S 4343 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPER•1'INO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL S 4343
BUILDING PROJECT IDEN'TIF'ICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
L/o / o �- 95a/ �-12 - `79
OWNHR'SNAME: PHONE CONTRACTOR'S NA E: LIC NO:
NIC CONTROL p
• ARCHITF,CT/ENGIN 3R: LIC NO: ADDRESS. ❑
CONTACT E BUILDING PERMIT INFO
)y a iu ll� 77 a�'�_ 77V• l;. ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
Low `Z^TLS 2., ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby aMon Nal I am licensed under provisions of Chapter 9(commencing _ JOB DESCRIPTION
�OZ wilb Section]11110)of Division 3 of the Businessand Professions Code,and my license is - RESIDENTIAL:
I-�, in full forte and effect. PERMIT ISSUANCE
license Clans Lica ❑SFDWL [I KITCHEN REMODEL
yea
Date Contractor APPLIANCES-RFSIDENI IAL []ADDITION ❑PLUMBING RE-PIPE
F O H
ARCHITECTS DECLARATION PANELS ❑MULTI.UNIT ❑STRUCTURAL
I..S
ZOy7-y 1onJcrsmnd my plans shall he used as public records MODIFICATION
OZ=O UPTO 200AMPS [I INTERIOR El CHIMNEY REPAIR
a�lCC';
Licensed Profcssionnl 201-INX)AMPS IMPROVEMENT SWIMMING POOLS
pCX2-J OWNER-BUILDER DECLARATION OVER["AMPS ❑BATH REMODEI/REP k.0 DEMOLITION
C Q I hereby affirm that 1 on exempt from the Contractor's License Law for the �/
3O bi U following re a.(Section 7131 5,Business and PmfeAmma Code:Any city or county SIGNS ELETRICAL ❑OTHER1.
0(A which requires a permit to conswct.alter,improve,demolish,or repair any structure
("'COs
prior it)its issuance,also acquires the applicant for such permit to file aligned stmunem SPECT AL Cl NCIJIUMISC.
a} that he is limusedpnrsmrn to thepr..visiomof NC Character's License Low(Chapter 9
W�00 (commencing wit Section 1000)of Division 3 of the Business and Professions Code)or TIME HR OR POLE INSi COMMERCIAL.
d e oC
that he is exempt Ihcref era and the basis for the Heard cxempiion.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
{+• Section 7031.5 by any applicant for a permit subjects the spheral to a civil penalty of POWER DEVICES
=pJ ❑TENANT ❑FOOD SERVICE
I. not mote than five hundred it',[] .5(10), IMPROVEMENT
CI O Ell,as owner of he pmpety,m my employees with wages as their sole conformation, SWI M MING POOL ELECTRIC
OAC isillduthe wmk,andthe saucmen is not iarendedmoffend for sole(Soe.7010.Business []OTHER
63�^ cad Pmfesxions Gdc The Contractor's License].so docs not apply man owner of OUTLE FS-SWITCHES-FI%TURES
property who milds or improves thereon,and who docs such work himself or through
his own employees,provide)that such improvements am not mended or offered for NEW RESIDENTIAL ELECIR SQ FT.
sale.IL however,the mildingur impi-vemmat issnld withinone yeatof compkrill SQ.FT.FLOOR AREA $/SQ.IT.
�mr-bui r will have the harden of Proving that he did not build or improve far p t,
ala),
as owner of the property,am exclusively contracting wit licensed contractors to TOTAL:
construct the project(Sec.7(114,Business and Professions Code:)Me Contractors Li-
cense Law does not apply it,an owner oflumeay,who hudds or improves t hemon,and QTY, PLUMBING PERMIT FEE
who contracts for such projects with a contractors)licensed pursuant o the Convectors
License law. PERMIT ISSUANCE
E] I i exmn oder Sec. H&P C fn this rw. t
Owner
iff ALTER-DRAIN&VENT-WATER(EA) VALUATION
e
'SCOM SANONrymym IJ 'LARATION BACK FLOW PROTECT.DEVICE JUN 2 4 1999
(hereby athrm under penalt f PfConsene nfthe df-ansowiog lkers s:
❑Ihuve ono willforbineCion 37 a of the Later ode,for the
Workerscetopeo- DRAINS-FLOOR.ROOF,AREA,GOND.
cation,as provided for by Section 3]W of the Labor Code,for Ne performance of the STORIES TYPE C UCTION
work for which this permit is issued. FIXTURES-PER TRAP
El 1 have and will maintain Worker's Compensation Insurance,as required by Section
37M of the labor Code,for performance of the work for which this permit is board. GAS-EA.SYSTEM.I INC.4 OUTLETS
My Worker's Compensation Insurance cagier and Policy number are:
Cartier: Policy No.: GAS-EA.SYSTEM-OVER 4(EAI
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIJINDUSTRI,WAS U7 INTERCEPTOR BUILDING DIVISION FEfS
This section need not he completedlithe permit is faros,hundreddollas(S 1(10) GREASETRAP
i or lens.) PLANCHFAK FEE
I certify that in the performmartifthe work for shich,his permit is issued,(shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner sonas te hem
coe subject te the Workers'Chat ENERGY FEE
O z codon Laws of Qtbnnio.Dam WATER HEATER WNENTAiLEC R
z C) Applicant O GRADING EEE
h NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTEMn BEATING
a �^ became subject te the Worker's Comlansation provisions.1 the Labor Cole,you most SOUS FEF.
_
{✓:1 foahwith Comply withsuch provisionsortispermit 0z111edcemedrevokeL WATER SERVICE
� zCONSTRUCT ION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
V O l hereby affirm that there is a construction lending agency for the performance of Orae oerve
F the work for which this permit Ls issotcd(Set.3099,Civ,C.)
O Ixnders NameTOTAL:
er
W Lend 's Address TO
0. 1 really that 1 have read this application and state that the above information is BUILDING FE
i.. 170'1 Corect.l agree m Comply with all city and county ordinances ordinate laws relating to QTY, MECHANICAL PERMIT FEE
V G buildingcomtntction,andhcrchy authorize representatives of this city tnenleFolur the SEISMIC PEE
above-mentioned property far inspection purposes. PERMIT ISSUANCE(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
l iabilam,.judgments.costs call expemes which may in any way acemeaguind said City ALTER OR ADD TO MECH.
in asequence of the granting of this permit. PLUMBING FEF.
APPLICANT UNDERSTANDS AND WILL COMPY WITH ALL NON-POINT AIR HANDLING UNTP fro IO,OW CFM)
SOU 11REGULATIONS. IT MECHANICAL
11 _ AIR HANDLING UN (OVER 10,000 CFM) CONSTRUCTIONT
Sire rcnfApplicant/ rot IJ:e EXHAUST HWD(W/DUCq HOUSING MITIGATION FEE
H R USMATE,RIAL DITSCI.OSURF.
Will the applic rt fmure building occupant store nr hantlehamNo material ((BATING UNIT(TO 1110,000 BTU)
as defined by the Cu Ino Municipal Code,Chapter 9.12,and the Health and Safety
Coda Section 25532(x)^ ((BATING UNIT(OVER 100,001 BTU)
E]yes ❑No O
VENTILATION PAN(SINGLE RESID) PAID —
Date BeceiptN
Wedousll the llpair coca or future building hccupvnay Area Air uor olManage ant BOILER-COMP UHP OR 100,11011 BTU)
. emit hazallom air contaminants as defined try the Ray Area Air Quality Management T 'AL
Maim?
❑Yes ❑No BOILER-COMN(OVER 100.IX1)BTU)
I have read the lmzaNhus mamolds requirements under Chapter fi 95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Cade,Sections 25505.25533 end 25531.l undersand that if the NEW RE.SIDENTIAI.MECH. SQ.FT. �] .-.
hui6'ng Jots not currently haveet t,that it' yrcq Filirymnotify thmccupum G
L rcyuiremc which must ma tion uancc oCeaificota of
21
1 ed agent )etc TOTAL: ISSUED BY: 0
OFFICE