29983 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT FEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING..MECHANICAL. 29983
BUILDING PROJECTIDENTIFICAI'ION
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMFFFALDAO
20194' STe%r=1JS GRtt-8b� (�S -Vfl- �.i 6
OWNERS NAMI�_ � _ _ � �/S �l�^���� RACTOR:S NAME: ^�6�
WNEIPP,RSN IHaI"�'wJLGeaQ^Tl a1 /4..'G�J L NIC CONTROL
ARCHITECf/ENGINEER: - LIC NO: ADDRESS: IQ(�• A.�p'�VWCap�C 1r e ❑
CONTACT: PHONE: BUILDING PERMIT INFO
��,( Nqn) "� ,5�j_f e <yjj,y"1-`Z ❑ Consultant Fees Paid by Applicant(Initial) BLDG CLF.C'I' PLUMB
LICENSED CON'FRACI'OR'S DT;CLARAHONQ'FY. ELECTRIC PERMIT FEIi
I hereby affirm that 1 am licensed under pmvwum s of chapter 9(commencing JOB DESCRIPTION
0with Section]0IX)of Division 3 of the Business and Professions Code.and my licemn,s
{�00 00 PIiRMIT ISSUANCE.
full Turco end of ,.
F<uu License Claa q �'2 LIf M -- 33� ❑S ❑PLUMBKITCHiNREMODEL
y6W Uam „�OD��(� Commnm APPLIANCES—RESIDENTIAL ❑A 10 ❑PLUMBING RE-PIPE
F7Pf ARCHIf[CTS DECLARATION PANELS ULTI-UNIT ❑STRUCTURAI,
zC) oz I understand my plans shall he used us public rcmrds MODIFICATION
OZ40` UPT0200AMPS El INTERIOR ❑CHIMNEY REPAIR
P„N,l"'41 Licensed Pr..feasinnul 2111-I(NNtAMPS IMPROVEMENT
•.1 - Oat I am exempt from
m DECLARATION., OVER I0M AMPS ❑BATH REMODEUREPAIR 0 DEMOLITION
C)YI 6 1 hereby.(firm that I am exempt from the Contractor's License Law for the
f�1(,O y U following mason.(Section ID31.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL OTHER
ta 0 N which requires a permit to construct,alter,improve,demolish,of oam,any s....am
�� prior,.its irnimal,also requires the applicant fmsuch pemtit m file a signed statement SPECIAL CIRCUIT/MISC.
a�
that he is licensed pursuant o the provisions ofthe Contractors License Law(Chapter 9 ef
O (commencing wilh Seetion 0001).1'Div inn3 oftho(Basin and Professions Cndu)m 'f EMP.MITER Olt POLE INS'I COMMERCIAL..
L y o K
that he is exempt therefrom and the be t1 for 0'c allege xemp,ion.Any violation of ❑N ITION IOLITIDN
i4f1 4•
Section 7031.5 by any applicant for. aan sth apdirma I...bil penally of POWER DEVICES
fin ,NANT FOODSERVICE,
06{{.. t Lorethan et11lop, dol x 500
01.es owner of the)rope anym •ill age>ux their sole compcnsntion. SWIMMING P001,ELECTRIC IMPROVEMENT
620 will do lM1e work;and Ne. cture ism ' We ruffered for role lScc.]0f4,Bminess [I OTHER
41 and Profession,Crede:T o License Lnw does not apply m an owner of OUTLETS—SWI"I'CHES—I'IXNNBS
L Formerly who builds or imp s't n,and who does such work himself or through
his own employees,provided N ,such improvements are n.,intended or offered for NEW RESIDENTIAL ELAE; SQ Fr.
sale.IL however,the builJingmi iprovement is sold within one year of completion,the SQ.FE FLOOR AREA S/SQ,P.
caner-builder will have the burden offorving dealbe did not build or Improve for par- t TFS1 LA 0
O
ismeof.saleJ.
L' G�3 B9
I,as owner of the prapeny,am exclusively contracting with licensed contractors to TOTAL:
rmi the project(Site 7N4,Bu.cinesx and From....in Cnde:)the C.mmcto/s Li. Q "JUL 02 1996
cams law does not apply to an owner of property who builds or improves Flown,and 9Y, PLUMBING PERMIT FEF.
who contracts for mch p bjecs with a contractor(,)licensed pursv.nuo.he Contractor's
License Law.
❑ , PERMIT ISSUANCE ( 11�,LLil I NO
Ian exempt under Sec. H&P C fur this reason CITY UE, V V
Owner Data
ALTER-DRAIN&VENT—WATER(EA) VALUATION
/�
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE /L �r-�b
Iherehy aR under penally of perjury one of the following declarations:
❑ l have and will maintain a Cenilicme of Consenun self-imur.for Worker's Conpen- DRAINS—FLOOR,RODE,AREA,COND. STDltlli5 TYPE CONSTRUCTION
swim,as provided de,for by Section 37M of the Labor Cofar 117,perfnmtancc of the
work for which this permit is issued. FIXTURES—PER TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section
] )of the Latin Code.for the performance of the work for which this permit is issued. GAS—P.A.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Worker's Cumpemation bsurelLce artier and Policy nyyyy,,��he ��������y,,,.,,,��
Carrier:�aa�W.48 a Policy No.:3� GAS—EA.SYSTEM-OVT:RY(EA)
tL-RTIPICATE OF EXEMYfION FROM WORKERS'
COMPENSATION INSURANCE. GREAMIJINDUSTRI.WASTE INTERCEPTOR
(This section need net becompleted if,he permit is parent,hundraddollars(SIM) EUILDING DIVISION FF.FS
err less.) CREASE'I RAP
I'LANCIIIiCK il?C
1certify that Flom,in any
oastwork for which this Permit is ers'CoIshall
not employ any person in any manner so asmbecome subject Workers' SEWER—SANITARY—STORM P.A.200 FT.
1 pen- ENERGY FEE
cation Lucas of Culifomia.Dm
a
z O Applicant WATER HEATER WNENT'ICLECTR GRADING FEE
Vy NOTICE TO APPLICANT:If,after making this Cmifiam of Exemption,you should WATER SYSTEMn REATING
abern mt,subject m the Worker's Grmpe...lion provisions of the Luhm Code,yon most SOILS PEE
(onhwith comply with such provisions nr lhispermil shell he Deemed revoked. WATER 111-11 ICE
0
CONSTRUCTION
mento LENDING AGENCY NEW RESIDF,NTIAI.PLMiI. SQ.FT. PAID
VQ work
which
the(themissued Ser.
307,Cis.agencyf.nhe perfamwnce of Date RecciPlM
w •+ the Landlek for which this pcnnit is issued(Sec.l(19],Civ.CJ
O F" Lender',Name TOTAL:
U Lender,e Adtlresx 'roTAL: -
Fy I rectify that l have neuritis application andstatulharthe above information is BUILDING FEE
t, to correct.I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT PEE
building construction,and hereby authorize represetuntives of this city to eater upon the SEISMIC FEE is se
above mentioned property for inspection purposes. f'ENMD'ISSUANCE
(We)agree m mtl
save,indemnify and keep N, eas the City of Copeman against ELECTRIC FEE
Iiabilitiex.judgmens,costs and expenses which may in any way accme againstsvid City ALTER OR ADD TO MECH.
in crosex uencia mthe granting of this pe reit. PLUMBING PEC
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON,POINT AIR HANDLING UNIT(O 10.000 CFM)
SOURCER„QIILATIONS. MECHANICAL FEE _
AIR HANDLING UNIT(OVER IQIXNI CFM) CONSTRUCTION TAX
gig nuZtac / /✓J ifs Daln, FXHAUS'I'HOODOYMUCf)
/
HAZARDOUS MA715�1D(SCU6/ I fOUSINGMITIGATiONPEE
HAZARDOUS MA R DSCL6SURE
WibythepylicantmfuLmiciplCode,Chaptsmrcor handlelHealih and Serial
HEATING UNIT(TO IW,011(1 BTII)
as detlned io the Cupenlno Municipal Cala Chapter 9.12,and the Henhh and Safety
Coda Section 25532(a)7 i{BATING UNIT(OVER I(Nl,(NIa B'TU) _
❑Yes *a PAID
VENTILATION FAN(SINGLE RESID) Data Receipt)
Will the upplicanl or future building Occupant use equipment or devices which UOILCRCOMP(3HP OR I W,IX10 BTU)
emit hazardous air contaminants as defined —
by the Bay Area Air Quality Management TOTAL:
District?
❑Yes 'Xi NU IiOILCR=COMP(OVER 1100,000 BTU)
I have read the hmaN.us mvtenais mquimmeme under Chapter 6.95 of the Call- AIN CONDITLONIiR - ISSUANCE DATE
fomla Health&Safety Cale,Sections 25305,25533 and 25534.1 understand thin it me NF,W RESIDENTIAL MECH. SQ.FT.
building docs nm combat,hum a tenant,than i,is my responsibility..city Ne occupant
oflhc m m tans which m®t be maa;Ph 's ce of a Cerogr c�f 0ccu ancy. 00
V, SlIk
Owe r u,Drize gem am TOTAL: ISSUED BY:
OFFICE