30554APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN ONLY
CITY OF CUPERTINO BUILDING ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBINGhIFCHANICAI.
PERMITNO. O
,
BUILDING PROJECT IDRNTIFICA'1'ION
BUILDING ADDRESS:
1'e
� s63 ZA BO .4 I].?/ 1'e-
SANITARY.NO.
AI'I'LICATION SUdMITTAI. DATE
6
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OWNER'S NAME:
OWNER'S
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N/C
CONTROL p``
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ARCHITECT/ENGINEER: LIC NO
URFSS:
7i Jfd��
CQ,N'racE PHONE:
BUILDING PERMIT INFO
Fr(� ////
El Consultant Fees Paid by Applicant (Initial)
EL0 PL ME❑l
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LICENSED CON 'IAACTOR'S DECLARATION
Chapter 9 (comencing
hereby affirm Nat 1 am licensed under provi.vions of m
oathSection ]t03)of0ivision 7aftbe Business an I' essiom Cade mylicenmis
in roll force and r
License ClJss Le.p V '� 7�
Date Contmcmr
ARCIIH ECPS DECLARN'ION
I underaand my plans I '�dy pub
jRs
QTY ELECTRIC PERMIT FEE
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JOB DESCRIPTION
RESIDENTIAL'
❑❑ SFDWL ❑KITCHEN REMODEL
ADDITION eMUMBING RE -PIPE
❑MULTh UNIT ❑STRUCTURAI.
MODIFICATION.
El ❑CHIMNEY REPAIR
IMPROVEMENT
H REMODEL/REPAIR El DEMOLITION
_
PERMIT ISSUANCE
_
APPLIANCES - RESIDENTIAL
PANELS
UPTO'_IXIAMYS
Licensed Profeaional--1 -
OWNER -BUILDER DECLARATION
I hereby affirm Nat I am exempt from the Contractor's License Law !or the
following reason. (Section ]03L5. Business and Professions Code: Any city Or county
quires a e.ani prove, decOlra nr a air o waare
which re t to conxo-un, allay, ;m p y s
that heiuearledpa,maitOdhathenppliantfnr.wchpermit tofileasigw(Cha meet
that heincingwit purstion7 N) f the Contractor's License Law
ipl-IOOIIAMPS
OVER 1000AMPS -r[IOTHER
SIGNS ELECTRICAL
SPECIALCIRGDIT/MISC.
TEMP. METER OR POLE INST.
COMMERCIAL:
El NEW BLDG/ADDITION El DEMOLITION
TEN T ❑ FOOD SERVICE
IM OVEMHNT -
�00
�0
d X c y
h•
W rn
^SQ
F
of Division
(commencing with Smdon]O00)ofDivision3 of the Business and Professions Code)or
Code) or
Nm he is exempt therefrom and the basis for Or, alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
permit
m mre
noNun five hundred dollen ($500).
E] C., owner of Oc prepeny.oraty employees with wvges as theirxole compensmion,
will do me work, and the stmctum is not intended oroffcred for sale (See. HO EBusiness
POWER DEVICES
SWIMMING POOL ELECT RIC
3 m
and Pmfensions Cade: The Contractors License Law does not apply to an owner of
property who builds or improves thereon, and who docs such work himself or daough
OUTLETS - SWITCHES - FIXTURES
his own employees, provided that such improvements are not intended or offered for
NEW RESIDENTIAL ELEC`TR - SQ FT.
,--)Q. FT.FLCORAREA
n i Is Lt
$/SQ. FT.
sale. If, however the building or improvemem is sold within one year ufcompletion, the
nu -builder will have the harden of proving that he did not build or improve for par-
p xe of yule.),
❑ I, as Owner Of the propcny, am exclusively contracting with licensed comracters to
answer the prajax, (Sec. ]MS. Basins, and Pmfasions Cade:) no Contractors Li-
SEP
TOTAL:
cense Law docs not apply to an owner of property who builds or improves thereon, and
QTY. PLUMBING PERMIT FEE
6 1996
who contracts for such projects with a contrucams) licensed pursuant to the Contractors
License Law.
❑ I am exempt under See .B& P C for thisreason
\.lir d..r LL(rs 111 `.V
PERMITISSUANCE
ALTER - DRAIN & VENT- WATER (EA)
Owner Dam
VALUATION '
WORKER'S COMPENSATION DECLARATION
BACK ROW PROTECT. DEVICE
I hereby alien under penalty of perjury one of Ne fallowing coolarations:
DRAINS- FLOOR, ROOF. AREA. COND.
'
❑ Ihaveend will mrinuide Carifiducof Consentmsed-iosom for Workers Comped-
nation, as provided for by Section 3700 ofthe Lahor Cody fon is perfnrnance atticSTORIES
TYPECONSTRUC ION
work for which this permit is issued
FIXTURES -PER TRAP
1 have anJ will mainmin Wmkern Camps nation Inm"I a required by Section
3]00 olthe laWrCWe, for theperfunnance the work for which this permit i. issued.
My WmkttSF>Agyyyiutt 1 a and Policy number ore:
I�Vq olicy No.:
GAS-FA.gYSTEM-I INGSOIITLETS
OCC. GROUP
APS
GAS - EA. SYSTEM -OVER 4(EA),
�Camer:
- CERLE CAITi OF EXEMPf10N FROM WORKERS'
'. COMPE.N SATION INSURANCE
('1Ti,cwfi n need not be bontpincd iOhe permit is for One hundred dollars IS 100)
m less)
GREASIIINDUSTRL WASTE INTERCEPTOR'
BUILDING DIVISION FEES
GREASE'1'RAY
YLANCHECK PBL
I cenify Nat in the performance ofthe work forwhich this permit is issued. I shall
not employ any pecan in any manner w as to become subject the Workers' Compeer.
SEWER -SANITARY -STORM EA. 200 FT.
F[iL
WATER HEATER WNENT/ELECTR
,Z
0
z in
a 7become
0
sada. Laws of California. Data
Applicant
GRADING PER
NOTICE TO APPLICANT: IL after making this Cenilicatc of Exemption, you should
subject to the Worker s Compensation provisions of Ne Labor Code, you must
OnOwith Comply with such provisions or Nis pemtitshall be deemed ravoked.
WATER SYSTLMrrREATING
- -
SOILS FEE
WATER SERVICE
:Dz
U 0
O U
1.. a
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Uz
CONSTRUCTION LENDING AGENCY
l hereby affirm that there is u construction lending agency for the performance of
the work for which thin perann is IssnCd (Se, 3097, Ci, C.)
Lender's Neem
tender's Address
NEW RESIDENTIAL PLMB SQ. Em
PAID
Date Receipt
r ,
OTAL'.
I commthat 1 have read this son
application and care that the aMve information is
r pp ids
building I agree to comply with all city and county ordinances and state law% relating toa
building construction, and hereby authome represenativer, nfrhis city eenterupon Ne
BUILDING FEE
QTY. MECHANICAL PERMIT FEE
SEISMIC FEL '
PERMIT ISSUANCE
ELECT RIC FRE
r
above mentioned property for inspection purposes. -
(We) agree to save, Indenmity and keep hannless the City df Cuperino againn
ALTER OR ADD TO MECIL
PLUMBING FEE
It A
liabilidcs,judgntenu, costs and expenses which may in any way acemcagainsi said City
in ronuquenee of the grdmia, of this permit
AIR HANDLING UNIT (TO 10.01)CFM)
MECHANICAL TLE
-
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONPOINT
AIR HANDLING UNIT (OVIiN 10.000CIM)
CONSTRUCTION TAX
-ig aureus' Ap eant/Comrvcmr Date
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HooDOvirucT)
HOUSINGsHmATI FEE.
HEATING UNIT (TO 100,000 BTU)
Will the applicant or future building occupant store or handle ha>adois material
as defined by the Cupertino Municipal Cade, Chapter 9.12, and the Health and Safety
Code, Sermon 25572(a)]
HEATING UNIT (OVER 100.000 BTU)
rYes 7 N
Will the applicam Or famre building occupant use equipment or devices which
emit trainman, aircontaminants as defined by the Bay Arta Air Quality Managemom
Diama?
E] yes 1-1 No
PAID
a Date ' Rb7cipl1
VENTILATION FAN (SINGLE RESID)
BOILER- COMP OHP OR 100,000 BTU)
'TOTAL:
BOILER- COMP(OVER 100,030 BTU)
AIR CONDITIONER
1 have mutation,havardous materials regaimnems ander Chapter 695 of the Cali-
ISSUANCE DATE
NEW RESIDENTIAL MECIL SQIN.
-
forma Health & Safety Calc, Sections 25505, 25533 and 25534. 1 undersmnd Nal if the
buildin g ores nouvttdntl yhwcuenant Na it ism nt'bilis yton.... hcoecti pan
'
.
Cenificare o(fkeupancy.
ofth<requitemeu which mon format priond issuance ofa
TOTAL:
ISSUED BY:
Owner ar as lmricul agent Dma
OFFICE