269742LICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PE
TY OF CUPERTINO DU LDDIINU-
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -
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BUILDING PERMIT
FEE PERMIT
BLDG PLUMB
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JOB DESCRIPT]ON
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FEE SUMMARY
OUTSIDE FEES
SANITARY Y
RECEIPT#
SCfI00L TAX Y
RECEIPI'p
/ PARK FEE Y
RECEIVE'#_
BUILDING DI V I. ON F
PLANCIILCK FEE
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ELECTRIC PER MIT
SEISMIC FEE.
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PERMIT ISSUANCE
FEE
LICENSED CONTRACTOR'S DECLARATION
APPLIANCES - RESIDENTIAL
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1laolbyaffirm that l am licensed underprovisionsofClapmr9(commencingwith
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Section 7001 of Division 3 of the Business and Professions Code, and my license u in
PANELS
full fore and effect.
FGW
Liccme Clara Lich
UPT02MAMPS
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Date Contractor
201 - 1000 AMPS
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ARCLIII=S DECLARATION
OVER 1000AMPS
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I undersmnd my plans shall be used m public records.
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SIGNS ELECTRICAL
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IicenxJ Profnssinrtl
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OWNER -BUILDER DECLARATION
I hereby affirm that I sum exempt from the Commctor's License Law for the
SPECIAL CIRCUIT/MISC.
FLLQvFi
y city or county
following reason.(Section 9031.5. Business and Professions Code: An t t
TEMP. METER OR POLE INST.
which rywrra a Iro�it m construct, alter, irnpmve, demolish, or repair any atmrmre
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to its issunnev..N. the Means rnr such tat idea signedsooemenl
prior requires pp pemti
POWER DEVICES
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that he is licensed pursuant to the provisions of the Contractor License law (Chapter
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9(commencing with Section 7000) of Division 3 of me Business and Professions Code)
SWIMMING POOL ELECTRIC
or that he is exempnhertfrmm and the bazis tonne alleged exemptiom.Anyvokinion of
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Section 70315 by anyapplicunt for it conit subjects the apphrmam a civil penalty of
OIJTLLTS-SWITCIIES-FIXTURES
Css
not more Ihw five Imndrea dollars (8500).
NEW RESID[IJ'DAL FLLCfR FT.
Fo
❑ 1,mownemfthepmpny.ormyemployeeawithwagesmmeirsolecomWnsation.
_SQ.
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will du the work,und the swctute is not intendcAoroffered forszle(Sce.70al Business
and Professions Code: The Contractors License Law docs not apply to on owner of
property whobuildsor Improvcx Ihemon, and who does such work him elfn r through his
ovonemployess,provided thm such improvements arc not intended oroffered for sate. If,
however, the buildingor improvement is sold within one yentrofcemplction. the owner -
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builder will have the burden of pmving that he did riot build or improve for purpose of
sale.). QTY.
❑ I, osowncr nl'tbe property,rim exclusively conmemina with licensed convnnorsm
PLUMBING PER MIT
construct the project (Sec. 7N4, Business and Professions Cede:) The Contractor's
License Wwd«anot apply man owncrofpmpertywhm buildsmimprovexmcrrogand
PERMIT ISSUANCE
whocontraces forasch projects with a communicant) Licensed purssanft the Contractors
Lice mLaw.
nl
ALTER - DRAINk VENT -WA' LER (PA)
❑ an exempt under Sec. . 13 & P C for this reason
BACK PLOW PROTECT. DEVICE
Owner Date
WORKMAN COMPENSATION DECLARATION
DRAINS- FLOOR, ROOF, AR FA. COND.
❑ I hereby affirm that I have a cenificatenfcomant m self -insure, or a certificate of
FIXTURES - PER'fRAP
nrkers' Compensation Insurance or nowified copy thereoff5ee. 3800. Lab C.) which
cover, all etnployee'a under this Permit.
GAS - E.A. SYS TEM -I INC. 4 O
OUTLETS
Pat icy 0
Company
GAS . EA. SYM-A.OVER 4 (HA 7
❑ Certified copy is hereby famished.
❑ Cliilied copy is filed with the city inspection division.
INTERCEPTOR
GRPASFJINDUSTRL WASTE; IN
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
COMPENSATION INSURANCE
(This section need not be onnplcrea ifthc permit is for one hundred dollars (I I(m)
SEWER SANITARY - STORMP
m Leri.)
I certify that in the performance of the work for which this Permit is issued.I shall
WATER HEATER W/VENT/ELE
not employ any person in any mariner so as to become subject to the Workers'
Compemdmn Lwsof Califomia. Dole
WATER SYSTEMfIREATING
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Applirmu
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NOTICETO APPLICANT: If. altermaking this Certificate of Exemption, you should
NEW RESIDENTIAL PLMIL S). FT.
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became subject the Workers Compensation Provisions of the Labor Code. you must
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Fonhwim comply with such provisions milds permit shall he deemed revoked.
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CONSTRUCTION LENDING AGENCY
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I hereby affirm that them is a construction lending agency for the aforroance of
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the work for which this Permit is bossed (Sec. 3097. Cis. C.)
1<ndcr's Name
Lanier', Add... Q1 -Y.
MECIIANICAL PERMIT
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1 cenify that I have read this application and state that the above information is
correct. lagree ser comply with all city and county endurances and state laws relating to I
PERMIT ISSUANCE
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builiingmaswction. and hemby authonre reprtunmtivea still city toenter upon the
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abrwearantloned property for inspection purposes.
ALTER OR ADD TO MECIL
at
(We) name ,, save, indemnify and keep harmless the City of Cupcnino ogshed
liabiliticx,judgrncnts,costs ccxpcrwcs which may in any wayaccom against said City
AIR HANDLING UNIT (TO 10,000 CFM)
`and
Krmit.
im��rmc�mft eg
{ifmix
5I6�4
AIR HANDLING UNIT (OVER IO.OW CFM)
Slgnemrcnl Appllcur/Com¢lor ore
EXHAUST HOOD (W/DUCf
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,076) BTU)
Will the applicant or future building occupant store or handle har,mmw material
HE4TING UNIT (OVER IfAI,INtO BTG)
m defined by the Cupcnino Municipal Code, Chapter9, 12, antithe Health and Safety
Code. Section 25532(a)4
❑ Yca � Nn
VENTILATION PAN (SINGLE RESIDE
Ask
Will theapplicant mfuturebuildingoccupont useequipmenlnrdevices which emit
BOILER - COMP(JHP OR 100.000 BTU)
rvrdom air contaminants as defined by the Bay Area Air Quality Management
BOILER - COME'(OVER 100,000 BTU)
District?
❑ Yea All
NEW RESIDENTIAL MECTL SQ. FT.
I have mad the hazardous materials requirements under Chapter 6.95 of the
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Catiornin llwlm& Safety Core, Sections 25505,25533 and 25534. 1 understood that
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if the building does not currently have a tenant. that it is my responsibility to notify the
cupanl rAthe mgyirernm sawbich must be met prior to issuance ofy Cenlficate of
GRADING [ME
SOILS FEE
A.2IXIPf. Ii ERGV FEE
CR
PAID
Date Recciot#
PAID
Date
L 50 aA I I
!''- ISSUANCEDATE
SEP 6 1994
CITY Ur curtHurrd
ISSUED BY:I
BUILDING IEE
SEISMIC FEE.
axia�
ELECOUCFEE
FEE
PLUMBING LEL
MECHANICAL FEE
CONSTRUCTIONTAX
PAID
Date
L 50 aA I I
!''- ISSUANCEDATE
SEP 6 1994
CITY Ur curtHurrd
ISSUED BY:I