30227 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. �O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL
INILIIING PROJECT IDENTIFICATION
227
1 BUILDLNGADDRPSS: SANITARY NO. APPLICATION SUBMI TIAL DAFT
03 NER'S NAME: 1'HONC: C NTRA(TOR'S NA E:- LIC NO:
L(-JL'b Int Y= Ne rh�s NIC CON ROLx
RCHITECT/ENGINEER: LIC NO: ALFRED 55:/4� p_FozO-�f.�dfeP—A, ❑
CONTACT: PHONE. CJ+ M/'tbC BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT 'LUAtB MEC I
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hercny afitrm mal 1 am licensed ander provisient,of Chanter 9(commencing JO DESCRIPTION
won Ih Section 7000)of Division 3 of the Bridecssvnd profession,C+dc,and my license is 1
❑100 wt j PERMIT ISSUANCE
Flyz in full force unJ (a) �L�35 SFDWL C3 KITCHEN REMODEL
QUU License CP vn SID Lie.p APPLIANCES-RESIDENTIAL GADDITION C1 PLUMBING RI-PIPE
HQ W Dete Contraft
P_C aa.n ARCHITECTS DECLARATION PANELS GMULTI-UNIT C:1 STRUCTURAL
Z O IAZ 1 unecrstand my plan,shit be used as public recoNs MODIFICATION
OZNO UPT02WAMPS DINTERIOR 0CHIMNEY REPAIR
F'?L-tit Licensed Prefeaienal 2014000AMPS IMPROVEMENT
�yfj OWNER-BUILDER DECLARATION OVER IIMOAMPS D BATH REMODEUREPAIR O DEMOLITION
6 1 hereby affirm Nm I am exempt from the Commerce,License Law far the
C 6 U following reason.(Section]031.5.Business and Pode.ssionS Cmk:Any city or county SIGNS ELECTRICAL []OTHER
u13 W co which requires a permit to construct,vlteq improve,demolish,or repair any sere
f�"�Cco prior o its Issuance,also requires the applicant for such permit it)file a signed statement SPECIAL CIRCUIT/MISC.
} that he is licensed pursamarto the provounis of the Comeactor's i,icen%c Law(Chapter 9
�. O connotheingwith Securn7U01qrfDlvi,nm3oftha Busimsxand Professions Code),), TEMR hall ?R OR PULL?INST. - COMMERCIAL:
C
that he is cxampl therefrom and the basis for the alleged extradition.Any violation of D NEW BLDG/ADDITION D DEMOLITION
W—y
Section 7031.5 by any applicant for a pemil,bjecu the applicmn ma civil penallyof POWER DEVICES
not mora than five hmmuchl dollars($500), GIMPROV [:1 FOOD SI?NVICE
F_Z i IMPROVEMENT
= n GLo the winsfml property,
struntonnyemployees wim wage.vustltheir(Sce. 04ki,Bsunei,on. SWIMMING POOI.ELECT
8FC will dolhewnrk.and the elmmureianots License Use
of apply to an Business GATHER
4�l—mom and Professions G+Oc The oc,dicmh License Law d«s not apply a an owner of OUTLIi I'S-SWITCHES F
a 3— property who nage,or improves thereon.arta who don such work nimseu rr thrmagn
his own employees.provided that such improvements arc not intended or offered for NEW RESIDEM'IAL EL° R Q
sale.If.however,the building or improvement is sold within one year ofcompletion,the SQ.FT FLOORAREA $/SQ.FT.
c,ti.ilder will have the buNen r(provirti bahedidnotbuildorimproveforparj.
-
pose of sale.).
G h as owner of the property,am exclusively connecting with licensed contractors to TOTAL:
consortia the ph+jem(See.7044,Business and Professions Coo.,,The Commne.s Li- JUL 17 1996
cense law does not apply to an owner of property who build.or improves thcmon.and QTY. PLUMBING PERMI FEE
who contracts for such projects with v coutmetor(s)licensed pursuant n the Contractor's
Licen,e Law. '
G I an+cxchq i under Sea .B A,P C for man
in rean PERMIT ISSUANCE GII 'I Ur UUYLYii HiftL
Owner Date
ALI'Hk-DRAIN K VENT'-WATER(EA) VALUXI ION
WORKER'S COM PENSATION DI hefolATION BACK FLOW PHUTECT.DEVICE
I heathyaffimtunder penally le perjuryons,ofthefollowingderker's ns. -
saIhavs,and will for byeCion 37 a of ConvenorCoe.for the
Workdece of the DRAINS-FLlH1R.RO0i'.AREA,COND. STORIES TYPIi CONSTRUCTION
work for
provided for by Senior 3]BO of the Labor Code.for IM1e perfom+ance of Ude
II(✓`,('yPrk forwhich ilisiis issued. FIXTURES-PER TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section
of the Labor Code,for the perfonvnce of the work for which this permit is issued. GAS-[A.SYSTEM-1 INC.4OUTLETS OCC GROUP APN
My WrrA .ri ComrenwlipWns�c�cmric�ld Policy nyg v</.76-1/ GAS-FA.SYSTEM OVER 4(FA)
Carrier. _ urn a F Cl (7 U 1
CERTIFICATE OF EXEMPTION MOM WORKERS' GREAS[/INDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(",,section need oat the completed ifthe parent is torose hundred dollars I$But GREASLTRAP
it,less PLANCHECK FEE
certify that in the performance ofthe work for which this permit is mated,I shall SEWER-SANITARY-STORM LA.200 FT.
not employ any Person in any manner so as to become subject to the Workers'Compre- ENERGY FEE
Z sation Laws of California.Date WATER THEATER W/VENT/13LEC'IR
z Applicant GRADING FEE
ti FN-d NO]ICH TO APPLICANT:If,after making this CeniBcutc oh L'xcn+pfion,you should WATIiR SYSI EM/TREATING
1 a , becodne suhjecl to the Workers Crmpenvtion provisions of the Laws-Center,you must SOILS FEE
r fe,hwith comply with such Provisions or this peon,shall he deemed revoked. WATER SERVICE
0
as CONSTRUCTION LENDING AGENCYracy NEW RESIDENTIAL PLMB. SQ.IT. PAID
U 0 Iherchy omen lhauhere a
isennswetion lending agegncy for the performance of Date Receipt
the work for which this permit is issued(Sec.3197.Civ.C.)
0 U Lemi Name TOTAL:
Lender's Amlren TOTAL:
CI certify that I have mail this application and state that the above information is BUILDING FEE
FuT correct.l agree to comply with all city and county ordinunas and state laws relating to QTY, MECHANICAL PERMIT FEF,
V Z building construction.and hereby authorize representatives ofthis city to enter upon the SEISMIC FEE
above-mmationed pmpetty for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep hmmless the City of Cupe,in,against ELECTRIC FEE
I'abp"es,jc rents.urs,,and caucuses which may in any way seems,against City AGrER OR ADD TO MECH.
cc tithe gru'in 's emtit. PLUMBING FEE
APP ANT NDERS'I'A A L COMPLY Willi ALL NON-POINT AIR HANDLING UNU(TO 10,00ICPM)
GUhA'I''ONS. MECHANICAL FEE
?15u AIR HANDLING UNIT(OVER IQ(IWCFM) CONSTRUCTION TAX
Signuwrc of Applicant onnacho O Daly J' EXHAUST HOOD(W/DUCT) HOUSING MITIGATION IMF,
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or furore building accupum anrcor handle hazanlous materiae HEATING UNIT(Y)100.000 BTU)
as defined by the Capetian Municipal Cale.Chapter 9.12,arm the Health and Safety
Cede.Section 255321a1' HEATING UNIT(OVER 100.000 BTU)
GYes GNo VENTILATION PAN(SINGLE RESID) PAID
Dam Receipt x
Will the applicant or furore building occupant use cyuiprtlem or devices which BOILER-COMP THP OR loots BTU)
emit hnzvNous air conmminums as defined by the Bay Arca Air Qualiry Management TOTAL:
District'? BOILER-COMP(OVER 100,000 BTU)
GYes ❑No
I have read the haemdous material,requirement,under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
hernia Health bb Sultry Code.Seninns 255115,25533 and 25534.P underslund that if the NEW RESIDENTIAL MECH. SQ,FT.
buildingme.,nolcurrently haven mnanl,net iibmy rc,soa,ilaiu, ,notify theoccupant
el the reyuirementx which mull Is met print m iesum ec of u Ceti Pica¢al'Onvi panty.
Owner er authanied agent Date 49bp ISSUED BY:
OFFICE