29931 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. �J V V 1-
BUILD7�:DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 231
LJ a9
pU11.DING PROJFC r IDPNI'IFICA'1'ION
BUILDINGADDRESS: /� SANITARY NO. APPLICATION SUBMITTAL DATE
OW 13RNN Mi: Q/ PHONE: CO AI R'S NA c /'t LIC NO:
L NIC CONTROL#
Ai
�sRCHI ECTMNGINLIC NO: ADD ESS
7 : l / El
coNTACD PHONE: /✓Pl_!-L ggz?La BUILDING PERMIT INFO
�� � ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
�S -35-3--35-3-a 9'Y 3
LIC(INS ED CONTRAC'TOR'S DECLARATION QTY. ELECTRIC PERMIT FEE ❑ Y�
1 hereby effmn ohm I am IicursW under provisions of Chapter 9(cmnmencing JON DESCRIPTION
OcC) with Section 40ME a(Division3 ofthe Business and Prafessious Codc,and my license is '
W p _ PERMIT ISSUANCE RESIDENTIAL'
I full force veld effect
�g.UU� Liaeme Class Lic.N IEIADWI. ❑KITCHEN REMODEL
E
NQ Dem Contractor APPLIANCES—RBSIDENTIAI.
Z ❑ADDITION �'1'LHMBING RE-PIPE
E..7h '11A HITECI'S DECLA ATI PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z Z y'ZZ I understand my plans shall he used as public records MODIFICATION
O
:JJ UPM200AMPS ❑INTERIOR El CHIMNEY REPAIR
5�RLicensed Pmfexsinnnl 201-10MAMPS µms` -
X OWNER-BUILDERDEthe Com ION OVER 10(X1 AMPS BATH IIF.# DEU> REPAI D- 10ITION
y 1 hereby affirm Ism I am exempt Tann the Conan$ is License Law for the
$d 06 U following rtit (Section IDBS.Business and Professions Gyle:Any city or nmmY SIGNS ELECIRICAI. ❑OTHER - 0 '
tri LL C{'2 which1n;isrequires n permit re conswn,al¢e ht far
demolish,or c3 ogrely statement
�� CYI 1
.a7 primmiB issuance,also rtquires the opplicamfor such permiunfilea signed stammem SI'IiCIAL CIRCUIT/MISC.
Qthat he is IicenuJ pursuant es the pmvimotn of the Cnmmcmrs License Urw(Chapter 9
DO (commencing with Secdnn 9f100)nf Uivisinn3afthe Business and Pmlessinns Cndo)or TEMP MBI'IiR OR POLE INST.
that he is exempt therefrom and the basis Write alleged ascap him.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLT ION
Section 7031.5 by any applicant for a permit subjects the applicant to a civil pettaltyaf POWER DIiVICES
j
But marc than live hundred dollars($500). ❑TENANT ❑P DSE iVICE
� Q Lnsownerofthe IMPROVEMENT
Q ❑ propeny,onnyemntended with for sale
Dili Business
SWIMMING POOI.ELECT RIC
will dothework,and no he Cmi isnot imm�dcreona.dosotsale(Sec.to a Business OTHNR
�' and Professions ids or improves
Contractor's License Law anus nal apply to if owner of OUTLETS—$WITCHES T E.S
propeny who builds or improves thereon,and who arcs such work deed of orthroughf
his own however
rcth presided that such improvements are not intended or catered for NEW RESIDISNTIAI til- SQ IW.
s
sale.ILhowar,dI once
bmdnofp...im issoldwithin one ild iui nmplctput the SV.ff.FLOOR ART iA $/SQ.FT,
erhailder will have the harden of proving Ont he did nal huilAmimprove tispelt- w
Pase of sale.).
L as owner of the propeny,am exclusively contracting with licensed conrazma,m
onmmn the Fmject(Seo,9014,Husineax rout Professions Cala)The Cnnaomnr's Li-
censs Law does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PER IT FE
who comracu for such projects with a comraaoKs)licensed pursuant man,Contractors
License Law. PI7RMIT ISSUANCE
E]I.n exde
empt unr Sec. ,B&P C for this ransom
Owner Date -
ALTER—DRAIN&VENT—WATER HEA) VALUATION
WORKER'S COMPENSATION DIICLARA'I']ON BACK FLOW PRO1'ECE DEVICE Lssy �
1 hereby nation under penalty of perjury one of the following dccli mtiosm:
I have and will maintain m Certificate of Consenuo self-insure for Workma Corrupter- DRAINS—[;LOOK,ROOF.AREA,GOND, STORIES TYPE CONSTRUCTION
umioo,as provided for by Section 9700 of the Labor Code,lir the Part nrntance of the
work for which this permit is issued. FIXTURES—PER TRAP
1 have and will maintain Workers Compensation Insurance,as required by Section
900 uI the Labor Codgfords,performance of the work for which this permit is Issued. GAS—EA.SYSTEM-I INC.Y OUTLETS OCC.GROUP APN
My Wmrke nMmiay�+tsumnc emm
cr and Policy number e:
Carrier •T 17 ��f Policy No.: GAS—EA.SYSTEM-OVER 4(EA)
1ERT_I1 ICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRI.WASTE INTERCEPTOR
( s section need not be completed if the permit is forone hundred dollars(SIM) BUILDING DIVISION FEES
nr less)ThiGREASE TRAP PLANCHF.CK FEE r7Z 45C
I certify that in the performance ofthe work for which this permit is issued,l shall SEWER—SANITARY—STORM GA.2110 PT.
not employ any person in any manner so as to became subject m the Wmkcrs'Cumpcn- ENERGY FEE
Ozsntion Laws of C.lifomis.Data WATER HI7ATER W/VENT/ELECfR
Z O Applicant GRADING FEE
y NOTICE TO APPLICANT:If.after m.king this Certificate of Exemption,you should WATER SYSTEM/TREATING
become subject rude s LhWorkers Contpecoomn pmviout of the ebur ou mst SOILS EEE Coda,yu
W tti forthwith comply wilhnuch Fre isians or this permit xindl be decnmdmvoke4. WATER SE RV ICP. _
Q
z .CONSTRUCTION LENDING AGENCY NfW RFSIDENf1A.PLMBSQ.FT.
PAID
U O Iherehy affirm that them isoconsvuminn leding agency for the perormncoof
Dom Rcaipt#
H. F the work far which this permit is issued(Sec.3097,Civ.CJ
O U Lenders Name TOTAL:
Lender's Address TOTAL:
1 1 certify that 1 have read this application and state that the above infonnmian is BUILDING FEE
V) correct.l agree it)comply with all city and county ordinances and state laws relating m QTY, MECHANICAL PERMIT FEC
U building construction,and hereby authorize representatives of this city as enter urym the SEISMIC FEE I'
abovemmntioned propeny for inspection purposes. < PERMIT ISSUANCE
(We)agree m Vice,indemnify and keep hamtless one City of Cupertino against ELECTRIC FEE
liabilities.judgments.costs and expanses which may in any way starve against said City , ALTER OR ADD TO MECH. PLUMBING FEE
in ennsequence of the gaming of this permit.
APPL NT ON .RSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL FEE
50 C RF.G TIONS.
AIR HANDLINGUNI'I'(OVER 10.030CFM) CONSTRDCTIDN TAX
Signature of Applicant/ antras m EXHAUST 11001)(W/DUCT)
HAZARDOUS MX[FRIALS DISCLOSUREHOUSING MITIGATION FEG
-
WilltheapplicantoffuturebuildingoccupantscoreorhandlehamNousmaterial H13AI INC,UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Calc,Chapter 9.12,and the Health and Safety
Coda,Section 25532(x19 HFATING UNIT(OVER 100,000 BTU)
C Yes ❑Nn PAID
VENTILATION PAN(SINGLE RPSID)
Will the applicant or future building occupant um equipolml or device.,which Date Receipt#
I
hazeN...nit contaminants us defined by the Buy Are.Air Quality Management I30H.ER-COMP(3HP OR 00,000131U)
TO AL:
DisWn9
Yes EI No BOILER—COME(OVER 100,000 BTU)
I have dead the hmerdous materialsAIR CONDITIONER
requirements under Chapter 6.93 office Cali- ISSUANCE DATE
fomia Health&Safety Gavle.Sections 25505,25533 and 25511.1 understand that if rhe NEW RESIDENTIAL MECH, SQ.FT.
building does not currently have a noun.that it is my re,onsihillty to notify the occupant
of the rquirencm s which must be cosponsor to ismance of a Certificate of Oceupancy. _
Ownemmmutharized engem Data TOTAL: ISSUED BY:
OFFICE
Inspection Query fora Specfic Permit 1/16/97
' PERMIT# SITUS ST SITUS STREET Lot# INSDESCRIPT IneT a DATEDESIRED DateDone
29931 22639 ISAN JUAN RD HOLD DOWNS 9/4/96 9/4/96
29931 22639 SAN JUAN RD SHR NAIL 9/9/96 9/9/96
29931 22639 SAN JUAN RD DRYWALL NAIL 9/10/96
29931 22639 SAN JUAN RD HOLD DOWNS 9/16/96 9/16/96
29931 22639 SAN JUAN RD BEAM FRAME 9/9/96 9/9/96
29931 22639 SAN JUAN RD HOLDDWNS/SHEA 9/27/96 9/27/96
29931 22639 SAN JUAN RD SHEAR NAIL 10/1/96
29931 22639 SAN JUAN RD DRYWALL NAIL 10/2/96
29931 22639 SAN JUAN RD FOUND.PRE-POUR 10/15/96
29931 22639 SAN JUAN RD LATH 10/23/96
29931 22639 SAN JUAN RD ISCRATCH COAT 10/29/96 10/29/96
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Inspection Query for a Specfic Permit 1/16/97
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Inspector Units Pass/Feil Code
CC 2P
AD 2P
AD 2P
JS 4P
AD 2F
AD 2P
AD 3P
CC 2P
JS 4P
AD 2P
AD 2P
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