme yemof comMetion,the $/SQ.PT.
ter-builder will have the burden of proving mat he did nor build or improve for pury
pose of sated.
❑I,as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
tuna rat the p chi($ee 7044,Business and Prof swa...Cod J The Cnntmenra Li MAR 1 8 1998
use Law does aotapply to to owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts partial projects with a contrachuhn licensed pursuant to the Contractor's
License Law. PERMIT ISSUANCE
FlreI am exempt under Sec. ,B&PCforthisabAT;
son B
ALTER-DRAIN&VENT-W
own Date ER(EA) VALUATION
er
WORKER'S COMPENSATION DECLARATION BACKFLOW PROTECT. ICE �'Z(JO ,
I hereby affirm under penalty of perjury one of the following dedtrminns:
I have and will maintain a Certificate ofConsentto self-insure for Worker's Compen- DRAINS-FLOOR,R R ND. STORIES TYPE CONSTRUCTION
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700of the Labor Cadet for the perfornsance.True work for which this permit is issued. GAS-EA.SYSTEM-1 INC4 S OCC.GROUP APN
My Workers Compensation Insurance comer and Policy number so:
Cocoa,: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCE
(This section need not be completed if the permitis for one hundred dollars($100) BUILDING DIVISION FEES
or less.) GREASE TRAP PLANCHECK PEE
Icertfy the,in the performance ofthe wmkfrr which thia molt is is ed,Ishall SEWER-SANITARY-STORM EA.200 FT.
not employ any person any mann r a o b object" (W., r Cooper- ENERGY FEE
Z sation Lawsof Calif. Dote
O Applicant gam, WATER HEATER W/VENT/ELECTR GRADING FEE
q NOTICE TO APP NT:If r haskin'tistartifi5ific of Exemption,you should WATER SYSTEMC BEATING
became subject m the Worke C pensation proor visions of the LabCode,you mast SOILS FEE
W forthwith comply wpm such pfn sions or this permit shall be deemed revoked. WATER SERVICE
Q CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
U 0 l hereby affirmthitrhere is aconstmction lending agency for the pertmnnorso f Data Receipt#
4L Be work for which this permit is issued(Sec.3097,Co.C.) TOTAL:
0 U Leader's Name
CU Lenders Address TOTAL:
fSs o I certify that I have read this application and state that above information is BUILDING FE 1.
h accord.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
V 4 building construction,and hereby authorize representatives ofthiscity to enterupon the SEISMIC FEE
above-mentioned property far inspeei.n purposes. PERMIT ISSUANCE -
(We)agree to save,indemnify and keep harmless the City of Cupenino against ELECTRIC FEE
Iitbi lines,judgments,costs and expenses which may in any way accrue againstsaid City ALTERORADDTOMECH.
in .asequence of the granting of,l,ia permit PLUMBING PEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLINGUNIT(TO 10.000CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Sumas dAppamatConbacmr Data EXHAUST HOOD(WMUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupantslore or handle hazardous material HEATING UNIT TO 100,000 BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)7 HEATING UNIT(OVER 100,000 BTU)
❑Yes nNo VENTILATION FAN(SINGLE RESID) PAID
Date Receipt#
Will the air amumorfuwm Mudding by the nt use Bay Are.
Air Qualitment or y
Manages ement
ant BOILER-COMP(3HP OR 100,000 BTU)
mit jet? us air comnminams as defined by the Bay Area Air Quality Management TOTAL:
isuic[!
F-1 Yet, No BOILER-COMP OVER 103,10)BTU)
1 have read the hammaterials aterials requireAIR CONDITIONERments ander Chapter 6.95 of the Cali- ISSUANCE DATE
humin Health Safety Com,Sections 25505525533 and 25534.I understand that if me NEW RESIDENTIAL MECH. SQ.FT.
building t onrendyhavm tenamJhm is my responsi 'nymnolify me occ pant a \
of the rc eats which must be met p,' c2 of t nifcaro 0 gu n �,1
Ow roraumodze 'agent t TOTAL: ISSUEDB �f IQ .i � O
OFFICE