29298 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO _ BUILDING-ELECTRICAL 'PERMIT NO. ,�
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
10201 N De Anza Blvd.
OWNER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
C he Jack D ond• CO 649915 "" `°NrROLx
�\ .CNO: ADDRESS: ❑ .
HOK P O Box 7430 Mt View CA
CONTACT. PHONE: BUILDING PERMIT INFO
Gil Hubbard 415-243-0555 ❑ Consultant Fees Paid by Applicant(Initial) BL ;NL PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT
Z FEE ❑
1 hereby aft that 1 am licensed under previsions of Chapter 9(commencing JOB DESCRIPTION
OCwith gection 7000)of Division3afthe Business and Prnfessinns Code,vnd mylicenu is
00 - PERMIT ISSUANCE RESIDENTIAL:
mlhu some arta errect. R. A4991,rj ❑SFDWL � ❑KITCHEN REMODEL
aUO License Cider _ Li°a APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING Rf PIPE
; i Date C'S DECLARATION
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
OFA PANELS '
CC f� I understand my plans ahvll beater!as publi<recnNs MODIFICATION
UP TO 200 AMPS
p - ❑INTERIOR ' [I CHIMNEY REPAIR
h4 Licensed Professional - 201-1000AMPS IMPROVEMENT
++�� OWNER-BUILDER DECLARATION Cor ION OVER HdCAMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
C C ti hereby affirm thin 1 1. exempt Tinto the Cemr ra Cod License cLawity
for Nc
O y V (011owing reason.(Section]OJ LS,Business and Professions Cak:Any city er county SIGNS ELECTRICAL ❑OTHER
sR 3 LL F' which in issuance,
permit re cnnswa,aline improve,demolish,or repvig nny swment
(r��O prior to iter issuance,also requires the applicant for such permiuolilen signal amtemrnt SPECIAL CIRC TSC.
{ } thatheatteen,olpursuann.theproAdmilof Ne Communr's License Low(Chapter 9 ,
K� p0 (commencing with Section 7000)of Division ofthe Business and Professions Cade)or TEMP.M R EINST COMMERCIAL:
N that he is esempt therefrom wd the basis far the alleged exemption.Any violation Of e ❑NEW BLDGIADDITION 0 DEMOLITION
Section 711L5 by any applicant for apermitaubjects Ne applicant to a civil partly of POWER DEVICES
y FTENANT ❑FOOD SERVICE
1„ZZ y not more than five hundred dollars($500). IMPROVEMENT
q a ❑I,as owner ofthe pmpeny,or my employees with wages as their sole compensation, SWIMMING LELF 'R
iSjLL O xnll do the work,wd theawqurc is notimenJW ornffeted for sale(gecJ1144,Rosiness ❑OTHER
ul3 and Professions Code:The Contractor's License Law fres on apply to an owner o LETS-SW -PIXT
GG properly who builds or improves themon,and who does such work himself or through -
his own employers,provided that such improvements are not intended or offered for, NEW R 'IDENTIAL . CI'R SQ FT.
sale.If.however the building or improvement is sold within one yearnfemaidetien,the ^ SQ.FL FLUOR AR ,SISQ. k(Z.
owner-builder will have the burden of pmving that he did not build or improve for put- 7 3{lJ'
E],e,opausairfrowner of the property am exclusively contracting with licensed comracnus to T ��tilt, I} a
consumer project(See.7044,Business and Professions Code:)no Contractor's Li-
cneLaw doesour apply toanowner ofproperty who builds orimproves thereon,and QTY. PLUMBIN RMFF FEE FEB 6 1996
who commmt(
contracts for such projects with a contracs)licensed pursuant is the Contractors
License Low. PERMIT ISSUANCE
I am esempt under Sec. ,B&P C for this reason f
it;L-Iduemugo
Owner Date ALTER-DRAIN&VENT-WATER HU) A
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE 1�I I Coo �•
I hereby affirm under penalty Witerjury one of the fallowing diannatimic ` ` N4/
have and will maintain a Certificate of Consent to self-insure for Worker's Compcn- DRAINS-FLOOR.ROOF,AREA,COND.
cation,as provided fm by Section 37M of the Labor Cale,for the performance of the STORIP_S TYPE CO 'TRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
❑I have and will monsoon Workers Compensation Insurance,as required by Section
37M ofthe Labor Code.for the performance ofNe work for whichthis permit is issued. GAS-EA,SYSTEM-1 INC.4 OUTLETS OCC.GROUP AM
My Worker's Campensvlion Insurance comer and Policy nnmhr are:
Cy Workers Policy No.:.'J'�Q.a-r: GAS-EA.SYSTEM-OVER4(EA) - i
CERTIFICATE OF EXEMPTION MOM R'SRR(hfy^'—"
COMPENSATION INSURANCE GREASEIINDUSTRL WASTE INTERCEPTOR ELflk,DIyfSION M%S
(Thissation need notMaumplueJ if the permit is farunehundredd011urs(SI W) GREASETRAP
or less.) PIANCHECKEE
I citify that mire pmfUr rUrUeofthe work fm which this permit is issued,Ismail[ SEWER-SANITARY-STORM EA.200 Pf.
not employ any person in any manner so as to become subject to the Worker'Compen- ENERGY
ZZ anion Laws of Celifomiv.Date WATER HEATER WNENT/ELECTR
O Applicant GRAD
y NOTICE TO APPLICANT:If.after making this Certificate of Exemption,YOU Should WATER SYSTENUTREATING _
F+ become sub eet 1.the Wmkeh Compensation f the Labor Cede,you and 501 F
j p Provisions
foNswiN comply with such provisions or this Permit he dcemN revoked. WATER SERVICE
.7. Z CONSONLENDING AGENCY NEW RESIDENTIAL PLMtl. SQ.FT: PAID Ue Raeiptp
V O (hereby nRm that thereem is aconstruction lending agency for the peHarmance of
the walk for which this permit is issued(Seo 3097,Civ.C.)
QU Lenders Name - - TOTAL:
{kl Lenders Address TOTAL:
0 G . I certify that I have read this application and some that the above into aion is BUILDIN FEE •��
V] corral.lance w emaply with di eityvndcoumy oodimncecand store laws relining to QTY, MECHANICAL PERMIT FEE
V z building construction,and hereby authorizempprexturives ofthis city to enter upon the SEISM( PEE
r+ .hove-mentioned Property for inspection Aurposes.
(We).91.m save.indemnify and(cep harm ss the City of Cupenino against PERMIT ISSUANCE ELECT
liebiliti<s,judgoacnts,cas'andexpe ,:a which ny way necmevgainn said City ALTER OR ADD TO MECH. PLUMBING FEE
in consequence or the granting of this permit
APPLICANT UNDERST AN L ITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL IEE -
SOURC TI
AIR HANDLING UNIT(OVER 10,000 CFM( CONSTRUCTIONTAX
ofApplican Common Dine EXHAUSTHOOD OVMUCO ROUSING MITIGATION
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fumm building Occupant score or handle harardous material HEATING UNIT TO 100,000 BTU)
av defined by the Cortina.Municipal Cale,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)T ' HEATING UNIT(OVER 100,000 BTU)
[Dyes y1No PAID
VP,NTILXRON BAN(SINGLE RESID) Uete ReccipM
Will the applicant or future building Oceupam ou equipment or dcvims which ryO11.ER-COMP CHIP OR IOO.t1NI BTU)
mro ufin
it hwadous air emarnto as deed by the Bay Area Air Quality Management
District'!
❑Yes KN. BOILER-COMP(OVER 100,000 BTU)
� '
I have rend the hazaNats arsenals tcyuinmema underChVier 6.95 of Ne Cali- AIR CONDITIONER ISSUANCE DAT
ramie Health&Safety Curie,Sections 25505,25533 and 25534,I Understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building doeenot currently have.te...L Out it is my responsibility to ratify the occupant
of the requirements which must he met prior to issuance of a Certificate of Occupancy. ` 1
Owner or vutho fired agent Date TOTAL: ISSUED BY:�
OFFICE '