29416 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY i -
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO
BUILDING DIVISION
APPLICATION/PERMIT PLUMBING-MECHANICAL - ./Q 4,1 6
BUILDING PROJECT IDENTIFICATION' Lam/ 1
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
19937 t_4 Mt2' p� _ 31G 6
OWNER'ell T S NAME: Js? On ��M AV Cre—D0-ml ME: 7ez MAP", 3N 3 NIC CONTROL#
ANCHITECTIIiNGINEGN: - Vl LIC NO. ppppp � ���N� ^� �� ��/ ❑
CONTACT: PHONE: el D BUILDING PERMIT INFO
- - ❑ Consultant Fees Paid by Applicant(Initial) 'BLDG ELECTPLUMB MECH
❑ ❑ Nr ❑
LICENSED CONTRACTOR'S DECLARATION - QTY ELECTRIC PERMIT FEE
.I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIP7 ON
'0Z with Section]WO)uLdvision3ofthe Business and Professions Code,and my license is RESIDENTIAL:
O PERMITISSUANCE
F m full force and effect. /_ 7 Q !L�
yW(:. t7 Q ❑SFDWL ❑KITCHEN REMODF.I.
U LicenseC s Contractor
APPLIANCES-RESIDENTIAL
Si Q Dam Conmacmr ❑ADDITION ❑PLUMBING RE-PIPE
'Doo ARCHITECT'S DECLARA'T'ION PANELS ❑MULTI-UNIT' l ❑STRUCTURAL
Z p h Z 1 undemand my plans shall4 used as public surds MODIFICATION
O Z—O 6PT02M ANIPS
F�tW Licensed Prnfessiunal C1 INTERIOR 11 CHIMNEY REPAIR
201-IOW AMPS IMPROVEMENT
OWNER BUILDER DECLARATION OVER IOWAMPS OBATH RGMODEL/RE('AIR [I DEMOLITION
C C sr 1 hereby affirm that 1 am exempt from the Contractor's License Law for th<
W0 BeF following Mason.(Section'70315,Business and Professions Code:Any city or county SIGNS ELECTRICAL - ❑OTHER
W m which requires a Permit to construct,ah e,improve,demolish,m repair anystructure _ s
prior,.its issuance,abs.eyuirnsme applicant forsuch permit o fileaeigrWmatmocul SPIiCIAL CIRCUIT/MISC.
that he is liceradi,nmern to me prova
isiuofine Coor's ntractLicense Law(Chapter Y
1100 (cotrm¢ncing with serum.l00B.fDivision3 ofthe Busincs,ind Professions Coi '[EMP.METER OR POLE INST. COMMERCIAL'
0. c yr mat he is exempt therefrom and the basis forthe alleged exemption.Any violation of 0 NEW BLDG/ADDITION ❑DEMOLITION
'^ Section 9031.5 by any applicant for a permit subjects the applicant to a civil Penalty of POWER DEVICES
�m than OIMPROV ❑FOOD SERVICE
not morewne five hundred
t,,dollars
yempl - IMPROVEMENT
�SQp ❑ Las
eivok,fmcpropcuctur ray.,mandeswl theirsale compensation, SWIMMING POOL ELECTRIC
p. will Pr Newark,and the he Contisnots License Law
ffered fmrot apply town Business ❑OTHER
Lad3 and erofeshe b Cade:The Cummeols License Law does not apply us if owner of OUTLETS-SWITCHES-FIXTURES 0
progeny who builds or improves t such improvements and who Jues such work himself oreredf h
his own oweveremployees.provided mat such entisold art not intended or offered for NEW RESIDENTIAL ELECfR SQ FT.
sale.If,however the have
the burdding or en
n of proving
t sold heddwithin one build
or improve
the SQ.bT."OR AREA D 5/SQ.Ff.
' cr-buildv will have the burden of Proving mm he did not build orimpmve for pun � "
p'se of teles, `
I,as owner of me property,aexclusively commeting with licensed conmors m ,TOTAL:
m tm
IW
consumer the project(Sea.7014.Business and Professions Codc:l The Conametor's Li- MAR .19 96
Li-
cense Law docs not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE 19
who contracts Iia such projects with u cnalmoor(s)lo,owd pormam m the Conroe n, ,
License law. PERMIT ISSUANCE C1Iy UC (/V.�
0m 1 aexempt under Sec. ,B&P C for this reason ' L"(I 1 I IYL!
Owner Doe ALTER-DRAIN&VENT-WATER(EA) VALUATION
• WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I bereby zRrm uttdor pcnehy of perjury ane of me following declarations
have and will maintain a Certificam ofCamonrto self-insure for Worker's Comped DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CON59'RULTION
ration,as provided for by Section 3900 of the Labor Code,for the performance of te
h
hiehthis permit is issued. - PIX'1'URES-PER TRAP
and will maintain Worker's Compensation Ino ranee,res required by Section
E Labor Code,far the perfortmence of the work fryorr which
arthis permit is issuueedd.. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC GROUP APN
C'ar r:rkZ tpSn Igeuyyt. rf�e Pot Policy Na.Y L5t1, '[s- GAS-ISA.SYSTEM-OV17R 4(EA)
(CEERRTTIIFIICCATEE OFF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR
' (This section need not becompleted ifthe Permit is nature,hundred dollars.t$100) BUILDING DIVISION FEES
or jests GREASE TRAP PLANCHECK FEE
I certify mat in me peromorecaf me work forwhabthis permit is issued.lshall SEWER-SANITARY-STORM EA,200 FT.
nm empty any Person in a.to ec object to the Workers Compcn- I ENERGY FEE
QZ ration Lawsof Cn' Dbe WATER HEATER WNPNT/ELECTR
z 0 Applicant a Qia•4�- -aiv' GRADING FEE
y NOTICE
FO'APPLICAIsL0fsffw,making Stilt Certificate ml Exemption,you should WgTEN SYS'1 EM/TREA'TING
a ? become subject to the Worker's Compensation provisions of the Isbor Code,you must SOUS FEE
forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE -
Q PAID
D z ff CONSTRUCTION LENDING AGENCY , NEW RESIDENTIAL PLM11.. SQ,PI'. Date Receipt#
I hereby oBan them es construction lending agency for the perm
formce of
wthe work for which this petrol,is issue)(Sec.JW'/.Civ.C.)
F0 Lender's Name - TOTAL:
} 0. Lenders Address IA1.' ...
I certify that 1 have mad this application and some that the above information is - BUILDING FEE
F' f0 sorsa.1 agree to comply with all city and county ordinarcees and sum laws relating to QTY MECHANICAL PERMIT FEE
LU Z builiin,ionamrim,mad hereby numnrize iepremnmtivec of this city to emerupon me SEISMIC FEE
alsove-mero
ntioned pgeny form,,senx.ion purpnmPERMIT ISSUANCE I
(Wit)agree to save.indemnify and keep hamdcss the City of Cupcnino against ELECTRIC ME -
liabilities,judgments.costs and expenses whichmay in any way accrue against said City ALTERORADDTOMECH. 6
in complicate of the gmndng of this permit. PLUMBING FEE
APPLICANT'UNDE NDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT LTO 100#CFM)
SOURCEREG(' f0 M[CHANICAL FEE
3// h NR HANDLING UNIT(OVER IO."CFM) CONSTRUCTION TAX'
Si of APplicu .on my Date EXHAUST HOOD(W/DUC) HOUSING MITIGATION HE
4 AZARD US MATERIALS DISCLOSURE'
Will the applicant or future building occupant store or handle hacamme material HEATING UNIT(TO IW.000 BTU)
a defined by me CupcAmo Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 255321a1'.' HEATING UNIT(OVER I W.000 B-rU)
O Yes o VENTILATION FAN(SINGLE kCSII» PAID
Will the a Tiered or future buildin t use equipment or devices which Date Receipt#
pp g by the BitQBOILER-COMP(3HP OR IW,000 BTU)
emit hazardous air contaminants as Acfined by the Puy Area Air Quality Management TOTAL.
•District? 1101LER-COMP(OVER I W."13'1'U) '
❑Yes r`���Q��
I have read me hreod,1v materials requirements under Chapterfi95 of the Cali- AIR CONDITIONER ISS -
❑smia Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if the NEW RESIDENTIAL MIiCH.. SQ.IT. � ,
building doxy nnmvrtently have a tenant,mm it is my responsibility,.nmify the tecupum
ofdw nal Our be pdormismenceofaCrnifica
truth uri Ume TOTAL: ISSUED BY:
OFFICE