30386APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
PENMITNO. S ^ ^
BUILDING DIVISION - APPLICATION/PERMIT PLUMBING -MECHANICAL
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30386.
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BUILDING PROJECT IDEN'TIFICAT'ION
BUILDING ADDRESS: -
SANITARY NO.
APPLICATION SUBMITTAL DATE
10tosq LAr,4 WAq N9Mn,JI0 ICA. 9591"it
q Kq, 6
OWNER'SNAME: PHONE: C
S AL.t - 11 7
'ONTRACTOR'S NAME: `,ICNO:
G E4� a O� TL 6 ! 3'1 �I
•\RCHITECTMNGINEER:
N/C
❑
CON'1'ROL4 .
- LIC NO:
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ADDRESS- -
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CONTACT: PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB MECH
❑ ❑ ❑
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LICENSED CONTRACTOR'S DECLARATION
I hereby Mo. than I am licensed under
y a provisions of Chapter 9 (commencing
with Section 7000) the Business and Prof ssions Cale, and my license is
mfull force and el' ,-'q t3/J98
License DD Lic. k —r-� _/ -
Dae Commc •4'�r'��p� ��-�
ARCHITECTS DECLARATION❑MULTI-UNIT
rand my plans sha�Ibyyyy laspublicrecord.v
(i1,(sp{��
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL'
❑SFDWL ❑ KITCHEN REMODEL
[]ADDITION PLUMBING RF, -PIPE
[]STRUCTURAL
MODIFICATION
❑INTERIOR ❑ CHIMNEY RI7PAIR
IMPROVEMENT
❑ BATH REMODEUREPAIR [I DEMOLITION
❑ OTHER —
PERMIT' ISSUANCE
APPLIANCES-RESIDEM1TIAL
PANELS
UPT021k1AMPS
W Licensed Park.nnal
OWNER -BUILDER DECLARATION
p 6'
3W Q I hereby affirm that 1 um exempt from the Contractor's License Law Endue
following reason. (Scnion ]11315, Business and Profesinnx Cndtt AnY city nr amnlY
W LL
201-IOIIU AMPS
OVER 11100 AMPS -
SIGNS Ii1.IiC1 NICAI, - s.
vFi which requires a permit to construct, alter, imprme, demolish, or repair any moio re
Q prior to its issuance. also requires the applicant for such permilto file a signedstammcm
that he is licensed pursuant o the provisions of the Commences License Law (Chapter 9
00 (commencing with Section 7(X10) of Division 3 of the Business and Profe,mrs Code)in
SPECIAL CIRCUIT/MISC.
I EMP.M E'TEk OR POLE, INST.
M '
C. 2 e C that he is exempt Frenchman and the basin for the alleged exerolnum. Any violation of
EW BLDG/ADDH ION ❑ DEMOLITION
POWER DEVICES
Section 703 L5 by onyapplicant fora pennitaubject, the applicant nor wlt
a civil pey of
n'
LLLL11 not mare than fisc hundred dollars (5500).
1, as owner of the property, nr my employees with wages as their sole compensation,
FFA E]SWIMMING
will do'he wark.ondthe.wrucmre is not intrad,doroffrred fors.le(Se,7HUBovines
TENANT ❑ FOOD SERVICE
ROVEMENT _
El OTHER
POOL ELECTRIC
OUTLETS-SWITCHIS- FIX] "URES
Iyl m and Professions Cale: The Contractor's License law docs not apply or an owner of
a 3 property who builds or improves Brennan, and who does such work himself or burned-
his own employees, provided that such improvements arc not intended or offered for
NEW RESIDENTIAL F,LECTR SQ
.s
sale If, however, the buEdingor ireprovcorent in sold within one y.,,,f Cumpletlnn, the
SQ. FL FLOOR AREA
S/SQ. FT
owner -builder will base the burden ofproving that he did not build or improve for par-
L�L�T]
SEP
poseofsale.).
❑ 1, as owner of the property, am exclusively contracting with licensed Common.. to
onstruct the Project (Sec. 7(94, Business and Profession, Code) The Contractor's Li-
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(�
TOTAL:
•se Law does not apply to an owner of property who builds or i mproven thereon. and
QTY. PLUMBING PERMIT FEE
VP� furL, Bli
who contracts for such projects with a comm nods) licensed pursuant o the Contractors
j
PERMIT ISSUANCE
License law.
ED 1 am exempt under Sec. , B & P C for this reason
s
ALTER - DRAIN & VENT- WATER (EA)
Owner Date
VALUATION
WORKER'S COMPENSATIONDECLARATION
BACK FLOW PROTECT. DEVICE
1 hereby affirm under penalty of perjury one of the following declarations:
DRAINS -FlAOR, ROOF AREA, COND.
❑ I haveand will malmaln o Certifcate.fCarwat lesclf-insure for Worker's Compen-
notion, as provided for by Section 3700 of the Labor CivE. for the perfonnvnce of than
STORIES -
TYPECONSTRUCTION
work for which this permit in is -C&
FIXTURES- PER TRAP
❑ I have and will maintain Worker's Compensation Insurance, as "Cited by Section
3000 of me Labor Care, for Ne performanccof the work for which this permit is ixsued.
My Worker's Cori pemation Insurance currier and Policy number arc
DEC. GROUP
APN
GAS - EA. SYSTEM -I INC. 4 OUTLETS
Currier: Policy M,
GAS - IIA, SYSTEM OVER 4 (IIA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This semina need not hcmmple,ed if me permit is Tomas hundred dollars(8100)
or less.)
GREASUINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
CREASI:'TRAP
PhANCHECK FEE
SEWER - SANITARY - STORM EA. 2WFU
ICeulfrlh.l in Ne perlonnance of the work for which this pennir is issued, l shall
not employ any person in any manner so any be�ymr/ to the Workers' Coupes-
ENERGY FEE
WATER HEATER WNENT/ELECfR
Oz
z
P
saloon Laws of , 'arc 7�9-7y
Applic:mt
GRADING FEE
TO APPLICANT: If, after making this Cenificmn at Exempnnn, you should
become subjaa m the Wmr em's sii arta satin. provisions of a Labor Cade, you most
fwar comply with suchp visionsorthispennitshall Jecmed revoked.
CONS'TRU'TION LENDING 'ENCY
Thereby affirm ma mem iso muncoon le Ing agcncY mor ate pcRomtance of
the wok for which this permit is issue Sec. 30 . Civ. C.)
Lenders Name
_
WATER SYS'I EM/TRPATIN'G
WATER SERVICE
tiNOTICE
>
Q
z
U O
F-'
O V
CLI
SOILS FEE
PAID
Date Rt,,o tp
P
NEW RP_SIUBNTIAI. PLMR. SQ. FC
'
TOTAL:
Ixnder'.c Addreu.v
T
OUILUING 1'CE
1 certify mm 1 have d smm that the uhovc in4snnnfmn is
QTY. MECHANICAL PIiRMIT FEE
Vl
U,z
/tha.Bonon,
cnnect.l agree mcomply wndnry finances and store laws relating to
a
beildingcmnactima and hreprennta softhis city toemer upon me
SEISMIC FEE
PERMIT ISSUANCR
ELECTRIC Hit.
above-mentioned properly frposes.
(We) agree u. cove, eep harodess a Ci,y of CCNriro.gair,,
ALTER OR ADD TO MECH.'
PLUMBING FEE '
liabilities,judgmems, costs and expenses which may in any ay aceme against said City
in conscquencc of Ne granting of suis pcnni,.
AIR HANDLING ON] '1'(T'O 10,000 CFM)
MECHANICAL FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
AIR HANDLING ON] T(OVER 10,00) CFM)
CONSTRUC'TIONTAX
Signature of Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(WNUCD -
HOUSING MITIGATION FEE
HEATING UNIT (TO 100,000 BTU)
Will meupplic.ni or fumrc bullding hwcupunt more or handle hllanfoas mlaused
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
HEATING UNIT (OVER 100,0011 BTU)
Cale. Section 25533(a)?
❑Yes �IJo'
n
• Will thea le,we m Nlurc buildin t unc c c t or deviri;a which
pp geecupvn Area
mi, havrdoux air conuminam, as definal by the Bay Arca Air Quality Managnnem
Uimric,?
❑Yee *No
PAID
Dam Reccipt M
VENTILATION FAN (SINGLE RFSID)
BOILER- COMP (31411 OR IW,000 BTU)
TY)TAL:
BOILER- COME (OVER 100.000 BTU)
AI R CONDI' I'IONER
I have mad the hnwdonsmaterial, regmonalms under Chapterfi95 of the Cali-
ISSUANCE DATE
NEW RESIDENTIAI, MECH. SQ. HU
fomia Health & Safety Calc, Sections 8505.8533 and 25535. 1 ualerstand that if the
building does net Currently have a tenon, ma, it is my responsibility m notify the occupant
ori 1 u which moot be met prior to issuance of aCqi'Cat-Q'cupancy.
/Vl,/1r-•I N _'
---
ISSUED BY:'
TOTAL:
Owner om agent DVate
OFFICE