30081 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY - /p�(1
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. 30081
� O O V 1
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J
BUILDING PROJECT IDENHFICATION
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUNMITIAL DATE
2e) ''oPP`f 12P CuPF — UN01 CAC 15014- G�Zo.g6
OW�1'ER'S NAME: PHO E: CONTRACfpR'S NAME: LIC NO:
l 0 JfJGI 0 8) 2 -0 1 C l» ON C -yj NIC ^ CONTROL x
CHOITECT/BNGINEO R: 15732-37 ADDRESS:
❑ (1 tgi
Ftaq
INTACT. ^_' PHONE: BUILDING PERMIT INFO
Tb�� N` /'flOT)AAZ—(�I�1 Consultant Fees Paid by Applicant(Initial) �L BLDG ELIiCT PLUMB MUCH
l l LAR 1 J l_l
LICENSED CONTRACTOR'S amOR:,DECLARATION QTY, ELECTRIC PERMIT FEE
1 hercion" d of shot 1 am licensed under and
Professions
Coca. 4 mylicense is ]OB DESCRIPTION
,O•mOZO with lI foo and
o(Division 3of the Business and Rvfessions Cale.and my license is PERMITISSUANCE RESIDENTIAL:
�W in full force untl cRul.
.R W F-' WL ❑KITCHEN REMODEL
<UV License Clean Contractor
P<S Date Conhacmr APPLIANCES-RESIDENTIAL CNDDITIONI Ll PLUMBING NE-PIPE
F•Dm ARCHOECT'S DECLARATION ❑MULTI-UNIT El STRUCTURAL
Z004 O 0 Z 1 understood my plans shall be used as public records PANELS MODIFICATION
O Z G { UP 1-IMIAMPS ❑INTERIOR C1 CHIMNEY REPAIR
Licensed Professional 201-10gIAMPS IMPROVEMENT
�d OWNER-BUILDER DECLARATION DE
I herehy affirm that I am exempt from the Cmamctora L coxa Iv .r t OVER 1000 AMPS [I BATH NEMODEVREPAIR Q DEMOLITION
ka0.F following reason,ISenion]03 L5,Business and lhnfexxiore Co,le: try ty n (.SIGNS ELECTRICAL ❑OTHER
null 4,y which requires a Permit to construct,same,improve.demolish,or"air any structure AUG e _
Q, prior to its iasu:mce,alaona,mras the upplicant for such peratina file.signed nammem SPECIAL CIRCUITIMISC. 14199s
Ithat he is licensed pursuant m the provisions of the Contmcmrs).icense Low(Chapter 9 um.-s
p p0 (commencing with Section 70)(0 of Division 3 ofthe Business and Professions Codi or TEMP. ETpR'OR POLE ST.7 COMMERCIAL,
0.p,is,1' Ihm he is exempt therefrom and the basis for the ullegcd exemption Any violmion of '' ❑NEW Br&?ADDITION-• O DEMOLITION
iCfL Section]031.S by any upplicant ford permit unbjeas the apPfcannnaciviapeneltyof POWER DP.VICP'S l
ul—w ' L . ❑TENANT ❑FOODSERVICE
{{1... n more than fvehuodrcJdollms(SSW). IMPROVEMENT
C ,O ❑Lasowner o(the property.
estructremyemployees d with wages ns their sale 0,14,Bsiinn SWIMMING POOLELECTR
C2
will dote work,Corbcand a he Care is not imcnense Law red far of apply to an,owner of
❑OTHER
G-3"b4r
and Professions who
Code:The Cees thanr'a License Lawthea
sucnotapplytolf or
OUTLETS-SWITCHES-PIXTURFS
progeny who M1uilds m improves thereon,and who Joey such work himself or thrmmgh
his own employccs,Provided thinsuch improvements ere not immoded or offered far NEW RPSIDfiNT1A1.ELECfR SQ FT.
sale.If,however,thehuilding orimpmvemem xsold witlonot yea"dria plctian,the SQ.FT.FI.(H)R AREA ,$/SQ.FT,
cr-builder.will have the burden of proving that he tlid nor build or improve for Pur- �a� ar�
poo an"'' .`7 S
owner of the properly,t xelit,wely contracting with Ilcensed enntrncmrx m
nvsuci the project(Sea](144,Business and Professions Cade:)The Conaoctors Li. �g
•mac Law does not apply it)tin owner of Property who builds or improves thereon,and QTV PLUMBING PERMIT FEE \/•�' 14
who contracts for such pri with a contmctnr(s)licensed pursuant tons,Contractors
License Law' PERMIT ISSUANCE
El I am aircraft undo Sm. ,B&P C for this reason
ALTER-DRAIN&VE -WATER ILA) VALUATION
tiloncr WORKER' MPF.NSAI'IONDECLARAT10N BACK FI PRO CT.DEVICE aa—'aI hereby affairunder enoaty ofperjmy one ifrhe fallowing declaration. 0\3a
Ibaveund will mainline Cenificareof Coots.."IN...re for Workers Compco- DRAINS- F,AREA.COND. - STORIES TYPE CONSTRUCTION
workas provided for by Section 3700.(the Labor Code,for the performance of the
far which this permit is issued. FI%TVR -PER*21
❑ I have and will main ch.Worker's Cmnpenmtion Insurance,as required by Section
37M ofthe Lidur Code,for rhe performance fthe work for which this permit is issued. GAS-EA.SYSTEM-11 VTI. S OCC.GROUP AI'N
My Workers Compensation Insurance carrier and Policy another are:
Cartier: Polley No.: GAS-EA.SYSTEM-OVEN 4 HG
CERTIFICATE.Of EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEIINDUSTRL WASTE INT R
(Thisseerion neWootbecomplutetl ifthepeialt is farroe hmmdnNdollim(Sl W) RI L 1 G 1VISION FEES
nr less.) GREASE TRAP PLANCHECK F
I,sm,peromim any
rite orkfm which to
the Wierm C,.aapsil SEWER-SANITARY-STORM EA.200 FT. ty�
net employ any Berson in any manner m as to haome subject m the WmkcrF Compcn- ENERGY FEL 1 w
OZ emion laws of Culifnmia.Date
O Applicant - WATER IIFATBR WNENTNLECI'R GRADING PIVj
t7 . NOTICE TO APPLICANT.If.after making Nis Cmificut of Exemption,youshould
H 7 hecome.suhject to the Worker's Compensation provisions of te Labor Cords,
you most
WATER SYSThM/I'REATING SOILS FEE
Eforthwith comply with such previsions nr this permit shall be decnmd revoked. WATER SERVICE
CONSTRUCTION LENDING ng agency
NEN'RESIDENTIAL PLMR. SQ.FT PAID
V O (hereby offirm thin there isuconatnmiun lending agency for the perfammvnce of Dine Re ipt
{ka H the work for which this permit is lamed(Sec.3097,Civ.C.) aas
O U Lender's Nmnc - TO L:
Landers Address O
50. 1 renify that 1 have read this application and sem that the ohove information is BUILDING
h career I agree mcmrapay with an city and cnumy ordinances send slate law,relating to QTY. MECHANICAL PERMIT 17EE g
V Z, building construction.and herebyauthodzereprexrttativea ofthiscity m eructation the SEISMIC FE O
shove-mentioned property for inspection purposes. PERMIT ISSUANCE
C4 ra (We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC
Iiabilitits.judgmenrs.costs and expenses which may in any way accrue against said City ALTER OR ADD TO MI:CH. ^
i it nscqucnceof the granting of this Permit. PLUMB( .E Y
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-PAINT AIR HANDLING UNIT(TO 10,000 CFM) MECHA L E 2
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
HAZARDOUS
Signmre of ApPlicaO MATERIALS
EXHAUST'H(>nD(WNUCO HOUSING MITIGATION US
HAZARDOUS MIALS DISCLOSURE
by
fMuniipal oe,Chaptroreur handle Hmatt usmmcrial
HEATING 11NIT(TfIIW,fXO BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade.Swann 25532(e)T HEATING UNIT(OVER 100.000 BTU)
Yes ' . ❑No VENTILATION FAN(SINGLE RRSID) PAID
Dine Rwei
Will the Napplicant or ansae building occupant use equipment or devices which BOILER-COMP(3HP OR 100,000 BTU)
t hazaous airir sornmminents as defatted by the Bay Arca Air Quality Management
TOTAL:
Mao BOILER-COMP(OVER 1(0,0011 BTIO
❑Yes ❑No
I have read the hio.or s materials mquircments under Chapter 6.45 of the Cali. AIR CONDITIONER ISSUAN A
Forms Health&Safety Code,Sections 25505,35533 and 25534.I understand that if the NEW RESIDENT[At,MUCH. SQ.Fr.
h tilding does not currently hove a ten.m,that it is my responsibility m notify the occupant
of the requirements which must be met prior to ismaneu of a CeniOcme of Occupancy.
Owner or amhonzed agent Dam A : ISSUED BY
OFFICE
Inspection Query for a Specfic Permit 1/13/98
Ins egffi ' nits P.asslFall Code
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Inspection Query for a Specfic Permit 1/13/98
F ERMI,T# ,,ITUSjSTj SITUS S.T;REET Lof# INSDESCRIPT In"sT,70 DATEDESIRE. Da4aRone
30081 22560 POPPYI IGARAGE 1 1 9/18/96 9/18/96
30081 22560 IPOPPY i JSTOP WORK 1 1 10/31/96 10/31/96
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