30396 (2) APPLICANTTO FILL IN INFORMATION WITHIN RE S-USE BALL POINT PEN ONLY f 40e S
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO. 3 0 3 9 6
BUILDING DIVISION APPLICATIONIFERJVNT PLUMBING-MECHANICAL J J
BUILDING PROJECF IDENTIFICATION
BUILDING AUU
UILDINIUUSANITARY NO. • APPLICATION SUBMITTAL DATI
O R`�Ejt.,, „ xiss,i PHONI?: CUNRACfOR'S NA �.. VIC NO: NIC CONTROLM
ARCHITECDENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONII, •' BU1I.DING PERMIT iNFG
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECN
❑ ❑ ❑
' LICENSF,DCONTRAC'POR'SDECL.A ION QTY ELECTRIC PERMIT FEE
1 hereby aRirrn that 1 am licensed under provisions of apter 9(commencing JOB DESCRIPTION
yyD1 00 with Section7000)of Division Sof me Ehimmex,tnd y Pmfcssi...C e,andanlicenxeis RESIDENTIAL
F�� in full brce.nl effect.. PERMIT ISSUANCE
�UV License Class Lick - CSPDWI, CKITCHENREMODEL
h6L Dale Contractor APPLIANCES-RESIDENTIAL. ❑ADDITION CPLUMBING RE-PIPE:
ARCHITECTS DECLARATION PANELS
g v2j-4 MULTI-UNIT CSTRUCI ATIO
Oz=1, IundeamnJ my plans shall hissed a..public mcoNs MODIFICATION
:7 UP T02110 AMP9
r,�,E.WLiansW Professional )CNF
IERIOR CCHIMNIiY REPAIR-� 201-IINNIAMPS � IMPROVEMENT
OWNE&BUILDER DECLARATION
I hereby affirm that 1 am exempt font the Contactors Liccnse Law for she OVER I"AMPS Q BATH REMODF.UREPAIR C:1 DEMOLITION
id a 6 F following reason.(Section 7031,5,Business and Professions Cade:Any city or coonlySIGNS ELECTRIC
[-1OTHERLLa1l V• which requires a permit to construct.alter,improve,demolish,or repair any nlrucwre'
1-=0 poor to its issuance,also require,the applicant for such pend”.file.signed statement
gn SPECIAL CIRCUIT' ISC.
} that he is licensed pursuant to the provisions of she Contractors License I-w(a.pIt
GCa (commencing with Section 78(10)of Division 3 afshe Business and Parfessime,Centaur MH METER OR fY)LF.IN ST, COMMERCIAL:
F mshot he Is exempt themfrom and the hasis for the.Ileged exemption.Any violinion of
I N Scene.7031.5 by any applicant for a Noinit subjects the applicant to a civil penalty of PO -R DEVICES C NEW BLDG/ADDITION C DEMOLITION -
I..Z t more than five hundred dollar,f$5W). C7ENgNT. CFGGD SERVICE
OI,as owncndthe pmpcny,or my employees with wages as their side atropensmi.n, SWIMM GPOOLELECIRICsct IMPROVEMENT
will do the war',and the stucmre is oat intended m aliened fimsale(Sea.7044,liusiness ❑OTHBR
6'3 m uad Pmfcsuixns Code:The Comracmr's License Late does not apply to an owner or OUTLETS-. ITCHES-FIX'fIJRES
^ property who build.,.,improves thereon,and who dos such work homelier through
his own employers;pravidcd that such improvements are not intended cr.1fe ed far NEW RESIDE L ELECIR SQ ET.
sal..If.however,the buildiagmionawc,mrra is sold within one year ofenmple ion,the - Q a.FLOOR AREA $/SQ.FT.
ownN
er-builder will have the huen or proving that he did not build or improve lin par- - C-- k LJ
pose of sale.).
El I,as owner of an,property,am exclusively onameting with licensed cam ll to TOTAL:
construct Ne Project(Sec.7W,Business and Professions CWC:)The Contactors Li- 1996
acro Law docs not apply a,nn owner of proporty who hui Ids or improves thereon,and QTY, PLUMBING P; MIT FEE 1�7 D
whoeommas forsuch poicas with acmntmcmr(s)licensed pursuant tothe Coulaetors SeCil v' ;
License Law. FERMI SUANCE UI• l+U,`Crllll
lam exempt under a; Bg+P21=FhQ.Of� ; U
ALTER-DRAIN&VENT-WAFER(E
all pure VALUATION
WORKER'S COMPENSATION DECLARATIO sued iRA!'1R;MW0P-%OTECrf%PJIJ�L'1sti0n
I hereby affirm under penalty of perjury one of the fal.win I tions:(
t )",
I have and will maintain a Cenificale ofComentto self-insure to r '1csGPl' ;Ae;; /aR INS)4 PC{IDR,ROOF,AREA,IC
sa0in,as provided for by Section 3700 of the Labor Code,for rho •rfonnunee cf.1ht, - STORIES TYPE CONSTRUCTION
work for which this perrnii is ismed. FeS--pQn Csl+'f',�' 1=FIXT[{IfER-PBR'1'rHP= r
❑1 have and will maintain Workers Compensation Insurance,as re said h.Semon
37M ofthe labor Code,for the performance of she work for which 0�R16b�1&�w „c ((ASni CR..Y RTC INC.40UTLETS OCC.GROUP ANN .
My Worker's Connpensmion Insurance carrier and Policy number arc: ;
Carrlar: Polie,No.: a�rI•i)' GAR,^i '='$YS'yEM-OVER4(EA)' ,.
CERTIFICATE OF EXEMPTION FROM WORKI' S'
COMPENSATION INSURANCE hermit Pao
(Thdollars . s G SIM B NTTiRCBFTOR BUILDING DIVISION FEES
section need nit becomphled Box,permit is for one hundred ( 00) GRCASF:TRAP -
orless.) LANCI IIiCK FEE ��
I really that in the performance of he walk far which this fmcd.l shall _ SEWER-SANITARY-STORM EA.200IT.
a employ any person in any manner us as to become subject m th!Wdk4ha E RGY IrBE
Z uithm Laws of Culiacan.Date
O A licans' WATER HGTER WNF.NT/F.LEC R
G
7 .•t PP GRAD PEE
q y NOTICE TO APPLICANT.IL after making this Cenilicam of Cx
hemme subject m the Wnrkcrs Compensation provisions of the L.Mr ale,you muss TFMRFATTNGSOILS F'EE
{'1 Q fomhwid,comply with such provisions or this Permit shall be deemed mvoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY Date: PAID
UQIherehy affrinshas there is.......atom lendingagene,fo der,cfannanceof Date 'Receiptp
E~ the work for which his permit is issued(Sec.3097,Civ,C.)
O Lembe.Name TOTAL:
_ Lenders Address TOTAL:
1 certify that I have read this application and store shat the above informmion is BUILDING FEE
faA correct.I agree to comply with all city and county ordinances and stale laws relating to QTY. MECHANICAL PERMIT FEE
U Z building construction,and hereby amhorize represenmtives ofthis city to enter upon the SEISMIC FEE
.hove-membe ed property for inspection perpaxes. PERMIT'ISSUANCE
(We)agree to save,indemnify rad keep hamdass the City of Cupertino iii ELECTRIC FEE1
babilities,judgments.costs and expenses which may in any way accme against said City ALTER OR ADD TO MECN
in consequence of the gaming of this permit. . PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1.NON-POINT AIR HANDLING UNIT(TO 10.000 CUM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10.000CFM) CONSTRUCTION TAX
Signature of ApplicanUConracter Date EXHAUST HOOD OVMUC17 HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT TO 100,000 BI'U)
as defined by the CuIn nino Municipal Cede.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? HEATING UNIT(OVER 10b,"BTU)
❑Yes No
VENTILATION FAN(SINGLE RPD) PAID Date Receipt p
Will the applicant or future building occupant use equipment or devices which- BOILER-COMP OHP OR 100,0g)RTU) 1
emit h rca ndous air contaminants sa defined by she Bay Arca Air Quality Management
District? TOTAL:
'[I Yes CNo BOILER-COMP(OVER 100,000 LIM
I have neat the barnNous mated.h p AIR CONDITIONER ISSUANCE DATE
requimtnents under Chapter 6.95 of the Cali a
forms Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.PT.
building does not currently have a tunat.rhos it is my re,iNasibila,m notify the occupant
if the requirenames which muss Muret prior to issuance of a Certificate of Occupant, "
Owner a authinzed agentDate TOTAL: ISSUED BY:
OFFICE
Inspection Query for a Specfic Permit Print 10/23/96
PERM IT# ITUS ST SITUS STREET AVE,CT,ST,RD Lot# INSDESCRIPT InsT a DATEDESIRED DateDone Inspector
30396 11557 ly
PLAND PIERS 8/19/96 8/19/96 Cc
30396 11557 UPLAND LIFER 8/19/96 8/19/96 CC
3039611557 IUPLAND JWY I JUNDRSLTB PLMB 9/24/96 jCC
30396 11557 UPLANDWY METAL COLUMNS 9/26/96 9/26/96 JS
30396 11557 UPLAND WY LOT 3 UNDFLR MECH 9/30/96 AD
30396 11557 UPLAND WY LOT 3 UNDFLR PLBG 9/30/96 AD
• P 1 •
Inspection Query for a Specfic Permit Print 10/23/96
Units Pass/Fail
2P
1P-
1 P 1P
1
2P
2P
.i
V
• P 2