29768 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL CO
BUILDING PROJECT'IDENTIFICATION V o
BUILDING ADDRISS: /0 OUC/N bCf /s /� �O r �1its SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'S NAME: PHONE: l/CO`UNTTRRAACCTOR;5 NAME: LUND: N
N/C CONTROL#
ARCHITECT/ENGINEER: LIC NO AUDRESS: yea ❑
CONTACT. "'TI/. Llks alQn�.y PHONe: !�� ' BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BRLDDG, ELECT' PLUMB MECH
CONTRACFOR:S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
wOOonCMZ with Section 7M))of Division 3 of the Business and Profession%GNe.and my license is RESIDENTIAL:
BPERMIT ISSUANCE
F F Li full force and ft?. �,a d
m sem_ ❑SPDWL E3 KITCHEN REMODEL
�UyU License Clnsx l.loM pPPL1ANCE5-RESIDENTIAL ❑ADDITION El PLUMBING RIiPIPE
rn<i Dom GS DELL
F,o`m ARCHITECTsS UIiCblic words
PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z p in I undcmand my plans shall be used as public rccnNs MODIFICATION
OZ—W UPT02IXIAMPS ❑INTERIORCHIMNEY REPAIR
j Licensed Profeuianal 201-100DAMPS IMPROVEMENT
�d ,..I OWNER-BUILDER DECLARATION OVER❑XIOAMPS Ll BATH REMODF.IIRF:PAIR [D DEMOLITION
C ¢ I hereby affirm that I am exempt from the Contractor's License Law for the
2OGU lidlowing rearm,.(Station]03L5,Bnsim,s and 11ndessior,s Coda Any city or county SIGNS I?hliCl'RICAL El OTHER
3 a y which require. .a permit ,,eon,tmm,ahcr.imp...s.demmien.m aT ter any stmeture
E"LLog Prior I,,it,v..once.Zl,.mgmZv,deit,licam for.such pc.it o file a signed vem,ouat SPECIAL CIRCUI DMISC.
��} that he is llcenseJ p moram to the provisions of the Contractor's License law(Chapter9
8100 (commencing with Santo 7000)of Division 3 ofthe Business and Pmfessions CW0or TEMP.METER OR POLE IN COMMERCIAL:
6 C.a that he is exempt therefrom and Ne basis for the alleged exemption.Any violation of El NEW BLDG/ADDITION ❑DEMOLITION
N, Section 9031.5 by any applicant for a permit offices the applicant to a civil penalty of POWER DEVICES
W^rte ❑TENANT ❑FOOD SERVICE
not mora than five hundred dollars(55(X1),
IMPROVEMENT
6 oiLaxownernllhc peanut oemY omntended w offien k)rsaIciSee.7empemaian, SWIMMING POO LECI'RIC
E O will dnthcwnrk,ande:The isZou Lienee owdols of apply to an,Business [I OTHER
0.3 and Professions Code:The Conttheret License Law does not apply s if owner of OUTLCF$- ITCHES-PI%TURI?8
property who builds or improves tbemm,and who docs such work himself or through
his own employees,pmcidW tea such improvements arc not intended or o1Tem1 for NEW .IDENTIAL ELECfR SQ FT,
sale If.howeveethe buildingthe bunh,rprovement is at he did none build
i ampletfoq the SQ.FT.FLOOR AREA 5/SQ.FT.
e.f'.1Jer will have the burden of Proving that he did not build or improve for par-
0 of aa1eJ.
❑ 1,as owner of the SeeE,opsrt,70sa ,Business exclusively nmt,,,i,mg with IicThe Caourna.6 k TOTAL:
onamm thepr,iot pply o ancwmund PZrfty who one Godo:) pro es thertore Ll- JUN 241996
nmlawdoeor such plyman with
aofpropeny whobaadsmimpra.ee Contra,andoe% QTY PLUMBING PER IIT PEE
who eomtan,for nate rmie<ta wire a wmmemrts)Baen,ed nnrsanm to the eantrannrs
License law. PERMIT ISSUANCE
❑l am exempt under Sec. .B&P C for this mason _+III .t' _k,'..,illN�
ALTER-DRAIN&VENT-WATER(F VALUATION
Deaner Date
WORKER'Srath, fpmjm,on DECLARADON BACK PLOW I'ROIECT.DEVICE
1 hereby infirm under pcmhy of pe jury one of the following Jcelvmtions
❑Ihave end will maintains Certificate of Consenuoself-Insure for Workers Campcm DRAINS-FLOOR.ROOF AREA,CONED. STORIES TYPECONS'FRUCION
ration,as providW for by Section 3900 of the labor Cole,for the perfmovim a of the
work her whichthis permit is issued. FIXTURES-PER TRAP / j/)
1 have and will maintain Worker's Compensation Insurance,as required by Section ' (i
37!X1 of the Lahor CWe.for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.J OUTLETS OCC.GROUP APN
My Wnrkcy'S tion yy� cy lso.y.motor are
:�9 mss' f
Carrier', y�(y�O e,, lysjj_ePandPNo.'. o1y'� I7" 9r' GAS-HA.SYS'1'EM-OVER4(BA) 'f�`11
GliRT11'IGATE OF IiXI.MP1'NN FROM WORKERS'
COMPENSATION INSURANCE GREASIVINDUSTRLWASTE INT' CEPTOR
BUILDING DIVISION FEES
(This section read not becompletW imepermit is for one hundred dollar(SIDE)
or less) GRGSEI'RAP PLANCHECK FEE
leertifythat in thepcart.mmnceofthe workforwhmhthispermit irissaed.Ivnall SEWER-SANITARY-S RM EA.200nnot employ'any person in any manner so as m become subject subjeco the Workers' li
Comn- ENERGY FEE
0 ,Z nation Lawsof California.Dae WATER BEATERW�N VELECI'R GRADING FEE
Applicant
'Z h NOTICE TO APPLICANT:If,alter nmking this Cerificam of Exanpti...you should WATER SYST'E REATING
? become subject to the Workers Compensation provisions of the Luber Code,you must 5011-S PEE
foMw4b comply with such pmvisions or Nis permit shall he deemed revoked. WATERS[ ICE
aQ
U O CONScONI.ENDINGAGENCY NEW SIDENTIAL PLMB. SQ.FL PAID Dam RcceiptN
I hereby affirm that thereem is is aa nmstmcunn lending agency for the performance of
the work for which this permit is iwual(See 3097.Civ.C.)
W ' Leader's Name 'IUTAL:
F-
U <nder's Address TOTAL:
�S LL1 BUILDING FEE
F 1 certify that 1 have read this aPplicmion and rime that the aMwe information is
TaA correct.I agree to comply with all city and county ordinances and state laws misting to QTY. MECHANICAL PERMIT FEE
V Z building construction,and hereby authovc mpresematives oftnis city to enter upon the SEISMIC FEE I
above-mentioned property for inspection pro,now,. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
Ii.1uIi1ies,jud11mnn1.eosuavd expense,which may in any way uceme againasnid City ALTER OR ADD TO MECH.
.sequence of the grunting of This permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TO 10.000 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTIONTA%
Sigrainof Applicant/Contmctor Date EXHAUST HOOD(W/DUCO HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSUR17
Will the applicant or future buildingixo,upant store or handle haimtous mmenal HEATING UNIT(TO 100,00 RFU
as defined by the Cupertino Municipal Code.Chapter 9.12,:ted the Health and Safety
CWa Section 25532(a)'i I HEATING UNIT(OVER 11X/ 111'1)
❑Yes VN. VENTILATION FAN(SI LE RCSID) PAID
Dae Rettipt M
Will the applicant in future building oecupam use equipment or devices which
emit hazarlous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3 OR 100.(X10 BTU) T
Di,vier^ BOILER-CO (OVER IIXI,IXX)ETC)
0y. No
AIR CON/ IONBR
1 have read the hazanou
is mamriels rcgquimori under Chapter 695 of the Cali- ISSUANCE DATE
fomia Health&Safety Code,Seeman,25505.25533 and 25531.1 u Wesvand Wet if the NEW SIDIiN`F AL MECH. SQ.FT
building does not currerdy have a mwnL Nan it is my responsibility to notify the occupant
of the require nes which gmst be met pd, m issuance
Is Cen.Iusimof panty
(wnerornmhoria gen ate TOTAL: ISSUED BY:
OFFICE