18517 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 28517
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
70 e—!/ 1-25--9,6
OWNERS NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
-tleee-7 Pt um Z./7 N/C CONTROL.#
.ARCHITECT/ENGINEER: LIC NO: ADDS ESS:
^ /q00 v a+ it -/y OS ❑
a
CONTACT. (-!•y Nt) PHONE: BUILDING PIiRMIT INFO
Cq L weS7e,eN $S L/ ,�T�Q ❑ Consultant Fees Paid by Applicant(Initial) BCT
BLDG ELE ' PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby alarm that 1 am licensed under partitions of Chapter 9(commencing JOB DESCRIPTION
CaZ with S«ton7W)ofl)ivision3nrmeeu.inexaand ParfesslonsCede.and mylicenxeis RESIDENTIAL
woo PERMIT ISSUANCE
sty mfull foa<nnde :Xul ❑SFDWL ❑KITCHEN REMODEL
Qz at License Clue 1.ic.# APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
N 6 q Uute Crntmcturdj
F.Orn T `s' /vARCHITECTS DI A'TION PANELS ❑MULTI-UNIT ❑5'I'RUCTURAL
Z O.1 Z I undershoot my plans shall be recd us Public records MODIFICATION
O Z..p UPTO200AMPS OINTERIOR ❑CHIMNEY REPAIR
Licenced Ptoomioml 201-IN)OAMPS IMPROVEMENT
OWNER.BUILDF;R DECLARATION MOVER IINN)AMPS BATH REMODEf/REPAIR ❑DEMOLTI'ION
G 1 herchy affirm that I um exempt from the Corfiv rs License Law far the
U fallowing reason.(Section 7031.5.Business and Profession's Code:Any city Cor County SIGNS ELECTRICAL. ❑OTHER
ywhich Ieyvires a pants m construct.alter,improve,demolish,or repair any struclun
�g prior m its issuance,also aspires the applicant for such Permit to file a signed statement SPECIAL CIRCUIT/MISC.
f W y that he is licensed pursuant to the Provisions of the Contractors License Law(Chapter 9
�CpO (mmmen<ing with Section70W)of DivisiunJof the Business and ProfessionsCedc)or TEMP.METER OR POLE INST. COMMERCIAL:
d 6 ey
that he is exempt thcrefarm and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
X^LL Section 7031.5 by any applicant for a permit subjects the applicant to a civil perwhy of POWER DEVICES W..y ❑TENANT ❑FOOD SERVICE
F Z>• not more than five hundred dollars(empl.
_< (] Lasowner
work,the pmpenicam myemployeesorbwages mtheir Sole compensation. SWIMMING PoOL.ELECTRIC IMPROVEMENT
SFO will dotbewrrk,ande The
toolnot Licensor ofered.doesufot applyWan,Pner ss
or []OTHER
3 m and Professions Cede:Thc Cnntmcmr's License Law tiros not apply In an owner nl' OUTLETS-SWITCHES-FIXTURES II
property who builds or improves dentin,and who dtas such work himself nr Through
his own employees,Fronded that.such improvements arc not intended or offered for NEW RESIDENTIAL IiLEC'I'R SQ 1'.
sale.ILLoweva,the building orimprovement it told within one yearofersai ton,the SQ.FT.FLOOR ARBA $/SQ.FT.
ser-builder will have the burden of proving that he did not build at improve for pur143
-
pou of sale.).
1,m owner of the pmpenX am exclusively contracting with licensed contractors to TOTAL:
emnuect the project(Sec.7(W.Business and Pod..lona Cade:)to.Contractors
1i—Law does not apply to an owner of property who builds or improves thereon,and QTy. PLUMBING PERMIT FEE
whocontractx for such markets with a come or(s)Iicem al ptimm nuo the Contractors
Liccnae Law. PERMIT ISSUANCE Q O
❑Ice Sec. B&P this reason
nr ALTER-DRAIN&VENT-WATER HIA) VALUATION
Ownerk D �^
�}'f��RKER' COMPENSATION DECLARATION BACK FLOW PROI'T:CT.DEVICE 2 '�l'l ('� V
Iharcbyoflilnt tarda Penahy of perjury nnc o[the following declomtinnx: 3 /L
• Q l have and will mainnona CcrifictileofCun.sant msal6inmre for W..ke-Cn... a. DRAINS-FLOOR,ROOF,AREA.CONDSTORIES 'TYPE CONSTRUCTION
action,as provided for by Section 37k)or the Lahr Code,for the perfa muncc of the
work for which this permit is issued. FIXTURES-PERI'RAP 67 oL
❑1 have and will maintain Workers Compensation Insurance,as required by Section
37M ofthe Labor Code.for the peifrsmmor,ofthe work for which this permit is issued GAS-EA.SYSTEM-I INC.Y OUTLETS OCC GROUP APN
My
CartWrkciIk ta n IrdUGrad Policy na
Policy No.: GAS-FA.SYSTEM-OVERa(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRGSEIINDUSfRL WASTE INTERCEPTOR
(This section used not he completed if the permit is for one hundred dollars(S[an) BUILDING DIVISION FEES
or].or) GREASE TRAP PLANCHECK FEE
I cenify that in the Performance ofthe work for which this permit is issued.I shall SEWER-SANITARY-STORM F.A.200 IT.
not employ any Person in any manner so as m hecome,wbject to the Workers'Comper- ENERGY FEE
0 Z xmom Luwa or California.Dale WATER HEATER WNENDELECI'R �J s 9
Z Applicant GRADING FEE
NOTICE TO APPLICANT:If,after making this Certifirme of Exemption,you should WATER SYSI'EM/TREATINC,
(•^ ^ hect me subject to the Wurkers Compensation provisions of the Labor Code,you must SOILS FEE
forthwith comply with suchpnownimoo,this permit shall be deemed revoked. WATER SERVICE
0.
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID
U ,'� Dare Receipt#
V l far which
that there issued(Sec.30 lending agency for the perfotmarce of
F' the work fur which this permit is izweJ(Sec.J097,Civ.C.)
us Lenders NomeOO�� TOTAL:
ULenders Address TOTAL' 03% BUILDING FEE
1 certify Out I have read this application and sate that the above information is
iF+ ut; correct.I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
V building construction.and hereby aatrrI representatives of this city to enter upon the SEISMIC HE
dvoc-mentioned properly for Inspection purrynm' PERMIT ISSUANCE
(We)agree to save,indemnify end keep hunnlca the City of Cupertino against ELECTRIC FEE
Iiabilltes.judgments,ensu and expenses which may in any way recruit,against said CityALTER OR ADD TO MUCH.
in noalwncc of the granting of this permit. PLUMHING FEE Qgs Cot
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,11X1 CFM) MECHANICAL FEE
SOURCE REGULATIONS,
AIR HANDLING UNIT(OVER 10.0110 CFM) CONSTRUCIONTAX
Signature mAPplicanotContractor Date EXHAUST HOOD(W/DUCO 2 199 OUSINGMITIGATIONFEE
HAZARDOUS MATERIALS DISCLOSUREae
Will the applicant or future building occupant store or handle hardoos material HEATING UNIT(TD 10X.000 BTU)
as defined by the Cupertino Municipal Carle,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100.000 B'TU) LII} h I �t L l 1 if
Code.Section 25532(x)'!
Cl Yes 6?
S96 `J07/e_
VENTILATION FAN(SINGLE RESIU) PND Dale ReceTl#
Will the n,plimm or future building ncamunl use eyulpmem or device,which
emit hurtNon,ow rnmamimnts as de lued by the Ifuy Area All Quality Managoncnl BOILER-COMP(31iP OR 100.000 BTU) TO'T'AL:
Distrix? BOILER-COMP(OVER Iwjtol B'ru)
❑Yes
I have read the harztdova mmaials tournament.under Chapter 6.95 of the CO- AIR CONDITIONF.N ISSUANCE DATE
farm.Heal Cede Sections 25505.25533 and 255311 undersmM am if the NEW RESIDENTIAL MECH. SQ.Fn
,as it=not cumI have a tenant that it is my responsibility to notify the occupant �jJ e- �I��jM��f
of the rtq' .which st stn Prig m ismattce of o Cenifinte of(kcupancy. Jig {i ,5/
Owner t custom 6 l— Iota TOTAL: ISSUED BY. (tree' Y3"ex-
OFFICE