30361 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. O
BUILDING DIVISION APPLICA•1•IONPERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILDINGADDNISS � SANITARY NO. APPLICATION SUBMITTAL DA'IL
.zoic /aeifi« Dr • Cu P�fvcd
rI OWNER'SNAME: PUONEas� ' CONTRACTOR'S NAM17 LIC NO:
O P 7G� A .� N/C CONTROL-9
IT
\RCHIEL MNGINEER: LIC NO: ADDRESS. ❑
'i9�o/�a�woad�d
CONTACT: - PHONE: BUILDING PERMIT INFO
❑ Committal Fees Paid by Applicant(Initial) BLDG ELEC" PLUMB MECH
❑ ❑ ❑
LICENSED CONI'RAC'IDR'S DIiCLARAI'ION QY.TELECTRIC PERMIT FEE
1 hereby affirm that 1 an licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
{0y1�Z with Section]COlgof Dlviei.n3afrhe Nusi.rssund Professions Code.and my license i. RESIDENTIAL:
FCS full force and effect. / PERMIT ISSUANCE
, Wt' Li ❑SFDWL ❑KITCHIEN REMODEL
QVt-y License Class ic
Lh APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
Q Y Dam Contractor
wpm ARCHI'IEC'TS DECLARATION PANELS ❑MULT6UNIT OSTRHLTHRAI.
Z,p ti Z I understand my plans shall he used us public records MODIFICATION
OZ--0 UPT0200AMPS [I INTERIOR [3 CHIMNEY REPAIR
1']u1 Lim.,xd Professional 201.1"AMPS IMPROVEMENT
Y�J OWNER-BUILDER DECLARATION
C OVER IMO AMPS ❑BATH REMOD' uuuttt PAIR ❑ W, OhH'
tY W Q I hereby arfirm that 1 am exempt form the Co,iorw C's e:Any c Law for the
6 U which oximassa(Section]0315,Bucitve lane) ve,d einne h,or:Any city or county SIGNS ELECTRICAL OTHER
'f whim Tequlrcs n permit re vires the pplic improve,demolish, file
repair any structure
F'�OJ
poor roi..issuance.also�equiresthc epPlicum for such permiuoicense aw pClmmem SPECIAL CIRCUIT/MISE.
!!(} that he is licensed pursuant to the provisions of the Contractor's License law(CM1apmr9
..00 (commencing with Section 7000)s1 IN vision 3ofthelsusin...mrd Preatsmon.c Cale)or 'HEM P.MEI IiR OR POLE IN ST COMMERCIAL:
a a e z that be is exempt thercfmm and the basis for the alleged exemption.Any violation of ❑NEW BLDG/AUDITION ❑DEMOLITION
ort
Section 7031,5 by any applicant for a permit subjects the applicant to a civil penally of POWER DEVICES (:)TENANT ❑FOODSERVICE
t more than five hundred dollars($500).
F=6 I,as owner of the n or employees with wages theirsule compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
C ❑ t'ast'e Y Y P Y Ses as R DOTTER
will do the work,and the structure is not intended or offered for safe(Sm.70e4.Bminesa
and Pnd'esamns Code.The Contractor's Liar Law docs not apply to an owner of OUTLETS-SWITCI ITS-FIXTURES if Q
property,who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECI'R SQ FT.
sale.If,however.the building or imprnvmnent owfid withinone ym ffcompletion.the SQ.F.FLOOR AREA EISQ.FIE
owner-builder will have the burden of proving that he did not build or improve far pur-
❑Las owner of the property,am exclusively contracting with licensed contractor.m TOTAL: AUG 4 1996
construct the tommi(Sec.)IHY,Business and P...fim loos Cala:)The Contractor's Li
-
monaLawdoesnotapply.)an owner ofproperty,who builds or improves thereon.and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a commicumq licensed pursuant to the Contractor's 1 1
Licence Law. PERMIT ISSUANCE
❑Isom exempt V Sec. .R&P C fm this reason
_ ALTER-DRAIN&VENT'--ATE F.AI VALUATION
Owner m
WORKER'S COM PENSATION DECLARATION HACK FLOW PROTECT.DE' •
I hereby effum under Penalty or perjury one of the following declarations:
I hove vmvicte mainbinnCesi fete of Gmscmr cofe.Tocfor Workeh Cnmpcn- pRAINS-FLOOR,kOOF, RA, D. STORIES 'TYPECONSTHI)(TION
cation,as provided for mi Section 37W of the labor CWe,fur the pcdinmance of the
wwk farwhich thispermitis orkJ. IIXTURPS-PER TRAP
I haveand will maintain Workers ante of.the w Insurance,acbis md byforted i Section
37W of the lahn Code.for the performance of ate work for which Nis permit is issued. GAS-EA.SYSTEM-1 INC.40I1TLETS OCC.CROUP APN
My Workers Compensation Insurance carrier and Policy number arc:
Carrier: Policy Na, GAS-EA.SYSTEM-OVER 4(EA)
CIERTB'ICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASIL INTERCEPTOR BUILDING DIVISION FEES
(This section need not be completed ifthe permit is forone hundred dollars l5 led) GHFASETRAP
.r less.) PLANCHECK FEE
Icertify that in the peadmoncneeof(bee work fnrwbich this permit isiszueJ,l shall SEWER-SANITARY-STORM EA.210 FT.
not employ any person in any manner so as to become sub cad to the Workers'Compen- ENERGY PEE
pZ vatma laws sf Cdiforma.Date WATER HEATER W/VENT/IELECIR GRADING FEE
Z Applicant
NOTICE TO APPLICANT.If,after making this Certificate of Exemption.you should WATER SYSTEMPMEATING
> cssubject m the Worker's Cnmpencmionm
pvldanv.f the Labor Code.you mus SOILS FTEbem.
forthwith comply with such Provisions or this permit shall be deemed revoked. WATER SERVICE
�1d Q PAID
.7Z CONhen is a'TIONLENDINGAGENCY NEW RESIDENTIALPLMB. SQ.P7. paw Nmeiptp
U I for which thi that ixsued(See.30tion lending agency for the performance of
the work for which this permit is lamed(Sec.109].Civ.C.)
C) Lender'.Name TOTAL:
W fender's Address 'TOTAL:
>. I certify that I have d this application and state ththe above information is BUILDING FEE
reaat
F'ta/i correct.)agree n)comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
UZ building constmetion,anf hereby aulhonxerepre.s:nwtivesof this city..eomrurym the SEISMIC IEE
above-mmnimpd property Tar inspection purpuus. PERMIT ISSUANCE
(We).,me to save,indemnify and keep mrmlca the City of Copan..against ELECTRIC FLIT
liubilities,judgmenu,costs and expenses which may in any way accrue against sold City AITERORADD'1'OMECII.
in PLUMBING FEEconsequence of the granting of this pemlni
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IO,"CFM)
MECHANICAL IIiE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,00 CFM) CONSTRUCTIONTAX
Sipatme sf A,fcam/Corincoor Data EXHAUST HOOD(WMUCT) I IOUSING MITIGATION FEE
HA7/ARDOUS MATERIALS DISCLOSURE
Will the.pplieduu m fumre building o eeparl oom m handle havaadous material 111EATING UNIT(TO 100.000 BTU)
as defined by the Cupeninn Municipal Code,Chapter 9.12,and the Health and Safety
Code.Sciatica 25532(0)] IIHATING UNIT(OVER RXLa"R'IU)
❑Yes No VENTILATION PAN(SINGLE RESID) PAID
Date Receipt#
Will the applicant or future building oecupunl use equipment or devices which
emit haavdaus ai.......amounts us defined by the Bay Arc.Air Quality Management BOILER-COMP(3HPOR I00.010BTU) TOTAL:
District'
1 E]Yes F1No HOLLER-GOMP(OVBR 1(X10(10 BTU) �/ 0
I have read the huardous materials requirenwats under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
farm.Health&Safety Code Secllons 255115,25533 and 25534.1 understand drat if the NEW RESIDENTIAL,MECH, SQ.FT.
building docs nm currently have v tenant,that it is my respnnsihiliry to notify the M.upant
of the acquirements which mus be met prior to issuance of a Certificate of Occupancy.
Owneror authoriud.gent Dam IIUTAL: ISSUED BY:
OFFICE