29793 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
I CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
�• BUILDING DIVISION APPLICATIOrERMIT PLUMBING-MECHANICAL n n 7 O 3
BUILDING PROJECT IDENTIFICATION G J 1 7
BUILDING ADDRESS: SANITARYNO. APPLICATION SUBMITTAL DATE
55 � � r1V £'• 6�� ���
OW E 'S NAMV: 1 'I O PHONE: O� C RACTOR'S NAMRi I LIwC NO: O NIC CONIROLa
ARCHITE.CT(ENGI`NEER: LIC NO: ADDRESS: 1tW\3 Z� L..F yj F_U30V. -PC� ❑
.. L-ps - Ca.
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG FkLEgr PLUMB MECH
❑ ❑ ❑
LICENSEDCONTRACnOR Sp UEConsof hap QTY ELECTRIC PERMIT FEE -
1h by )fidenot I of the
Bdiunderprevisions Chapter9 my license
JOB DESCRIPTION
F'��Z with 5 t will fD J fthe Rusi e -and Profe-sion:CMe.and my lice se is RESIDENTIAL:''
�� full ft Je ct. - PERMTT ISSUANCR -
y.u1F '" s _ I a,-103,1 ❑SFDWI. ❑KI'T'CHENREMODEL
4 V U Lice class s Lis a
P—U Datc Cont et Ayraag tt�OD��' APPLIANCES-RESIDENTIAL C1 ADDITION ❑PLUh1BING RE-PIPE
on ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z p y Z 1 understand ny plans shall be used as public rends MODIFICATION
O UP TO 2m AMPS El INTERIOR El CHIMNEY REPAIR
Licensed Prefesdiaral 101-10MAMPS PROV- I
'y�; OWNER-BUILDER DECLARATION
C M st 1 hereby affirm that I am exempt from the Compactors License Law for the OVER["AMPS ATH REF,,= Er.REPAIR ❑DEMOLITION
�• L U following reason.(Section]031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL TH.ER
3 0.m which requires a voint to construct,alter,improv",demolixh,or repair any ehumure
of; prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
fly that he is licensed pursuant previsions pursuano the pvisions ofthe Connectors License Law(Chapter 9
COQ (commencing with Section 7")ofDivision 3 ofthe Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
a t c C 'bat he is exempt themGom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
'M'A Section 703 L5 byany applicant for a permit subjects the applie:nn to a civil Penalty of POWI7R DEVICES
-ul—y []TENANT L1 FOOD SERVICE
SSCnot moss than fax se prop)dollars(Sem)' IMPROVEMENT
QLothewoowner rf sale cmadon, SWIMMING POOL ELECTRIC ❑OTHER
p., will dothewons C dthe he Contra tors Lici ndc Law ed dower of apply to an,Rosiness
u�1 m and Professions Code:The Contractors License law does not apply m an owner of OUTLL-1'S-SW'ITCHES-FIXTl1HE5
,"�'.. property who builds or imM,d,thereon,and who does such work himself of through.
his own employees,provided that such improvements we not intended or offered for NEW RESIDENTIAL ELECTR SQ IT.
sale.If.hoc'ever,the building or improvement issold within one year ofcompletion,the SQ.FE FLOOR AREA 5/SQ.IT.
onow-builder will have the burden of proving that he did not build or improve for par-
po a oI wl,)
❑ L as owner of the property,am exclusively comructing with licensed contractors to TOTAL:
construct the project(Sec.]OM.Business and Professions Calc:)The Contractor's Li-
cense Law does net apply to an ownerofpmpeny who builds or improve,thereon,and QTY. PLUMBING PERMIT 'FEE
who cintmcts for such projects with a conumcow s)licensed pucsuentao the Commetor'x
License Law. PERMIT ISSUANCE
❑l um exempt under See. ,B&P Cl in this reason s
Owner Date ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROOIC.DEVICE
I hereby affirm under penalty of pc, ryone of the,Hollowing declared,,.,:
❑ Ihuvc and will maintain aCenificate of C...emmself-inmrefor Worke('s Compcn- DRAINS-FLOOR,ROOF.AREA,COND.
STORIES TYPE CONSTRUCTION
satiun,as provided far by Section 37m of the Labor Code,for the f percarcomed of the
work for which this permit is issued. FIXTURES-PERTRAP
yhave and will maintain Worker's Compensation Insurance,as required by Section
l roof the Labor Cale,fdnhe Psdunuance of the work for which this permit is issued. GAS-13A,S YS9'HM.I INC.4 OUTLETS OCC,GROUP APN
My Woty,� Campcn. tie more currier and Policy numlxr
Cmtiee`0.\ nP tPJ.hcy NoauP Teo AO Ub cul GAS-EA.SYSTChbOVERiIEA)
CERTI IC OMP12 EXEM INN FROM WORKERS'
- COMPIiNSAT1ON INSURANCE GRF.ASFIINDUSTRI.WASTE INTERCEPTOR
BUILDING DIVISION PEES
(This section need not becnmplctcd if permit is lin one hundred dollars(Sloe) GREASE TRAP
rr less.[ PLANCHECK FEE
I cenify new in the Nrfarmnncemthe work forwhichthis .is is ismed.[,hall SEWER-SANITARY-STORM EA.200 FT.
not employ any parson in any manner so as In become subject m the Workers Compen- ENERGY FEE -
s ZZ Applicant Law s of Caliliams,Date WATER I[LATER W/VEN DELHCR GRADING F[31
re, NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTE,VTREATING
a ? become subject to the Worker's Confirmation provisions of the labor Curif you most SOILS FEE
LkI r forthwith comply with such provisions or this permit shall be deemed cooked
WATER SERVICP,
d 0 '
CONSTRUCTION LENDING AGENCY NEW RESIDEN'1'IAh B.PLMSQ.14. PAID
V O Dae Receipta
th
1 hereby affirm that there is mnsuaclending agency for the performance rl
e work for which this pends is issued(Sec..30 309],Civ.C.)
F LcndN,No. TOTAL:
W4 Lender,Address ), TOTAL:
fy� 1 cenify that 1 have read this application and seam that
he above inlormation is BUILDING FHL?
f.. W correct.I agree to comply with all city and en..ty coca...res and state laws redoing to QTY, MECHANICAL PERMIT FEE
�.) Z building construction,and hereby authorize repre.entame%of this city to enter upon the SEISMIC FEE
above-mentioned property for insper ion purposes. PERMIT ISSUANCE
(We)"gree to save,indenmily and keep handers the City of Cupertino against ELECTRIC FRIT f
liabilities,judgmenu,costs and expenses which may in any way accme against sud City ALTER OR ADD TO MECH. PLUMB ING FEE
in asequence of the granting of this permit. -
APPLICANTUNDERSTANDSANDWILLCOMPLYWITHALLNON-POINT AIR HA LADLING UNIT(TO 10.000 CFM) MECHANICAL FEE
SO t CEREGULATIONS. '
n
AIR HANDLING UNIT(OVI?R I11,000 CFM) CONSTRUCT ION TAX
Sign...of ApllcanVCoonwon Dam—_� EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEF.
HA]ARDOUS MATERIALS DISCLOSURE
Will the"ppliewu or future Mildoo.dupanutwe or h:mdle hamdous material HEAP ING UNIT(TO Im.M0 RTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health Ind Safety
Cale,Section 255321a1'! HEATING UNIT(OVER 100,010 BTU)
A1No
E3SCI VEM17ILATION FAN(SINGLE RESID) PAID Dam Rtteipta,
Will the applicant or future building occupant use equipment or devices which
emit lb,,doftao,air rant I 'vdefined by the Bay Area Air Outlay Managerent BOILER COMP CHP OR 1000(fl BTU) _ 'fOGU
Dismu4 — AR In, 391
E3 Yes ggNr BOILER-COMP(OVER 100.001 BTU) is, . -
AIR CONDITIONER
I Health
Safety
h ode.Sections
55 5,L5533 ns under 1 and roand that Cnh- IS(gUA1k��C DATE
Toni.4lealth&Safety Calc Stations 25505.2553]and 155331 undersand that;[the NEW RESIDENTIAL MECH. SQ.FT.
building does not a currently have tenant,that it's y responsibility m notify the occupant Y
-
wrem\en,Ia`what us,tM1(�.,mly'y au�F- me of Cmifisae r(kc/u�Fa cY.
UIL�YIQs i(Na�Ylj�) 11"� -'1� I El's I
Owncre,authorized ugcm - "• Data TOTAL: E Y:
OFFICE
�,I"I`I,• ti���� E /tiF � /���AN
j ISSUE GATE(MM/OD/YY)
V r V! 9/09/95
PPODUCEN
��µ;:... :: ......_ . ..
ANU
CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE
Ca I co Ins Brokers & Agents DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
2000 Alameda de las Pulgas POLICIES BELOW.
P.O. Box M COMPANIES AFFORDING COVERAGE
San Mateo, CA 94402-0080
415-574-0773 COMPANYLETTER A
Calif Casualty Indemnity Exch
COMPANY B
INSURED American Automobile Ins . CO.
Don Wade Electric Company COMPANY
16320 Harwood Road LETTER C
Los Gatos , CA 95032 COMPANY
LETTER D
COMPANY
LETTER E
COVERAGES >
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEENISSUED TO THE INSURED NAMED ABOVE FOR THEPOLICY PERIOD
INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LMITS SHOWNMAY HAVE BEEN REDUCED BY PAID CLAMS,
Co
LT,
T TYPE OF INSURANCE POLICY NUMBER POLICYEFFECTIVE POLICVEXPIRATIO LIMITS
DATE(MM/DD/VY) DATE(MM/DD/YY)
GENERAL LIABILITY GENERAL AGGREGATE
500000
B X CONMERCIAL GENERAL LIABILITY 895MZG80626253 9/20/95 9/20/96 PRODUCTS-COMP/OP AGO. $ 500000
CLAIMS MADE FX1 OCCUR. PERSONAL & WIN. INJURY $ 500000
OWNER'S & CONTRACTOR'S PROT. EACH OCCURRENCE E 500000
FIRE DAMAGE (Any one lire) $ 50000
MED. EXPENSE(Any one person t 5000
AUTOMOBILE LIABILITY COMBINED SINGLE
=
3 X ANY AUTO 895MZG80626253 9/20/95 9/20/96 LIMIT 500000
ALL OWNED AUTOS BODILY INJURY 9
SCHEDULED AUTOS (Per person)
X HIRED AUTOS BODILY INJURY S
X NON-OWNED AUTOS (Per accidenl)
GARAGE LIABILITY PROPERTY DAMAGE S
EXCESSLIABILITY EACH OCCURRENCE q
UMBRELLA FORM AGGREGATE 9
OTHER THAN UMBRELLA FORA
WORKER'S COMPENSATIONX STA TUTORVLIMRS
A
AND
WC1900006001 10/01/95 10/01/96 EACH ACCIDENT .$
... 1000000
EMPLOVERS'LIABILITV DISEASE-POLICY LIMIT $ 10110000
DISEASE-EACH EMPLOYEE S 1000000
OTHER
DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLESISPECIAL ITEMS
CERTIFICATE'HOLDER ;; ;: CANCELLATION
SHOULD ANY OF THE ABCVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
: £ MAIL 30 DAYSWRITTENNOTICE TO THECERTIFICATE HOLDER NAMEDTO THE
CITY OF CUPERT I NO YI` LEFT.BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
10300 TORRE AVENUE ::E LIABILITYOF ANY KIND UPON THE COMPANY,ITS AGENTSOR REPRESENTATIVES.
CUPERT INO CA 95014 ..`.! AUTHo EP es TAnve
C14 0270000
ATTN: ELECTRICAL INSPECTOR
;kCORD 26-8(r7190I ..'E}?ACORDCO ATION1:980 :=