30002 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING,-ELECTRICAL PERMIT NO. 30002
BUILDING DIVISION APPLICATIONMERMIT PLUMBING-MI?CHANI CAI.
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
143 V iCL P ,iso E l,oY 8- 96
(l ER'SN M PHO/Nj,40 q� CONT CTOR'SN ME: LIC NO:
eMf_&4re$ 41.G -Ma6�a �� 1/C/D JIgeN/ N/C CONTROL#
•HI ECTIENGINEER: LIC NO: AI DRESS: ❑
u er �cl„�eats aCIA: Acme-f& Su tisfe 1760
CONTACT: PHONE: I - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB SUCH
e Coo rP�6D6 Ig [XTOCkT
LICENSED CONfRACR:SDEC.ARA'fION QTY. ELECTRIC PERMIT FEE
1 hereby affirm Nen
at 1 am licensed under provisions of Chapter 9(commcing JOB DESCRIPTION
be ZO with Second7")D(Division 3 ofthe Business and Professions Code,and my license is PERMIT ISSUANCE .]V /�7 ✓ RE.SIDENTfAL
m full force and effect.
W 0P. FDWL [I KITCHEN REMODFiI.
�U1f License Class Lic.# APPLIANCES—RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
Nina Date ' n no"r �-yt�
ARCHITECPS DECLARATION Iy MULTI.UNIT El SI
[..O y PANELS
Z O vv/�7j- I understand cry plans shall he used us public records MODIFICATION
OZ=ll--1••..�u1 UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
Licensed Professional 201-1000AMPS IMPROVEMENT
•.I OWNER-BUILDIIR DECLARATION
—1 OVER ItAM1AMP5 ❑HATH REMODEI/RCPAIR ❑DIiMOLITION
Q 1 hereby affect that 1 1Sexempt from the Cession,Co License Lew for the
0,U 1.11mwhich ng rensoa(Semon]1onstru t,aincxs and ver demolish.
Code Any city or county SIGNS ELECTRICAL ❑OTHER
3 LL which mquirea n pemso re cores the eller,improve,demolish,ore a sig any structure
doprior e its issuance,also.,..the thcvi,ina ci Ror mchperminnfence,Lnc(Chament SPECIAL CIRCUIT/MISC.
> shot me cing with
it#Sectio 70(a)of Division 3 the eBusin ss an Professions
Luw(s CodOr9
el. that he is ixemithhereiromad[li Division]oft he Business endon,An ions CtdO Dr TEMP.METER OR POLE INST. COMMERCIAL:
0.0.c�' thatheis exempt Therefrom and Rm basis for the alleged applicant to Anyil Penalty of NEW SLOG/ADDITION ❑DEMOLITION
�^'t Section]mnriv an licamforapermit subjects applicant h f POWER DEVICES
..ti Y YaPp J Penalty ❑TF7JANT ❑FOOD SERVICE
Ont tenon Nan Ove hundred dollars($Sts#.
IMPROVEMENT '
Q ❑Lnsownerk,the property,r mycmployecs withwages r lale(Se.mm,Busition, SWIMMING PO0I.ELECTRIC
O will do theProfessions
work,node:The Cute is no sintendedicese Lae do for of apply o i4,Business DOTTER
171
and Professions Cale:The Con, reread,
License Law dors work i toll owner of OU'fLEI'S
—SWITCHES—FIXTURES
3 his o ny who builds or improves thereon,andalpa who epee such work himself of through
his own employeese building
Nut such improvements tion oat intended or altered for NEW RESIDENTIAL F.L[CTR SQ FT.
sale.If.however the building orimprovemem issold within One year of completionJhe q/1 v /1 SQ.FT.FLOOR AREA S/SQ.FT.
owner-builder will have the burden of proving that he did no build nr improve for par- A Koss 06'- im_— 1tel• Q �J m/:2
pose°fsoTOTAL:
le.). / ^�� O 41 Ok /+ ,
1,as owner of the property,ran exclusively contracting with licensed contractors m K �J �k
construct the project(Sec.71A4.Business cad Professions Col,The Conmacmr's Li-
ase law does not apply to an owner of property who builds or improves danced,W QTY, PLUMBING PERMIT FEE
who contracts for such projects syiih a conuactons)licensed pursuant to the C°nnnnor's
License Law. PERMIT ISSUANCE
1 am exemptun r Sec. ,B&P C Tonhis reason
ALTER—DRAIN&VENT—WATER IRA) VALUATION
Owner —
WORKI?R'S OMPENSATIONDECLARATIDN BACK FLOW PROTECT.DEVICE i 4ys; 66 y
I hereby affirm under penalty of pe jury one of the following declarations:
•0 I have and will maintain"Certificate of Consent to self insnon for Worker's Compen- , DRAINS—FLOOR,ROOF,AREA,COND. STORIES
l'YPECONSTRUC`HON
salon,us provided for by Secumt 37M of the Lobo,Code,for the performance of Ne
work for which Nis permit is issued. FIXTURES—PER TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section
3700mNe Lobo,Cale,far the peefmareoceafthe work for which this permit is issued. GAS—EA.SYSTEMA INC.4 OUTLETS I f.RrvUP 'UU APN
My Warkeei Compensation Insurance currier and Policy number arc: AQ� JJJ
Cartier. Policy No, GAS—EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' - -
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FF,IiS
(fhkseaio"need not he completed if Ne permit is forms hundred dollars D that ORHASETRAP p
or less) PLANCHECK PER 533
Loy any that inthe in performaanymannce ro the as to
Inrk Bn wubjtch to the Workers
orks Grout ill SEWER—SANITARY—STORM EA.Zoo IT.
not employ any person in any manner rcr aero hecomesuhJ«I lathe Wnrken'Compen. ENERGY FEE
,Z cation Lawsof Czlifomi0.Dam WATER HEATER WNENT/F.LECTR
yO O Applicant GRADING FEE
❑ NOTICE TO APPLICANT.If,afar making this Certain.of Exemption,you should WATER SYSTEMITREATING
abecome subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
G foMwithcomply with such pmvisinas°r this permit shall Tedeemcdrevoked, WATER SERVICE
Q
5z 'CONSTRUCTION LENDING AGENCY NEW RESIDF.NTIALPLMR. SQ.17. PAID Dam Rcmiptp
1 hereby affirm thauhete is a conswctinn lending agency forthe perfarma"m of
ILO the work for which this peris issued(Sec 3097,Civ.C.)
ILmit Lender's Name / A TOTAL:
O V Lemder'a Address TOTAL: R _ -
�" 1 certify that I have read this application and state that the above information is BUILDING FEE 7 _
Tia) correct.I agmen comply wi@all city and..my ordinances and slate laws relining to QTY. MECHANICAL PERMIT FEE SEISMIC FEE j
V building construction,and hereby authorize represc"tmives°f this city to enter upon the r.3.
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree t0 savq indenmify tine ke<p hannlcss the City Of Cupcninn against ELECTRIC FEE /
liabilities.judgments,costs and expenses which may in any way acme against said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMAING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,0011 CPM) ^�G
SOURCE
(�BxyGULATIO�sS. MSCI{pNICAI.PEE ii0 e
d'ewe DO AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCf10NTAX a D
Signamreof Applictint/C, mcmr Duane 7!' EXHAUST HOOD(W/DUC11 HOUSING MITIGATION FEE �0
HAZARDOUS MATERIALS DISCLOSURE
Will the npplicam or future building rccupam ume nr handle hazardous material ITRATING UNIT DO 10y"BTU)
es defined by the Capsicin,Municipal Code,Chapter 9.12,and the Hculth and Safety
Code,Sectio°25532(0)? HEATING UNIT(OVER HOODOO BTU)
❑Yes ON. VENTILATION FAN(SINGLE RESID) PAID
Will thea applicant or future building occupant use equipment or devices which - Orae Receipt#
pp go pun quip BOILER—COMP(311P OR M0,000 BTU)
emit beatitude.,Dir ronlaminants as defined by the NayArca Air Quality Manugemem
District TOTAL: / S
❑Yes ❑No � BOILER—COMP(OVER 100."BTU)
I have read the horrendous mmeri:ds re,ponemcros under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health A Safety Cede,Sections 25505,25533 and 25534.1 understand that if me NEW RESIDENTIAL MECH. SQ.FI'.
building docs not currently have a tenant,that it is my responsibility to notify the txcvpam
of the requiamems which must he met prior,)issuance of a Cenincale of Occupancy.
Owner or authorized agent Date ISSUED BY:
OFFICE