S 1258 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECT RICAL PF,yIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL 1258
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLiCAT10NSUBMITTAEDATE
9 Jam. a- l B-96
O'NEI'S PHONE: CO, CTOR'S NAME: LIC NO:
t' ✓-��)H Vebll - 1 9V N/C CONTROLp
60.3 q
ARCHITECT'/ENGINEER: LI .NO: ADDRES. C �-1 n/� ••__II ❑
' 0 97 r ba 14n2n.. IOls�l, 1
CONTACT: PHONE: _ BUILDING PERMIT INFO
❑ Cra eultant Pees Paid by Applicant(Initial) BLDG ELECT PLUMBI MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTy, ELECTRIC PERMIT PEE
I nerebr amrtn mat 1 tiro beenaea rend'.pr'vi.i.na.r Chapter v(e'tntnetteing JOB DESCRIPTION
O3 C, with Section 70ZhPpfDm,ion 3 ofihc Businessand Professions Code.and my license is p
00 PERMIT ISSUANCE RESIDENTIAL E
awrin fen a nce,Class d effect ❑SFDWL ❑KITCHEN REMODEL
UU License Class LiaN APPLIANCES-RESIIIENTIAL
yZW Dam Contractor El ADDITION 9,4sLUMBING RE-PIPE
ABOUT DECLARATION PANELS ❑MULTI-UNIT STRUCTURAL
Z p y 2 I understand my plans sM1ull he used as public recorJa MODIFICATION
p 4 t gll UI'TO HIO AMPS ❑INTERIOR CHIMNEY REPAIR
F.4..F.G1 Licensed Professional 201-1000AMPS IMPROVEMENT
ecowt� OWNER-BUILDERexemptDI?CLAommen cJOSWIMMING P00L$
pp,,CC as 1 Hereby affirm That I um exempt from the Commdor's License how for the OVER 1000AMPS El BATH kEMODELBEPAIR �UL'MOLITION
pq 3 W F fallowing reason.(Section 703 L5,Bushsss and Professions Codc Any oily or comity SIGNS ELECTRICAL. ❑OTHER
m which requires a permit m mm,a,alma Improve,demolish,oT hi any sltncho,
Fpp,"f0�< prior to its issuance,also requirestheapplicant fnrswh permit m fie asi,and sediment SPECIAL CIRCUIT/MISC.
up a,
that he is licensed parsnanim ate pro,kinnef the Contractor's Limmov Law(Chapter 9 t
6� (commencing with Section 7000)of Division 3 of the Business and Professions Code)or 'TEMP.MCrER OR POLL INST. MM R I
y' that he is maim t thcrcfrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
XlX..v Section 90315 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
not more man rive hundred dollar,($500)" TENANT ❑FOOD SERVICE
vSC
E]1.as owner of m
the property or y employees with wages as their sole compensalion, SWIMMING POOL ELECTRIC 1'ROVEMENT
will do the work and ffiedo eme is not intended or offered for wile(Sri.7044.Business
and Professions Gide:The Comenewea License Low doe,net apply In an.coact of OUT LEI S-SWI TCHES-FIXTURES
property who builds or Improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ PP
sale.11;however,'alreldi....imprommem is sold within tine year ofwnTl'tam the ESQ.Irl'.FL AREA $/SQ"FI'.
u-huildar wAl hme me burden of pnrving that he did nm build oIrrtprove for per- 7
pme'f sok.). �P
I f the priffery,am exclunively rumbach.,wan hipmed camarwhas In 'TOTAL:
conautthe p j t(See 7044 Busies adfnf.:' sCan ,his,C Isa.re L'
terp,Law does notapply t ofproperty who builds or impreve,thereon,and QTY PLUMBING PERMIT FEE FEB '1 7
pronounce,f aht d) 't enl t OI �licensed u thC tows r, .S V ANS.®
Liweres,Law. PERMIT ISSUANCE CITY Ur
Iuman
exemptder Sec ,B&PCfnrdhi,m.,,,n
AL'1'Bk-0RAIN&VENT-WATER(LA) Ah ON
Owner Date
WORKER'S COMPENSATION IIHCLARA'i'ION BACK FLOW PROTECT.DEVICE
1 hemhy athrm under penalty.f perjury,tine of the full mw...declared l'n,
(] Ih.,,.ad will maidum uC,,ifcac'f C...em l'nelf-inure for W.Ame,Compete- DRAINS-FLOOR,ROOF,ARE A.COND. STORIES TYPE CONSTRUCTION
set....as provided for by Section 3700 of the Labor Gale,for the perf'rmanre of the
work for which this permit is i,and. FIXI'U RBS-PER TRAP
I have and will maintain Worker's Compensation Insurance,as required by Section
3700ofthe Lather Code,for lBepedmommeoflhe work for which this permit is issued GAS-EA.SYSTEM-I INC.4 GO mcL 'r5 OCC.GROUP APN
My% ,Co Iemarc c and Policy 11 rare
Carrie ens a -.1 arae Policy No.'. �'6�-q�`/�(-I�'_ GAS-EA.SYSTEM-OVER4(EA)
CERTIa CATE OF E)EMPTION FROM KE( ER)1
COMPENSATION INSURANCE GRFASFJINIIUS"URLWASTE INI'ERCEMOR
(This section need net becomplemdif ilePernit is(Drone hundred dollars($100) BUILDING DIVISION PEC9
or less.) GREASE TRAP PhANCI RICK PGE
I entry fire in the performance ofthe workf'rwhim this permit is issued,l shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as to become subject m the Workers'Con Item ENERGY V171120 z ration Laws oI California.Date - WATER HEATER WNGNT/ELECTR
z O Applicant GRADING FEE
y NOTICE TO APPLICANT:11;after making this Certificate of Exemption,you should WATER SYSTEMn R17AI INC,
become subject to the Workers Ce rdemaZ tiob provisions time boon,Code,you must SOILS FEE
Wti forthwith comply with such provisions or this permit shall be decmedip,mmd. WATER SERVICE
Q
CONS're iso eIONLENUINGAGENCY NEW RESIDENTIAL PLMB. SQ,FT. PAID
Up I foreby whichrn thermic is issued muclSte.3097in ,
Cm.agency for the perfonnanecof Date L I
Lks the work riot which this permit is issued(Sec.J097.Civ.C7
ULeader's Name 3gli
W Lender's Addre.s 'FO LAL:
I certify thin l lemnaad this application and state that the have information is BUILDING
rF-r lip, i agree m comply with all city and county ordinances and state laws rclaing to QTY. MECHANICAL PERMIT FEE
U a7 building construction, er
ction,and hereby authorize representatives ofthis city mentupon the SEISMI FL'L'
ah.ve-mentioned propcny for inspection purposes. PERMI'iISSUANCE ELECTRIC FEE
(We)agree to save,indemnify and keep harmless the Clly of Cupertino against
liabilities,judgments.costs and expenses which may in any way accmc against said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit PLUMBING E
APPLICANT UNDERSTAZAND�LMPLY WITH ALL NON-POINT AIRHANDLING UNI'F(1010.000CI-M)
5 IIRCQ HGLNS. /ma�yy Ogg MECHANIC
"E
AIR HANDLING UNIT(OVEk 10.0(10 CPM) CONSTRUCTION TA
Sig of plicvnUCanuaamr Date EXHAUST HOOD(W/DUCT} HOUSINGMITIGA'I'I [ZEE
HAZARDOUS MATERIALS DISCLOSURE
Willtheapplitma afiumboldingoccupatmem or handle harmism,nattered HEATING ON['1'(I'U 00,000 HI U)
as defined by the Cupertino Municipal Code,Chapter A 12,and the Health and Slimy
Code.Section 25532(a)? HEATING UNIT(OVER 100.000 BTU)
❑Yes [D No PAID
VENTILATION FAN(SINGLE RPSID) Date Reecgh It
a Will the applicant.f future building by the Bt use Area
Air Qu or Marra which
emit air iontamiwnts as dekneJ by the Buy Area Air Quality Management HUILF.R-COME(3HP OR IW.WU BTU)
District) . TOTAL:
❑Yes ❑No BOILER-COMP(OVER IOO,IIW tl'I'U) "
I have read the fie a dma materials requirement.under Chapter 6.95 of me Cali- AIR CONDI'I'IONF,R EssuAtLaE DATE
firman Health&Safeay Cale,Seouo 255(15,25533 tend 25534.I undrulnnd find the NEW RESIDENTIAL MECH. SQ.F-E
lding d h nave- thm it is my re of acanfil notify the rparcy. ,
ort c d ichm ods ePoCerl...many
Ownerorauth rbedagent Irate TOTAL: ISSUED BY:
OFFICE