30536 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-]ELECTRICAL PERMIT NO, 30536
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: /U' S� �� ' I h SANITARY NO. APPLICATION SUBMITTAL DAT
OWNIiR'S NAME: � ( PHONH: C CONTRACTOR'S NAME
(07 96
' NO: : LIC NO:
oSaj _ r � N/C CON'I'ROLN
ARCHITECT/ENGINEER__ LIC AD SS:ArN
'. 4160
12
CONTACT: PHONE:
BUILDING PERMIT INFO
— - ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CON'1'RAC FORS DECLARATION ❑ ❑ ❑
1 hereby offers that 1 am licensed under provisions of Chapter 9(commencing QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
WOZ whh section 2lagBnrnivisiom3onhe Bu,ma,and rrofaxion.Coda.and my Beeae is RESIDENTIAL
F O 'n full to- and cR PERMIT ISSUANCE
�UV License Class Lica & ❑SFDWL ❑KITCHEN REMODEL
iZz W� Dae—�Commetnr f .__.I'-I,($^'+s Ct. APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
ARCHITECT'S DECLARATIONFyly MULTI-UNIT ❑ N
STRUCRAL
Z O yj.Z. 1 undcrsmnd my plans shall h used as pPANELS
record. MODIFICATION
O Z UPTO 2IX1 AMPS
V0-, Licensed Professional ❑INTERIOR ',CHIMNEY REPAIR
,J 201-I000AMPS IMPROVEMENT
�YE OWNER-BUILDER DECLARATION — UR�1}- DEMOLITR)b ,
C�Q I hereby uttm vma
erer Ihml 1 uexempt from he Connr's 1 iccnse Law for be OVER IOINIAMP ❑BATH REMODE
�666$IIIOaV following mason.(Section]031.5,Business and Professions Calc Any city or county SIGS ❑OTHEIR p ,
F W O G which requites a permit t0 commc
tt cher,improve,demolish,err repair any structureNELECTRIC yJAVo
yst prior to its issuance.also"clock Ne applicant for such permit to file a signed statement SPECIAL CIRCLE MISC
� Thaty
he is],Cansesl pursuann0 the pmvrsmms of the Comment, License law(Chapmr9
�tY�O (commencing with Section 7000)of Division 3 ofhe Business and Professions Cale)or TMvIR MWrfR OR POLE INST. COMMERCIAL
L E e that he is exempt therefrom and the hats lin the alleged exemption,Any violation of
XmDEMOLITION
� Section703 L5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES CINEW BLDG/ADDITION ❑FOODSERVI
not more than five hundred dollo, S5gp, ❑TENANT ❑FOODSERVICE
=
>,
0Las owner ofthe property,or my employees with wages as their sole Compensation. SWIMMING POOLELECTRIC IMPROVEMENT
aN will do the work,and the stricture it not intended or offered fnrsalc(SIC.91U4,Business ❑OTHER
3 m and Professions Code:The Contmemrx License law does not apply m an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements arenm intended or offered for NEW RESIDENTIAL ELECTR SQ IT.
sale,If.however,the building or improvement is sold within one ycarofcompletion.the SQ.FP FLOOR AREA $/SQ.ET
owner-builder will have the burden of proving that he did not build or improve for pur-
pone nl sa1eJ.
El I,as owner of the property,am exclusively contracting with licensed eommicters to TOTAL: P A B
construct the project(Sec.70W4,Business and Professions Code:)The Contractors Li-
cense Law does not apply to an owner ofpropemy who builds or improves thereon,and QTY. PLUMBING PERMIT FEE OCT ��
who contracts for>vchp jeas with a contracmr(s)licensed pursuant to the ComactOrs ^a�^
License Law PERMIT ISSUANCE 5996
I amexempt under Sec. ,B&PCfonhis renwn
Owner Dme ALTER-DRAIN&VENT-WATER(EA) VNI[I
WOR KERS COMPENSATION UECLARAI[ON BACK FLOW PROTECT.DEVICE dh 1
• 1 hereby affirm l' 3S{9_ O�
under penalty of Perjury one of the following declarations: /P
l have and will maintain a Certificate of Consent rosclt-inmre for Workers Compcn- DRAINS-FLOOR FA EA NO. / STORIES TYPE CONSTRUCI'IOh
cation,in provided for by Section 37M of the Labor Code,for the perfnorm nce of the
work for which this permit is iscerl. FIXTURES-PER TR
I have and will maintain Workers Compensation Insurance,as required by Section
3700 of the Labor Code.for[lie performance of the work for which this Permit is issued, GAS-EA.SYSTEM-11 UTLETS OCC.GROUP APN
My Works' pperPPscion 1 arae carte and Policy numherare:
Carries rQ�Set.,..•1' Policy No.: /.l L((f 7S—R[ GAS-LA.SYSTEM-O'.R 41 A)
CERTIF[CATEOFEXEMPTIONFROM WORKERS' 4(1l jR7
COMPENSATION INSURANCE i GRGSFAND RLWASTEINI'ERCEPTOR
(This section most not hcenmpleted iffe porn rs is formic hundred dollar,(MPP) BUILDING DIVISION FEES
or less.) GREASETRAP PLANCHI3CK PEE
I comity that in the performance ofthe work for which this poroma is issued.[,ha]l SEWER-SANITARY-STORM B.200 FT.
not employ any person in any manner so as to become subject m Ne Workers Compeer- ENERGY FEE
,Z, cation Law,of Califnmis,Date
2 Applicant FNT/ELECTR
WATER HEATER WN r
Z r, NOTICE TO APPLICANT.If,after making this Cenifcme of Exemption,you should GRADING FEE
a ; 1 become subject m the Workers Compensation WATER SYSTCWfREATING
�
forthwith comply With such provisions or thisis previsions of Ne tabor Cede You must permit shall he deemed revoked WATER SERVICE SOILS FEE
91.1 CONSTRUCTION LENDING AGENCY NEW RESIDENTIALPLMB. SQ.FC PAID
U O l hereby affirm Na Nem is a construction lending agency for the performance of Date Receipt
W r-t the work for which this permit is issued(See 3099.Civ.C.)
0 U Lenders Name TOTAL.
Landers Address TOTAL:
f}^ y 1 certify Nal 1 have read this application end stem that the above information is BUILDINE�F.
C01 correct.l agree to comply with all city and county Ordinances and state paws relating to QTY, MECHANICAL PERMIT FEE
U Z building constriction,and hereby authorise representatives of this city to enter upon the SEISMIC
above-mentioned property(or inspection puryose, PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cuperlso against ELECTR
habilaies.judgments.costs and expenses which may in any way accrue against said City ALTF:ft OR ADD TO MECH.
in nso,mm,c ofhe granting of his permit PLUMBIAPPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 8000 CPM)SOURCE REGULATIONS. MECHAE
AIR HANDLING IT' )V INXI CPlW/ CONSTRUCTION TAX
Sigmtumaf Allenernt/COntracmr Date EXHAUST HOOD Cf
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION HE
Will Neapplicaut or(umre building necupantsmeorhanlle hazardous material HEATING UNIT(T 107.0(o
as defined by the CuPenino Municipal Code,Chuptcr 9.12,and the Health and Safety
Cafe,Section 25532(a)9 HEATING UNIT(OVER 100,000 BTID
❑Yes Wer"
VENTILATION FAN(SINGLE RES Of PAID
Will the applicant or future building occupant use equipment or devices which Date Recoil q
Chair hawdous air contaminants as defined by the Bay Area Air Quality Management BOILER-COME CUP OR I BU,sho B'IL)
IS...cB
❑Yes WIN. NOILEft-COMP(OVER 1(p.BIXI BTOTAL
TO) :
I have teal the hateachos Caroms,requirements under Chenwr 6.95 of Ne Cali- AIR CONDITIONER
I'omiu Health&Safety Code,Sections 25505.25533 and 25534.1 ural l thin if the ISSUANCE DATE
building doemolcumnd,have a mnunl.[hit it is my mupomsislity m notify Ne occupant NEW RESIDENTIAL MECH. SQ.I'L
afthe myuirearnts which mint he and p' to issuattcc ofa
Carl
of I 2cyi
v h
Owner or euNOri gen Use TOTAL
usueD
OFFICE