31413 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. w I
BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MECHANICAL -3111
BUILDING ROJEC'IIDF.NTIFICA'I'ION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DA
OWNE ME: PH( li: ACTQRSNqAMB: LIC NO:
/V A N/C CONTROL#
ARC ITECT/ENGINF.E CNO: DRESS: V ❑
- 27— O49
ACT. PHONE: BUILDING PERMIT INFO
I ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
Y ❑ ❑ ❑ ❑
LICENSED CO'NTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
Qi%Z
1 Thereby affirm that I am licensed under provisions of chapter 9(comment.ng JOB DESCRIPTION
with Section 7000)of Division 3ofthe Business and Pnsfe.vsions Codetold in,license is R -ID NTIA .
F in full force and effc f PERMIT ISSUANCE .� I�
I-UU Lmensc Co.,.# ❑ADDITI ITCHENAC�EL
yG4 Date a Cuctor APPLIANCES-kESIDENTIAL []ADDITION PLUMBING RE-PIPE
s RCHITECTS DECLARATION 11MULTI-U ❑NIT STRUCTURAL
Z p m Z 1 unJcrahind my plans.Hall be used as public records PANELS
MODIFICATION
O Z UP TO 200 AMPS
Q� 1a01 Licensed Pr.teminnul OWNER-BUILDER DECLARATION El INTERIOR CHIMNEY REPAIR
,..l4201-IIXp AMPS IMPROVEMENT
6 1 hereby affirm that 1 am exempt from the Contractor's License Law for the OVER 1000AMPS ❑BATH REMODEL/REPAIR ❑DEMOLITION
a'O Wy U following reason,(Section 7031.5.Business and Profecsiuns CsNc Any any Or county SIGNS ELECTRICAL HER
3 W b- which requires a Permit to construct,alter,improve,demolish,or repair any.someone
tEto prior to its lssuince,also requires the applicant for such permit o file a signed statement SPECIAL CIRCUEDMISC.
that he is licensed pursuant 1. he pn,oionsof the Cummctor',License Law(Chapter 9 Ic-ol
W1'�0 (commencing with Section 7000)of Division 3ofthe BusicOmdPmfes,mns C.de)or TEMP.METER OR POLEINST. COMMERCIAL'
a e than be is exempt therefrom and the bassi,fur the alleged exemption.Any violation of
W LL Section 703 L5 by any applicant fora ❑NEW BLDG/ADDITION [I DEMOLITION
W,may permit subjects the applicant penalty of POWER DEVICES
not more than five hundred dollars(ESW). ❑TENANT ❑FOOD SERVICE
❑I,as owner of the propeny,or my employees with wage.vas their sale compensation. SWIMMING POOL ELECTRIC s/ IMPROVEMENT
as
l-cawilldothe work,oadthexvaaureisnot intended or offered forsole(Sec.70H4,Business ❑OTHER
L3 and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
pmpeny who builds or improves mereon,and who does.such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELEC R Q
sale.If,however,the building or improvement is sold within one year ofecmpletion.the SQ.1`17.FLOOR AREA E/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for put,
pose msole.).
11 1,as Owner Of the progeny,am exclusively contracting with licensed contmmo,to TOTAL:
construct the project(Sec.7014.Business and Rofessions Calc:)The Coneactors Li-
ill Mkt�;
censeLaw nine,not apply man"-act.fmopeny no,builds or improve,thereon.aid QTY PLUMBING PERMIT FEE
whocontmets torsion projects with a commissions)licensed pursuant m the Comtmctnr's
License Laws.
[:] PERMIT ISSUANCE HS A r
1 am exempt under Sec. ,11&P C fur this reason Ir
•Owner Date
ALTER-DRAIN&VENT-WATER(EA)
VALUATION
WORKER SCOMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE NOV 061996
1 hereby affirmm under
er Penalty of ry M
perjuone of the following dedications
❑I haveand will mainmind Certificate ofCOmcnt t.self-insure Bn Wakcr'SCompen- DRAINS-FLOOR,ROOF.AREA.COND.
cation,as pmoidN for by Section 37M of me Labra Code,for the performance of the STQRICC$ TYFI-gpNSTHUCfIO
work forwhich o1ok,ermir is fooled. FI%TURES-PER TRAP Vllr Uf- VV tnlfl\V
E)I have and will m.inmin 'ricers Compensation In.wmnce,as required by Section
3)00.1 lhelrbm Coda LLr a fthe work for whim this pemdt is issued. GAS-EA.SYSTEM-1 INC.40 ETS
My'A Compen. nurgmrcanerrand Policy h _ OCC.GROUP APN
Coria' Policy No: GAS-__GAS -OVER4 ,A)
CI!kTthlC 'TE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRF,ASFJINDUSTRL WA INTERCEPTOR
or les,,)
(Ibis section need not he completed tithe permit is foronc hundreddollars($100) GREASE TRAP BUILDING DIVISION FEES
PLANCHECK FEE
Icenify mat.the anynmmo,o,the wmkfor which mis Permit isirsuN,lshull SEWER-SANITA -STORM EA.200 FT.
not employ any person iany mnnnen"as m hecane subject m the Wnrkeri Compcn-
F,NERGY FEE
O Z ration Laws of California,aData WATER HEAT WNVF IELECfR
O Applicant
Z
N
NOTICE TO APPLICANT:If,aper making this Ccnificme of Exert tion,you should GRADING PEE
a � become subject to the Werkees Com p WATERSY libf/TREATING
peor this
previsions of the Labor Code,you moa SOILS FEE
forthwith comply with.each provisi.n..or this permit shell M deemed revoked.
Lk1 Q
WATER :RVICE
0.
OZ CONSTRUCTION LENDING AGENCY NEW ESIDENTIALPLMH. SQ,FT. PAID
U work
by which
Ou cane isadScqconstruction30 lending agency for the ped'omunre of Data keceiprN
U the work far which Nis pcmtir,i,issued(Sec.31197,Civ,Cd
Lender's Name
O V Leaders Address TOTAL:
F0.Wi I certify that I base read this application and state that the above mbar ation is TOTAL:roBUILDING FEE
h career.l agree m comply with all city and county ordinances and shite laws relating to QTry, MECHANICAL PERMIT FEE
V Z building nswctum.snit hereb,mahonu reptenemariven of Nis cirym cmempontbc SEISMIC FEE
.hove-mentioned property for inspection purposes. PERMIT ISSUANCE
(We).gree m lava,indemnify and keep barnless rti
the City Of Cupeno against ELECTRIC IEE
Iiobilities,pdgmenu,antisocial expenses which may in any way acemeagainstsaid City ALTER OR ADD TO MECH.
in consequence of the grunting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IQOW CFM)
SOURCE REGULATIONS. MECHANICAL PEE
AIR HANDLING UNIT(OVER IQIKKI CFMI CONSTRUCTION TA%
Sign.mre of Applicam/COmmetor Data EXHAUST HOOD(W/DUC17
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATI FEE
Will Reapplication or future building acu,.,,,rc m handle hmatdous material HEATING UNIT(TO 100,000 BTU
as defined by the Cupamin,Municipal Come,Chapter 9.12,and the Health and Safety
Cade.Smion 25532(x17 HEATING UNIT GVHR I(X), BTI)
C]Yes ❑No
VENTILATION FAN IS LP.R6SID) PAN /
Will the applicant or future building effed h,on,B y A equipment Or devices which ate Receipt N
emir hneaNnus air conmminum,as tlefineJ by the Bay Arta Air Quality Managemem BOILER-COMP POR 100.000 BTU)
District'.
❑Yes ❑No BOILER-C P(OVER 100,000 BTU) TOTAL.
47 X
I have read the bearable,materials requimmenn under Chapter 6.95 of the Cali- AIRCO ITIONER —�
forma Health&Safety Cole.Sections 25505.25533 amt 25534.1 understand that if the ISSUANCE DATE
building does not currently have a tenant,that it is my msponnibiliry to notify the oveapanr N' RESIDENTIAL MECH, SQ,IT.
Of the ost,immenu which must be met prior to issuance of a Cenificate Of Occupancy.
Owner or amhorued agent pate TOTAL: ISSUED HV:
OFFICE