29494 (2) APPLICANT.TO FILL IN INFORMATION WITHIN RED LINES-'USE BALL POINT PEN ONLY ' -
CITY OFCUPERTINO, - .. t. 'BUILDING-ELECTRICAL PERMIT NO. /� App /r qqq
BUILDING DIVISION APPLICATION/PERMIT" PLUMBING-MECHANICAL - - -/9 9
BUILDING PROJECT IDENTIFICATION - L V J
BUILDOING ADDRESS: ) 161 N1 1 SANITARY NO. APPLICATION SUBMITTAL DATE
O 'g N4�f:: L HONE: TR O M NO: -�V
Q' 1 N/C CONTROL#
ARCHITECfIENGINE : - LIC NO: RE ❑ ,I -w
CONTACT: - - PHONE:' BUILDING PERMIT INFO
f' ❑ Consultant Fees Paid by Applicant(Initial) BLDG EC PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE 0
I hereby af@m that I an licensed under provisions of chapter 9(commencing JOB DESCRIPTION
aO ZO
with Section]000)ofDivision3of the Business ans
nd Pfofesv ns Code,and my licee is PERMIT ISSUANCE RESIDENTIAL,
r in fall force and effect.
Cis,
U License Clas t-• Lic.M - - - - ❑SFDWL ❑KITCHEN REMODEL
rnQL � � �Qomructor APPLIANCES-RESIDENTIAL. El ADDITION El PLUMBING RE-PIPE
A ITECT'S DECLARA I ❑MULTI-UNIT ❑STRUCTURAL.
O2 22 4 1 understand my plans shall he used as public records PANELS
J UP TO 2M AMPS MODIFICATION
Licensed Professional exempt INTERIOR. ❑CHIMNEY REPAIR
IM OWNER-BUILDER DECLARATION 201-IOMAMPS 'IMPROVEMENT
I herebyff fh to DVER'I000AMPS -, O BATH REMODEL/REPAI ❑DEMOLITION
a rim pt from the'Comracm L' Law for the
O y U following reason.(Senn 7031.5,Business and Professions Code Any city nr coumy ❑OTHER _
I" which requires aperant m eanswet alters i SIGNS ELLCfRICAL
P demolish,h p y structure
IC
that he
in Bac also requires the Ic tf such g SPECIAL CIRCUIT/MISC. is
y Pp perm o f d statement mem
e0 (hath I licensedpauam to the of
for Contractors L LawCodect9
GO (commencing with Seeirentan)of basis 3 [N dProfessions AnCode)or TEMP.METER OR POLE INST. COMMERCIAL
Sect{y M Nm h is exempt therefrom and he hairs i r thealleged manna Any l Penalty
of - ❑NEW BLDG/ADDITION ❑DEMOLITION
a� not in-'himIn 7031.5 by hundreany'appd canars($Permit subjects the applicant foacivil penalty of POWER DEVICES TENANT ❑FOOD SERVICE
ZZ ja not more than flue hundred dollars(ES W).
60 ❑Lo the work,fhe propmy,re hourimende,withwages for
compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the he Contractors
not intended proffered for sale(Sect 004.Business OTHER
and M properofe who
Code:The oyes t emo License Law does not apply to if owner of OUTLETS-SWITCHES-FIXTUR
" his O ny who builds or improves thereon,and who does such work himself or through -
his own employees,provided that such improvements thin not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
saleIf,however,thebuildingthe
burden
of proving
is at hediwithin one year unarm letiom me SQ,PT.FLOOR AREA $/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for Par-
pose of sale.). � 6- ht tl
IID I,as owner of the Property,am exclusively contracting with licensed contractors to TOTAL:
construct the project(See.7044,Business and Professions Cade)The Contmmor's nsLi- APR 24 1996
cee Law does not apply to an owner of properly who builds or improve,,thereon,end QTY, PLUMBING PERMIT FEE
who contracts for such projects with a confusio(s)licensed pursuant to the Contractor's
License Law. PERMIT ISSUANCE
❑ I am exempt under Sec. ,B&P C for this reason .I�} UI- I/U14Lrll IIYU
OwnerALTER-DRAIN&VENT-WATER(RA)
Aare ' VALUATION
W $COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
Iherebyaffrm underonderpeneltyofp jury one of me following declarations: -
(have and will maintainaCertificnta of Coatent to self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,ARE ,GOND. - STORIES TYPE CONSTRUCTION
tion,as provided for by Section 37W of the Labor Code,for fe hperformance of the
yofk for which this permit is issued. FIXTURES-PER TRAP
have and will thommm Worker's Compensation Insomm.,as required by Section 1 i
00 of Ne Labor Cafe,for the performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-1 ING4OUTLETS OCC.GROUP APN
MY Worker's o e Insurance carrier and Pulicy n be aro
Camer.IPoliNERE :.� GAS-EA.SYSTEM-OVER
CBRTIFICA EOF XEMPTION FROM KERS'
COMPENSATION INSURANCE - GREASEfINDUSTRL WASTE INTERCEPTOR '
(This section Beed not le,completed ifthe permit is for one hundred dollars(s too) GREASE TRAP
BUILDING DIVISION FEES
or less.) PLANCHECK FEE,
Loy any perhatnath any ofthe Walkfarh subject
permit rk vCompen- ^ SEWER-SANITARY-STORM EA.200 FT.'!. -
not employ any pennon m any manner n as to b bj ct to the Wok Compen- ENERGY FEE '
scion Lows of Califomi Dare
O A Ilcant - WATER HEATER WNf3NT/ELECTR
7 PP - I GRADING FEE
Fly NOTICE bj APPLICANT If,after Compensation
this Certifisof of Exemption you,you mull WATER SYSTEM ITREATING
a become subject to it Worked,Compensationprovisions of the Labor Code,you must SOILS FEE
W�t Q foMwith comply with each Pmvisidns or this permit shall he deemed rcvnkW. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
V p '. Thereby affirm that there isaconswctinn lending agency for the Performance of Date Receipt#
4, the work for which this permit is issued(See.3097,Cu.C.)- `
p,` Lenders Name _ TOTAL:
4k47 Lenders Address
.I certify that I have rod this application and state that the above informationis BUILDING FEE
i-r h cmrem.I agree m comply with all city and county ordinances and slam laws relatinK to QTY, MECHANICAL PERMIT FEE
V building conanution,and hereby nation.representatives offhi,,city to enaropon the SEISMICFEE "
above-mentioned Property for inspection purposes,- PERMIT ISSUANCE -
(We)agree m ml
save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way inmeagainstsaid City ALTER OR ADU 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 10,000 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,(0(1 CFM) - CONSTRUCTION TAX
Signature of Applicand(Contowtor Dam EXHAUST HOOD OMDUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE -
,r Will the applicant or future building occupant store or handle hazadous material HEATING UNIT TO 100,000 BTU) - - -as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety - -
Code,Section 25532m)] HEATING UNIT(OVER 100,000 BTU)
❑Yes No VENTILATION PAN(SINGLE RESID) PAID "
Will the applicant re futubuilding occupant use equipment or devices which Reccipt#
sh BOILER-COMP(SHP OR 100,000 BTU)
it hazardous air contaminants as Defined by the Bay Area Air Quality Management � '
Dhna] I BOILER-COME(OVER I W,DW BTU) TOTAL:
❑Yes ,7 No _
Fhave read the hazardous materials AIR CONDITIONER-
req meats under .1 understand
the Cal - - ISSUANCE DATE
fomm Health&Safety Code.Sections 25505 25533 d 25534 I understand Nat if the NEW RESIDENTIAL MECH. SQ.FT.
build gdees not currently have a tenant n'f y mibility to ratify the Occupant
•of the u swA rm the mefp o ec o ertficaty fO
ufn
Owneroraoz m !it . Date TOTAL:
ISSUED BY:
OFFICE'