30128 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES USE BALLPOINT PEN ONLY
CITY OF CUPERTINO ' BUILDING-ELECTRICAL. ., 3 PERMI"f NO. ^ 0 a�
BUILDING DIVISION APPI,ICATION/PF,RMIT PLUMBING-MECHANICAL - JK .IL L�XJ
RUILDING PRfkJEC'T IDENTIFICATION
BUILDING ADDRESS: Vwt -LO1 SANITARY NO. APPLICA'T'ION SUBMITTAL DATE
;21 3o Sf•� ` 's if Bl vD Cu f..n o -cA 1to II+ Z 46
OWNE 'S NAME: PHONE: /! CONTACTORS E: LIC NO
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NIC12
HITECT/ENGINEER' ' LIC NO:_ • ADDRESS:
(�
" CONTACT: ._ ` PHONE: /-- /k BUILDING PERMIT INTO •
Consultant Fecs Paid by Applicant(initial) BLDG ELECT"' PLUMB MECH
408- ❑ ❑
LICENSED CONTRACTOR'S DECLARATION —
QTY. ELECTRIC PERMIT FET?
1 hereby amrm and 1 am li[cnuJ under provisions of Chapel 9(commencing JOB UESCRII''PION '
woo wMWZith Seatien70(Xrof Divis,m3gflhe Bucirwomad Pnffessin is Cale.al]dl]ry licemc is RESIDENTIAL,
•F41� in fall force and effect. PERMIT ISSUANCE ❑SIrUW), '[3 KITCHEN REMODEL
�UZtJ License Class Contractor
- APPLIANCES-RESIDENTIAL ❑ADDITION [D PLUMBING RF,-PIPE
Q li Dme T'S DEC +
F O m
ARCHITECT'S DECLARATION - ❑MULTLUNIT ❑STRU&RAL
yy PANIiLS
ZOtnF lundersmnd my plans shall be used us public recoN.v �� X-� MODIFICATION
OZr--Q - UPT02WAMPS I J[1 INTERIOR ❑CHIMNEY REPAIR
hicenud lhofcssionul 21161 WOAMPS ,`IMPROVEMIiNT'
Ih OWNER-BUILDER DEthe Com ice OVER 1000AMPS ❑BATH RE.MODEUREPAIR DEMOLITION s
(yj a 1 hereby affirm that 1 on exempt from the Commctnr's License Law for the
x3 G.U follow n8 lea (S r ]IIJI S B J P f. C d A Yty r e nmty SIGNS ELECTRICAL ❑OTHER
F y O which acquiresm perI I urear,der, p denwhim.or repair an, sea ours,
qq
prior to its Nournee.also requirestire apphromf hI rmnl filea ngte maurrocl]l SPECIAL CIRCUIT/MISC.
2thill .t he slcelicensed II m p s fth C ntract s1'cen La (Chapter 9 -
W O� (nom 6 th5 do--,"Of Doomed tftheB .' ea dP t Code)er TEMP.btftER OR POLL INSr. COMMERCIAL, -
6 y m y
that hens exempt therefrom and the Mvsis f rr the alleged exemption Any violation of ❑ EW BLDGIADDITION ❑DEMOLITION'-
4X1 R S¢nce701I,S by any appli[antfor a permitsubjects theappli[anuoacivil penalyof POWER DEV HS �y
^'m IJ(1'ENANT ❑FOOD SERVICE
6ZP not more than five bundle]Dollars($SIVA. MPROVEMENT '
p0 ❑1,as owner of Ne progeny,or my employees with wegesmtheir sole compensation, SWIMMING POOL ELECTRIC '
$$y'''GG••.. wIII J6lhc work,avd the suumure is not lmm�ded oroffncd for Hale(Sec.]044,Businoss O'PHER
•4,3 and Profusions CMe:The Conceives License Law does but apply to an owner of OUTLETS-SWI TCHES-FIX111RES
.. propeny who builds or improves throw,and who docs,such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIUEN'I'IAL ELECTR SQ FT..
sale.IL however,she building or improvement is sold within one yearof completian,me SQ,FT FLUOR AREA -62SQ,F1'.
nfaow nor-build'r will hove the harden of proving mm he JiJ nm build or improve for pur- A q
sale ia] U
[:11,m owner of the,notai ty,con exclusively uul]marin,with licensed conlmnnrs to TOTAL:
e mevum me projat(Sec.70Y1.Business had Prefessinm Axle:)The Contract x Li- �/ q '
Li-
close Law docs not apply In an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE JVt 021996 -
" whnconmcks fnrsoch projects wirhacomrear,o)licensed punuanTtothc Comainu . !s[I� JJ
Licenu law. PERMIT ISSUANCE t✓ U1,
Cl 1 all]exempt under Sec. ,B&P C f or This reason (+(]parry J
Owner Dam ALTER-DRAIN&VENT-WATER IEA) Vp1.UA'GON
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
�r. I hereby affirm under penalty of perjury one of the following declumno re . .
Q Ihave and will amemalna Cenlf,menf Consent t rualf-insure far Worker's Compem DRAINS-FLOOR,ROOF,AREA,COND, -
station,as provided per by Section 3]00 of the Labor Code,for me Performance of the STORIES 9'YPECONSTRUCTION
work for which(his permit is Issued. u FIXTURES-PER TRAP,','
❑ 1 have and will mnivmin Workers Compensesion Insurance,as rtquiresl by Section
3]00o1'rhe Luber Coda,fill the perfnnnunwnllhe work for which this pertl]h is lashed. GAS-EA.SYSTEM-1 INC.4OUTLETS - OCC GROUT'- AI'N
My Workers Compensation Insurance carrier and Policy number mc: , ,
Cartier: Policy No, GAS-EA.SYSTEM-OVER 4(EA) '
CERTIFICA'T'E OF EXEMPTION FROM WORKERS'. _ " '
COMPENSATION INSURANCE GREASMNDUSTRLWASTE INTERCEPIUR
(Thi...liver need nor he emntplet d Hoc permit is(anion hundred toll.s IIID) BURDIN(1 DIVISION FEES
or less.) GREASH.TRAP
PLANCHECKFEE
Irenify thrpersa the anycrperformanceto a,,he workfor wdijov,cla .,he jt is okers ed,I shallCmapr. SEWER-SANITARY-STORM EA,200 FL
not employ any person in any manner m us m become subj«t ro me Workers'Compen- ENERGY FIiF. r
0 z sarms Lows et Callfomia.Dme WATER HEATER W/VENTdiLEC'FR -
O Applicant GRADING FES
Z! NOTICE TO APPLICANp.If,after making this Certificate of Exatnption,you should WATER SYSTEM?REATING
a5" become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
W foMwull comply with such provisions onM1is pesoulball he deemed revoked. Wq'IER SIiRVICP.
Q
7z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Fr. PAID
U 0 l herehy affirm that thereis a construction lending agency for the Performanceof Date Receipt#'
the work for which shin p[mir is issued(Sec.]119],Civ.CJ
V., E"' Lenders Name TOTAL:
LU LmdaeAddress - TOTAL:
(, I certify mm 1 have read this application and state than the above information is ' BUILDING FET? k
Zt camera.I agree m comply withal)city and wunty onlimmeas and ,are I....cludng in Qq-Y MECHAN[CAL PERMIT Fit-E, -
U z building construction.and hereby amhorize representatives of this city to enter upon me SEISMIC FEE
xhove<l]emtioned Profanity for inspection purposes.
' (We)agree to save,indemnify and keep harmless the City of Cupenine against PERMIT ISSUANCE, ELECTRIC PES
liabilities,judgments,coses and expenses which may in any way accrue against said City g1.TER OR AUU TO MECH. '
in consequence of the granting of this permit. PLUMBING FER
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT At R HANDLING UNIT 10.000 CEAU '
SOURCE RIiGULATIONS, MC:CHANICAL FEE -
AIR HANDLING UND(OVER 10.00)CFM) - CONSTRUCTIONTAX
Signal..of Appli[am(Comregof - Dam EXHAUSTHOOD(W/DUCT) HOUSING MITIGATION FEE s
HAZARDOUS MATERIALS DISCLOSURE
•" ' Will Recoilieam errmme Wildinguccupumwmre nr handle moundous muterlal HF.A'1'ING UNI'I'(TO 100,004)BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety '
Code,Section 25532001 /// - HEATING UbEf oOVER 100,1100 BTU)
❑Yes l I]B Nn VENTILATION FAN(SINGLERESIU) PAID
.Date Receipt p
Will me applicant or future building by the Bl am m Air Qu or devices which 'BOILER-COMP(JHP OR 100,110(1 BTU)
,rib i al?. ns air contaminates m defined by the Buy Arm Air Quality Management TOTAL:
DlsafCl" ,. -
❑Yes BOILER-COME(OVSR 1011,0001 B'Tlp. -
I have read the hmardom materials requirements under Chapter 6.95 of me Cali- Alli CONUI'1'IONEk
9 a _ ISSUANCE DATE
-a folio Health&Safety Calc,Sections 8505,255]3 and 25534.1 rmdasmnd that if the NEW RESIDENTIAL MECII. SQ.ET.
building loesnotc mn0yhnvenmrria"Iatt ismym%ponsibilitytonodfyrheoccupal]i
film rcyulrmyulr/ dwhldlmus roes fa Cenifi3cam7opQss pancy, +
' Orman d ear � �T/'m TOTAL:
4 g ISSUED ItY!
OFFICE