30425 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 3 0 4 2
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANI'T'ARY NO. APPLICATION SUBMITTAL DA'
A-71 S`GL.Cf l af_J 0 10 0 W N
OWNER'S NAME: 'PHONE: 2 CONTRACTOR'S NAME: LIC NO:
ZJ 7J n'/C CONTROL#
�4RCHITECT/ENGINEHR: LIC NO: ADDRESS: ❑
CONTACT: PHONE: C1 Consultant
PERMIT INFO
Consultant Fees Paid By Applicant(Initial) BLDG 5 ELECT/ PLUMB MECH Ate- El �f� ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of chapter 9(contmeoving JOB DESCRIPTION
WOOxith Section 7000;m Division 3 fthe Btsinessond Prafeomm,Code,and my license is
'n full force and effect. PERMIT ISSUANCE RESIDENTIAL'
F
GU�j Liceoe Class Lic.N DSFDWL D KTICHEN REMODEI
1FZW Date Commemr APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RIi-PIPIe
Fdt ARCHITECTS DECLARATION PANELS EI MULTI-UNIT El STRUCTURAL
zc),z I understand my plonssholl be used as pideic records MODIFICATION
OZ- 0 UPTO 200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
Licensed Pafe"emeol DER 201-1030AMPS IMPROVEMENT
OW NE
C�Q I hereby affirm that 1 amm exempt DECLARATION from the Contractor Licensa Law for the OVER IOW AMPS ❑BATH RF.MODIiVREPAIR D DEh101,IT10N
X6XOiU following reason.(Seetion]03L5,Businc,,.dd Rol'cssions Cde:Any city or county SIGNS ELECTRICAL DOTHER
W 3 vFi which deputies a permit in construe,short,improve,demolish,or repair any smmetmc
prior to its issuance,also requites the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISE.
[list he is licensed pursuant 10 the pmviasms of the Contractor License Law(Chapter 9
Iy rYpO (rommcncing with$xtion]011(O of Division)of the Business and Profeal...Unkfor TEMP.METER OR DOLE INST. , '
dM m rG that he is exempt therefrom and the basis for the alleged exemption.Any violation of D NEW BLDG/AUDITION D DEMOLITION
uXl o,, Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of POWER DEVICES
�' nm more Nan five hundred dollars($50%
DTENANT El FOOD SERVICE
f=0 Dl,as owner of the progeny,or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
F. will do the work,add theebdeture is not inteadedoroflbred forsuie(Sm.](W4,Bu...
ew DOTHER
W sod Profession on
Code:The Contractors License Law docs not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property whit builds m Improves thereon,and who docs such work himself m Rough 1110
his own employees,provided that such improvemeres are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.IL however,the building or improvement is sold within one year ofcompletion,the SQ.FT.FLOOR ARBA $/SQ.FT.
peccr-builder will have the burden of proving that he did not build or improve for par-
of sale). 3
Dl,as owner of the prnpeny,am exclusively contracting with licensed contrecmrs a TOTAL
mama (14
. AUG6 bb 7 1996
the project(Sm.] 4,Business and Professions Code:)To,Contractor's Li-
seLaw does and apply to an owner of Property who buildN,or lnmproms memo.,and QTY. PLUMBING PERMIT FEE
who summer%for such projects with a morticians)licensed punuanno the Cootmaod
License Law. PERMIT ISSUANCE Gill I lit- k)ur L-ft:BtJ
IV,am exempt under Sec. ,B&P Cforthiseeason
ALTER-DRAIN&VENT-WATER(LA)
52
Owner. Date - VALUATION
WOR KER'S COM PENSATION DECLARATION BACK FLOW PROTECT.DEVICE
• coy affirm under penalty of perjury one of the following declarations: nP�NC5HECKME I havcand will mainmit.Certificate ofConsent to self-insure for Worker's Comped- DRAINS-FLOOR,ROOF,AREA,COND. TYPEcation,as provided for by Section 3]00 of the Labnf Coda for the perfrmance of thework for which this Perin is issued. FIXTURES-PER TRAP1 havesud will maintain Worker's Conmpensation Insurance,as required by Section37Mafthe laborCode,for the performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS My Workers Compensation Insurance carrier and Policy number are:Cmricr: Policy No: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMP ION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
(This section need nor to,completed if[he permit is fur one hundred dollars IS IW) ING DIVISION FEES
or IessJ CREASETRAP1cenifythat inthe performance ophework fmwhich thispermit is issued,I shall
not employ any person in any daramso as to beconmesub/ano the WorkersComport- SEWER-SANITARY-STORM EA.200 FT.
Z sation laws Of California.Date ENERGY TEG
Z O A Applicant WATER HEATER WNENT/ELEC
Z r FP B GRADING FEE
y NOTICE TOct1.tiCAN:If,Co making this Cixions f of Exemption,You should WATER SYSTEM/TREATING
a ? become subject y it Worker's Compensation this Permit
of the Labor Code,you must SOILS FEE
tTl fonhwimh comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
d
Uz CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL YLMB. SQ,FT. PAID
U O IM1r,by which
firm that Nerd isacnnsweti30 lending agency lonM1e performance of Date Receiptp
� H rhe work fur,which tis permit is issue)(Sec.3119],Civ.C.)
Lenders Name
0 U TOTAL:
HIZI LendeLI Address TOTAL:
Rr 1 cenify That I have read This application and slurs that We above information is BUILDING HE
Tq correct.l agree m comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
UZ building conduction.and hereby authorize representatives of threity toenterupon the SEISMIC FEE
above-mentioned property far inspection purpsws.
(We)agnee m save,indemnify and keep harmless the City Of Cupertin.against PERMIT ISSUANCE ELECTRIC FEE
liabilieco.judgments.costs and expenses which may in any way accrue against said City ALTER OR ADO TO MECH.
in consequence of the granting of this peril PLUMBING HE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO H1000 CFM)
SOURCE REGULATIONS. MECHANICAL FF.12
AIR HANDLING UNIT(OVER Ig000 CFM) CONSTRUCTION TAX
Signature ofApplicanVCo rommr Date EXHAUST HOOD(W/DUCTT MOUSING MITIGATION FEE
MATERIALS DISCLOSURE
Will the applicant or future building Occupant start or handle hazardous material HEATING UNIT(110 I10I.000 BTU)
as defined by he CupertinO Mmdcipal Code.Chapter 9.12,and the Health and Safety
Code.Section 25532(¢)? HEATING UNIT'(OVER 100,000 BTU)
❑Yes No
VENTILATION FAN(SINGLE.RESID) PAID
Will the applicant or future building Occupant use equipment or devices which Dam Receipt Y
emit hmatdous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU)
District?
TOTAL.
D Yea DNO BOILER-COMP(OVER 100.000 BTU)
I have read he hiaardous noomds rcquimcanatx under Chapter 6.95 of the Cali- AIR CONDITIONER
Ronnie Health&Safety Code,Sections 25505,25533 and 25534.1 mdemmnd that if the ISSUANCE DATE
building does rtutmonallly have summit.that i[is my responsibility mnmify the Occupant NEW RESIDENTIAL MECH. SQ.FT.
ofthe Oquirenmoms which ins[be mit prior m issuance urn Certificate of Cmupency.
Owner or mthorired agent Date TOTAL: 1
ISSUED BY:
OFFICE