31029 (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. 31029
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NU. APPLICATIONSUBMITTALDATI
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P N@ CONTRACTOR NrkMEc LI�CN'O, N/C CONTROL#
sHC UECI'l1iNGINEF.H: LIC NO: A DRESS: 7-4 6� !{"�
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CONTACT: PHONE: BUILDING PERMIT INFO
� l / /�— �-„ ❑ Consultant Fees Paid by Applicant(Initial) BLU ELECT y. PLUM MEECCH
B i�� C,Y
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under Provisions of Chvpmr 9(commencing _ JOB DFSCRIPTION
OUZO with Section700fof Dividon3ofthe Businessand PofcssionoCNe.and myliccrue is PERMIT ISSUANCE S 0 RESD LNTIAL: CHENREMODIiI-
F full tome and effect. /LJ 3 '
�UZU
License Clas lois.# APPLIANCES-RESIDENTIAL C1 ADDITION El PLUMBING RIz_PIPE
h d G Date Conuucua
ARCHITECTS DECLARATION C1 MULTI-UNIT El STRUCTURAL
Z O.z 1 understand my fleas shall be used as public records PANELS MODIFICA'T'ION
UP TO 200 AMPS ❑INTERIOR El CHIMNEY REPAIR
atoo Itni1 Liccnmd Professional 201-1000AMPS IMPROVEMENT
W OWNER
C?Q I hereby affirm the 1 am emlmptlfrom the Conte CLARATItars License law for the OVER["AMPS ❑BATH REMODEfJREPAIR DEMOLITION
xax i U following reason.(Section 0031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL (]OTHER
W 3 a hwhich requires a permit to comtruct,alter,improve demolish,or repair any amucom
FLLOJ poor to its issuancalso minutes the applicant for such pemtit m file ed le a signstatement SPECIAL CIRCUIT/MISC.
f
to-5
e that he is licensed romarnmthe provisions of the Contras.,',License Law(Chapter 9
u�i�QpO (commencing with Section 7000)of Division 3 of the Business and Profcssi.ns Qdc)or TEMP.METER OR POLEINSL COMMERCIAL:
e.a cm,that he is exempt therefrom and the basis fur the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
XMN Section 90315 by any applicant for.pernit subjects the applicmt to.civil penalty of POWER DEVICES ❑TE NT ❑FOOD SERVICE
,ant more than Eve hundred dollars($51X0.
ROVf:MENT
SQ I,nx.wner of fie propcnY..r my mnpinyccs with wugowath.ir sole congens:nion, SWIMMING POOL ELECTRIC
p.G will do the work,and the someone is not intended or offered for sale(Set.9(W<,Business OTHER
W 3 9 and Professions Cole:The Contractor's License law does not apply to an owner of OUTLETS-SW,ICHES-FIXTURES
property who builds or impmvec thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ IU
sale.If,however,the building mimpr.vcrmal m mold withinone yearn(completion.the 41 SQ.FT.FLOOR AREA $/SQ.FT.
ncrbuilder will have the bumlca of proving that he did not build or improve for par-
om fa.la} mTOTAL: ti p @, I D
1. owner of the ppeny,am exclusively contracting with licensed contractors to
onsimet the project(See.7014.Business and Professions Cade)The Commetor's Li-
cense law does not apply to an owner of pmpcay who builds or improves thereon,and QTY. PLUMBING PERMIT FEE IID
whocontracts for.such pro with aanttralum,)licensed pumuunt tothe CommcmrMAR's s� 11
License Law. PERMIT ISSUANCE J V
❑It exempt under See. .B&P C for tbi,mmo. 'Ior I ir uljetii I IVO
ALTER-DRAIN'&V12N'I'-WATER(EA) VALUATION
)wner Date
WORKER'S COMPRNSA]'[ON DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of pejuty on of the following declarations: `C%��• ��
i] I have and w in maintain a Ccniticate of Consent to self-insum for Workers Compen- DRAINS-FLOOR,ROORAREA,COND. STORIES TYPE CONSTRUCTION
sari..,m provided for by Section 3701 of the labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
O 1 have and will maintain Workers Compensation Insurance.as required by Section
3900 of the Lahr Code.for the performance of the work for which this Permit is issued. GAS-EA.SYSTEM-I INC.a OUTLETS OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number are:
Caricr: Policy Nn: GAS-EA.SYSTEM-OVER a(EA)
CERTIFICATE OP EXEMPTION FROM WORKERSGREASE/INDUS'TRI-WASTEINTERCEPT)R
COMPVNSA'I'ION INSURANCE BUILDING DIVISION FE S
(Tla,o,Oi.n need not b.co....ca [Hole penult is Tot rare hundred doll:',IS I(H1) GREASE TRAP
.r lcxs2 PLANCHECK PER
(certify theinthe performance he work for us
ich jectto peranithe W,kers'cd.Ishall SEWER-SANITARY-STORM EA. IT.
not employ any penwn in any manner xo as w become subject to the Workers'Compo. ENERGY FEE
OZ onion lawsof California.Dae WATER HEATER WNENT/ELECTR GRADING FEE
Z O Applicant
h NOTICE TO APPLICANT:If,after making this Cenificam of Exemption,you should WATER SYSTEM/IREATING
become subject to the Worker's Compensation provisions of the labor Code.you must SOILS FEF.
0 Jonhwith comply with such pmvl.xirs or this Permit shall be decmcd mooted. WATER SERVICE
7z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMP. SQ. PAID Date Receiptp
V p I hereby affirm that thercis acnmometion leadingagous,for the performareco[
(~ the work for which this o m s is issued(See.91199,Civ.C)
U. 9amdefa None TOTAL.
W Leisloas Address TOTAL:
1 cem y that I have read this application and state that the almve information is BUILDING FEE
to correct 1 agree to comply with all city and county ordinances and state law,relating to QTY. MECHANICAL PERMIT FEE
C„) ,Z building emtstmetion,and hereby authorize representatives oftlikeity to emmripm the SEISMIC 17EE
slave-mentioned pmpeny,for inspection arpor'. PERMIT ISSUANCE ELECTRIC HE
(We)agree to save,indemnify and keep harmless the City of Cupommo against
liabilities,judgments.costs and expenses which may in any way accrue against said City ALTER OR ADD*10 MECH.
PLUMBING FEE
in asequence of the granting of this Permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 C1`M) MECHANICAL PER
SOURCEREGULAT NS oiz--�
�rxp,q AIR HANDLING UNIT(OVER W."CFM) CONSTRUCTIONI'AX
Sig.uore of Apploam m
/Corncmr O Date EXHAUST HIGH OSIDUCT) HOUSING MITIGATION PER
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future huilding occupant store or handle hazardous material HEATINGUNI'1'('10100.000BTU)
as dcfned by the Capstan.Municipal Calc,Chapter 9.12.and the Health and Safety
Code.Section 25532(.)? HEATING UNIT(OVER 100.000 BTU)
Yc,
FN,,
O T VENTILATION FAN(SINGLE RESID) PAID Dae Receipt or
W II the applicant or for..building secopam use equipmem or devices which
emit hvaMous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP OHP OR 100,000 BTU)
TOTAL:
Di'mmY
❑Yes '
BOILER-COMP(OVER 101000 RTU)
xrs
I have mad the hamrdous mttrous requirements under Chapter 6.95 of the Cali- AIR CONDITIONIiN ISSUANCE DATE
Ibr.in[health&Safety Cade,Sections 25505,25533 and 25531 I undersand that If phe NEW RESIDEM'[A].MECH, SQ.FT. R
submit,does not currently haven mumu,phut itismy responsibilityusnotifythe iaxa,ra ll/71{•`././/`I
of the requirements which must be met prior to issuance of a Cerf Gc.m or Occe,rey
Owner or uuthnrized agent Use TOTAL: ISSUED BY:
OFFICE
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1 aeq r:BN•oF - I
'LD
MAR 7 1997
c,uci• CITY OF COUPERT NO DEPARTMENT
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FEE COPS
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MEW C4 'T/%VG ik IN &HIZY R1.
APPROVED
IN ACCORDANCE WITH THE CITY Ot
CUPERTINO CODES AND OR
yD�NCES:
SIGNED ecihcations 1 U r
This set of Pans and sP
k
e t on the ybb at all,tir.es and 'tis un
ratfons
be P alta
an es
or
i c. g
n
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na
a
m
lawful toiritten n from
In same wit�e`t NCity of Cupertino.
ue bu:ding Dept-, eclficetions
lie s.amp.ng of ihis plan
Ind.Spec
or to be en .
NUI be head to per
roylslG➢.^
ya; uY
the dn�ance.01
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