30374APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINOBUILDING - ELEcrRICAL
BUILDING DIVISION APPLICATIONTERMIT PLUMBING - MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMIT NO. O ^
3
BUILDING ADDRESS:
/9971 Or
SANITARY NO.
APPLICATION SUBMITTAL DATE
5C�
�PHONE:
�++1
COCTOR'S NAME LIC �NO�e'S
s
NIC
El
CONTROLY
ARCHITF.Cf/ENGINEER: LIC NO:
A R13SS l� r
029'7 I✓ri/OnzV /C..CN./
CONTACT. PHONE:
q2o7
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BEEF ELECT PLUMB MECH
❑ ❑ ® Ell
' LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section Tfl(thaf Division 3 of the Business and Profeai... Cvde,endmyliceremis
in full farce and effect.
License Class onor
Dore Contractor
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION _
RESIDENTIAL:
❑ SFDWL ❑ KITCHEN REMODEL.
❑ADDITION 9 FhHN'IBINGRE-PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEUREPAIR ❑ DEMOLITION
❑OTHER
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
ARCHITECTS DECLARATION
1 understand my plans shall be used as public recoNs
'
PANELS
OTTO 200 AMPS
Licensed l'rufit ssianot
DECLARATION
OWNER -BUILDER I a. excerpt
1 hereby aFiltration 1 am excmpl from the RATION a Licenser Law for the
following .... (Secti..7031.5, Business and Pmfeselans CMe: Any' city or county
which requires a permit to construct, alter, improve, demolish, or repair any stmemre
prior to its issuance, also requires the applicant for such permit n File a signed statement
that he is licensed pursuant o the provisions ofthe Contractor's License Laos (Chapter 9
(vimmencing with Section 700(d.f Division3efthe Busincssand Professions Code) or
Nat he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section ]031.5 by anyapplicant for a permit a.hjcct, the applicant to a civil penalty of
not mom than five hundred dollars (S500).
❑1, as owner of theproperty, or my employees with wages as theirsole rnmpcnsntion,
will do be work, and theatruclurc is nil inle led or..ffered fmaule Sec. 9044. business
and Professions Cade: The Conn-cmr's License taw does not apply m an owner of
pmpeny who builds or improves thereon, vad who does such work himself., though
his own employees, provided that such improvements arc not intendal or offered for
sale. If,however. the building or improvement is sold within one year ofcompletlom the
owner-hailder will have the burden of Proving Nat he did not build or improve for pur-
puce of sdnJ.
❑I. as owner of the property, am exclusively contracting with licensed contractors to
construct the protect (Sec. 2(N4, Business and Professions Code:) The Contractor's Li-
cense Low does not apply to an owner of pmpetly who builds or improves thereon. and
whocontracts for such projects with a commeton s) licensed pursuant m the Comrocmr s
License Law.
1 ant excnapa under Sec. . B & P C for Nis ,ruse.
201-1000AMI'S
OVER I"AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
-
TEMP. METER OR POLE INST,
COMMERCIALI-
❑NEW BLDG/ADDITION ❑ DENIOLRION
❑TENANT , ❑FOODSERVICE
IMPROVEMENT
El OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTIAL ELECTR SQ FT.
-
SQ. FT. FLODR'AREA L'A
AUG 23 1996
UC uuf Lit l imI
I/SQ. FT_
TOTAL:
QTY. PLUMBING PERMIT FEE
i
PERMIT ISSUANCP.
ALTER - DRAIN & VENT - WATER (EA)
Owner Date
VALUATION
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following decla ationr.
InIM1avcvnJ will mainmina Certihcatc of Conscnuosell-inwre for Workers Cnmpen-
atiothe peafone of the
sn, as provided for by Section 37M of the tabor Cade, Iia nunc
work for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance. as required by Section
37M of the labor Code, for the performance of the work for which this permit is issued.
My Works )C tion l once carrier ad Policy number4 �� a
Cauo�lt/ e ,y�* Policy No.: _,/ /�J
CERTIFICAI E OP EXEMPTION FROM WORKERS'
.• COMPENSATION INSURANCE
(Thisstion nccJ not be completed if the permit is (Drone hundred l5l W)
m le".)e
(certify that in the performance of the work for subject to the W is issued. mishnll
not unplxy any person in any munnersn-s na hese,roc whjecn mlM1e Worker: ComPen-
onion Laws of Calif main. hale
Applicant
BACK FLOW PROTECT. DEVICE '
DRAINS- FLOOR. ROOF, AREA, CONE).
STORIES
OCC. GROUP
TYPE C(lNSTRUCfION
APN
FIXTURES -PER TRAP
GAS - EA. SYSTEM -I INC. J OUTLETS
-
GAS-EA.SYSTEMAVER4(EA)
GREASE/INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
GREASE TRAP
PLANCHECK FEE
� SEWER -SANITARY -STORM EA. 2W FT
ENERGY FP.P,
WATER HEATER WIVENT/ELECTR
GRADING FEE
NOTICE TO APPLICANT: IL aBe, making this Certificate of Excerption, you should
became subject o the Worker's Compensaion Provisions of the Labor Code, you must
forthwith comply with such provisions or Nis permit shall he deemed revoked.
CONSTRUCTION LENDING AGENCY
I lambyaffirm thauhere is a con-Imminn lendingagency fur the perfomaer. of
me work for which this permit is issued (See. 3097. Civ. C.)
Lender's Name
•WATER SYSTEMOREATING
SOILS FEE
WATER SERVICE
PAID
NIiW RF.SIUfiN'I'IAI. PLMtl. SQ. EL.
Date Receiptk
TOTAL:
.
Lender's Address
TOTAL:
BUILDING FEE
I certify that I have tend this application and state that Lha .hove infornunion is
correct. l agree to comply with all city and county oreinancesand state laws relating h'
building construction. and hereby authorize iepreuntaives of flic citym enter upon the
above-mentioned property for inspection purposes. I
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilides,jol,rin is costs and expenses which may ON, wuyzccmeagainst said City
in no,tiv cif the gontin :.permit. -
APPLICANTUNDER' AND WII .' PLY LTH ALL NON -POINT
SOURCE RE
20-G/'
l TT VV
QTY. MECHANICAL PERMIT FEE
-
SEISMIC FEE
PERMIT ISSUANCE
ELECTRIC FEE
ALTER OR ADD TO MECH.
PLUMBINGFEE
AIR HANDLING' UNIT(TO Im1NN1 CFM)
MECHANICAL FEE
AIR HANDLING UNIT()VERIa.0a0CFM)
CONSTRUCTION TAX
De
Signaure tcarocvntmctar o
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant one, or handle hanotmeus material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code. Sedan 25532(-)^
❑Yes E-1 No
or ants a definedding occupant use ea Air Qu or Maras which
Will the air contaminants
(emit haanNuus air etmdminants as defined by the Bay Area Air Quality Management
UisWn(
❑ Yes ON.
Ihave reed the hazardous incomme requiremcn¢ under Chapter 6,95 of the Cul i-
Farm Hmlth & Safety Cade, Semina 25505, 25533 and 25534, I undersand that it the
ot emnlly have a mnam, Nm it i.Iny responsibility,, notify the aecupant
building Aaea nre
.raw req domperu which mon be men prior,. mossuren of t C.Pifie. of Occupancy.
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION FEE
HEATING UNIT UO 100,000 Bl ID
HEATING UNIT (OVER 100,000 BTU)
PAID
VENTILATIONFAN(SINGLERESID)
Dole Receipt
BOILER - COMP (3HPOR II)I,WU BTU)
TOTAL:
BOILER -COMP (OVER I W,0010 BTU)
AIR CONDITIONER
_ ISSUANCE DATE
a
ISSUED BY:
NEW kES1UEN'I'IAI. MECH. SQ. PI'.
'
TOTAL:
Owner or authorized .at Dae
OFFICE