29958 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
. CITY OF CUPF.RTINO " - BUILDING ELECTRICAL PERMIT NO. 29958�•S ^ r.../N
BUILDING DIVISION APPLICATION/PF,RMIT PLUMBING.MECHANICAL L `9`9`4 Js VX
BUILDING PROJECT IDENTIFICATION
BUILDINGAODRESS: SANTI'ARYNO. APPLICA'T'ION SUBMITTAL DATE
y uLS5868p
OWN NAME: - PHONE. CO TRACT R NAME: LIC NO
I SVA)- NIC CONTROL Is
ARCI II IECT/fiNGINEIiR: IAC NO, Aql e(Snot 411 O
CONTACT: PHONE: / aI
1BUILDING PERMIT INFO
e5+Q_V?J QT 1 W I s 7 V G ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
ID I.
❑ ❑ ❑
LICENSED I CONTRACTOR'S DECLAIIAC Chapter
QTY ELECTRIC PERMIT FEE
1 hereby affirm tbm I .1 licensed under provisions of Chapter 9(commencing JOB DBSCRIPTION
OZ with Smntion]011111 of Uivilion7nfthe Business unA l'ndesvione Cale.and my license is RESIDENTIAL
F- full farce and effect. PERMIT ISSUANCE
TUzU License Class Lic.N ❑SFDWL ❑KITCHEN REMODEL
N6L Date Common, APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
ARCHITECT'S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL.
Z p r.=4 Z 1 understand my plans shall be used as public record PANELS
O Z:J UPT0 Aa AMPS yMODIFICATION
m
h F"LLOLL1I Licced Professional C1 INTERIOR IEICFIN NEY REPAIR
OWNER-BUILDER DECLARATION 201d000AMPS IMPROVEMENT
yy t.4 1 hereby affirm that T ten em nat cram the Contractor's License L.w for the OVER RKKIAMPS ❑BATH REMODEUREPAIR O DEMOLITION
ig34F following reason.(Section
]031.5,Business and Professions Cade:Any city ar county SIGNS ELECTRICAL. ❑OTHER
1IYY 4 Om¢ which requires a Permit to cannot,alter,improve,demolish,or repair any structureJ primm I,,anamce,alsnmmoneslhe applicant tnrsonh permit to Ele.dinedswtmmeml SPECIAL CIIICUIT/MISE.
2mol that he is licensed pursuant to the provisions ofthe Contractors License Law(Chople,9
X00 konancncing with Smtinn l0110)nf Divisinn3 of the Business and PmfessinnsCWe)or TEMP.METER OR POLE INST COMMERCIAL:
L` WW��'' that he is exempt therefrom and the basis for the alleged esmalta nn.Any violation of [I NEW pLDG/ADDITION
.1Z
Section 7031.5 byany applicant fare perm it subjects the applicant to.civllpenalty of POWER DEVICES [I DEMOLITION
not more Nen five hundred dollars(5500), [I TENANT ❑FOOD SERVICE
(] I,ee owner of the property many employees with wages as their Hole compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the thrown,is not intended or offered lin sale(Sec.70D,Business ❑ ER
a 3$ and Professions Code:The Contractors License Inw does nor apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who huilds or improves thereon,and who does such work himself ar through
his own employees,provided that such improvements arc not intended or offered far NEW RESIDENTIAL ELECTR SQ PE
to.If,howevecthebuildingorimprovement is sold withinone yearofcompletion.dr, SQ.FT FLOOR AREA $/SQ.FT.
owner-builder will have the burden ofproving that he did not build or improve for pury pp p T51
pose m"I le.).
❑h as owner of the property,am exclusively contracting with Honmed contractors to 'TOTAL:
construct the Limiter(See,]044,Business and Professions Cale)The Contractors I.i- MAY '311996
come Law docs not apply n an owner of properly who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contras for such projects with a commands)licensed pimme ntto the Commoners
License Law.
E3 am exempt under Sec. ,B&PC for this reason PERMIT ISSUANCE
4:IIY Ur u�'tnII1�U
ALTER-DRAIN&VENT-WATER(FLA)
Owner DIO 30DLOTION
WORKER'S COMPENSA'T'ION DECLARATION PACK FLOW PROTECT DEVICE - =v
1 Hereby aRrm under penalty of perjury one of the following declamations o
Ihave and ponidel maintainSeems.ficamol the man toLabor
Code,far the Worker's Camper DRAINS-F1.00R,RODEARIiA,CONE.
satlon,us mvided far h SwJon J]00 of the Luhor Calc,I'or the STORIES TYPI?CONSTRUCTION
P r peanrmaamc none
work for which thisniis issued. FIXTURES-PER TRAP
. [I1 have and will maintain Worker's Compensation Insurance,as required by Section
3700ofthe Luhor CWe,for the perform ccoflheworkfnrwhichihispenmilie issueJ. GAS-EA.SYSTEM-IINQ 4OUTLEIS
OCC.GROUP MIN
My Worker Co tpe etiad ur ace mer end P.HcYM:"3`a
Carrico Policy No.: ' ` GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATH(IIs Ix dMiTION FROM WORKERS'
COMPENSATION INSURANCE GRHASE/INDUSTRL WASTE IN ITECEPTOR
(This section need routine completed ifthe perch is Tomos,hundrtd dollars(S half BUILDING DIVISION M.IS
mless.) I GREASETRAP PLANCHECK PER
I certify that io the performencenlthe work for which this permit is issued,l shall
not employ any person in any manner so as to become subject to the Workers Com n: SEWER-SANITARY-STORM EA.200 FT.
z union Laws of California.Date 1 pe ENERGY IEE
ZApplicant WA'I'BR HEATER W/VP.NT/1?LECTN GRADING FEE
s-a FN-t NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYS'TEM/TRrATING
became subjen In the Worker's Cumpemnion Fro,kiansol'(Je Lubar Code,you must SOILS FEE
forthwith comply withmeh provisions or this permit shall he deemeJ revoked. WATER SERVICE
Q
� z CONSTRUCTION LENDINGAGENCYagency NEW RF,SIUI?Nl'IALPLMB. SQ.PI'. PAID
U T for by which
affirm that emit I issued(Sect3097,ding agency Tenho Performance of Dae Receiptp
LNs f'+ the work for which thio permit is issued(Sec.3119],Civ.C.)
O U Lender's Name TOTAL:
W Leaders Address - TOTAL:
96 1 codify that I have read this application and nate that the above information is BUILDING FEE
(4 norma.I agree In comply with ud city and county n di....c,and aurae laws tel.ing m QTY. MECHANICAL PERMIT FEF.
U Z buiWingconswnion.andherebyauthonrcrepresentativesnftNscitymerceruponthe SEISMIC FEE
r above-mentioned property for inspection purposes
(We)ngreo to ruse,indemnify and keep Iuulnless the City of Cupenino.,Itincl PERMIT ISSUANCE ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way accrue against avid City ALTER OR ADDTO MECH.
in consequence of the grunting of this Permit. PLUMBING FEE
APPLICANT NDERSTANUS rD WILL COMPLY VJITH ALL NON-POINT AIR HANDLING UNIT(TO Rodtf10 CFM)
SOUR .GULAsis. / � ) MECHANICAL FEE
v 3/ G AIR HANDLING UNIT(OVER 10.003 CPM)
CONSTRUCTION TAX
ignature of ApplicanVContradcr Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupanlnore or handle hazardous material HEATING UNIT(TO f0d"BIG)
es defined Cupertino Municipal the CupMunicipal Cale,Chapter 9.12,and the Health and Safety
Cak,Sation 25532(.)7 HEATING UNIT(OVER 100,000 BTU)
❑Yea F1 No PAID
VENTILATION FAN(SINGLE RESID) Dam Receipt p
Will the applicant or future building occupant use equipment or devices which BOILER_COMP IMP OR I W,IXq BTU)
Emil h tourdous air emuminams as defined by the Bay Amo Air Quality Management
Dishiay TOTAL:
f ❑Yes ON. BOILER-COME(OVER Up"BTU)
7 AIR CONDITIONER
1 neve cud the ha>ardout ma¢nels rtquirtments under Chapter fi.95 of the Cali ISSUANCE DATE
fomia Health&Safety C de.Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.Fr..
to does nm oonrunly have.Inman,lash it is my responsibility us notify the occupant
of the mommmcnts which must he met prior to issuance of a Cadifictte of Occupancy,
Ownaror.uthonood agent' Date TOTAL: ISSUED BY:
OFFICE