30306APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPNRTINO BUILDING • ELECTR
RUB,DING DIVISION APPLICATIONIPLRMITIs. PLUMBING. MECHAI
ITKNI I NO. 30306
5- L3 -`)C�
RTIHTECT/13NGINEBR: _—'�_ LIC NO:
4DDRESS l
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LCONCF:PHONR:e-,,
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BUILDING PERMIT INFO71pj
\As,CAP4)xr �C�v1.JJ
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❑ Consulfant Fees Paid by Applicant(Initial)
HIM ELECT PLrU—MMB/ MECH
❑ ❑ LJ ❑
LICENSED CONTRACTOR'S DECLARATION
O,t00Z affirm I hereby arm that 1 ant licensed under.... Won, Of Chapter 9 (commencing
fthe Business and Fortes inns Catic, and my license is
�� in full farce and effect..
S LUQ❑SFDWh
, with Smdmu7fMKF.fDi*Affl:TEC�'�S
Licetve-Le-p
QTY ELECTRIC PERMIT
PERMIT ISSUANCE
FEE
JOB DESCRIPTION
RESIDENTIAL.
]KITCHEN REMODEL.
,,,��
❑ADDITION 91w.UNIBING RE -PIPE
❑MULTIUNIT ❑STRUCTURAL,
MODIFICATION
❑ INTERIOR El CHIMNEY RfipplR
IMPROVEMENT
El BATH REMODEL/REPAIR (]DEMOLITION
❑ OTHER
aUU
IN„pDamonvacntr APPLIANCES - RESIDENTIAL
t�n 111CILAIA'I'10 PANELS
z O �, 1 undersmnJ my plana shall be used es public recoNs
,OZ -C UPT0200AMPS
Licensed Professional `
.ti DECLARATION
Oat I am Contr ON
G a � 1 hereby affirm that 1 oat exempt train the Cnntracmrs License Law far the
5c a 6 U fallowing mason. (Section 7031.5, Boniness and Preep,si... CvdR: Any city m county
4411 Oa which requires a permit m constmct, afro., improve, demolish, nr .pair tmy swcmre
kph.] pdnnoits issuance, also requires We applicant for such permitmElea sa, ad,tmement
p. that he is licensed pursuant to the provisions ofthe Contractor's License Law(Chapmr9
2011(N0AMP5
OVER If00AMPS
SIGNS ELECTRICAL
_
SPECIAL CIRCULI'/MISC.
COMMERCIAL,
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT [I FOOD SERVICE
IMPROVEMENT
❑OTHER
00 (commencing with Section 70001of Division lot Ile Business and Pndeaal.ns Coda) or
66i5� c C Nat he is exempt therefrom and the basis for the alleged exemption. Any violation of
Wim Section 7031.5 by any applicant for a permit subjecrs the applicant to a civil penalty of
fF... } not more shah five hundred dollars (S500).
C Q ❑1. m owner of the property, or my employees with wages as their auto compensation,
CXCX will do the work,and the smmcure is not intended artificial! iinsele(See. 7044, Bmincas
TEMP. METIER OR I'OLHUsST,
POWER DEVICES
SWIMMING POOL ELECTRIC
W and Professions Code: The Cana h License Law does not apply to an owner of
d 3 - pntpeny who builds or improves thereon, and wha does such work himself or through
OUTLETS -SWITCHES -FIXTURES
his own employees, provide that such improvements are not intended m offered for
NEW RESIDENTIAL ELECTR SQ IT.
SQ. Fr. FL(2QR AREA'
VSQ. FT.
mli.If. h.weveq the building Or improvement is sold within One yearafmnnection.the -
owner-huilder will have the burden of proving that he did not build or improve for t ur
pane of sole.).
M I, as owner of the property, nm exclusively contracting with licensed mmmnms to
nmmm th
rue Instill (Sec. 70I4, Buniacw and Professions Coca:) The Canwemr's Li-
; TOTAL:
AUG �' 3 1996
censeLuwdoesnotapplytoanownerof pmpeny who builds or improves thereon, Old
whoeommsu
ets farch proje.mwitha eoamano(s)Ileeaee pursuant m Ow Coutrucmds
LEl icense law.
am exempt under Sec. , B & P C for this reason
QTY PLUMBING IT
PERMIT ISSUANCE1
FEE
n
CII V UC t/Wraor II DYU
Owner Date
ALTER -DRAIN & VENT- WATER BIA
VALUATION
WORKERS COM PINSAHON DECfARATION BACK FLOW PROTECT. DEVICE
Ihereby off mtder penalty of perjury occur the following dealandmi:
] I have and w ill nmimum a Certificate ofConsem to self -insure for Worker's Compea-
motion, as provided for by Section 3700 M the Labor Cale, for the performance of the
DRAINS- FLOOR. ROOK AREA, CONSTORI[S
TYPE CONSTRUCTION
work for which this permit is issued.
FIXTURES - PER TRAP
I 1 1 haveand will mainmin Worker's Compensation Insurance, as required by Section
1
3700ofthe labor Code, for the performantt.fthe work for which this permit is issued.
M W' ak -cccarrierand P.1my .man
Carrier: PcyNo: -
GAS - FA. SYSTEM -t INC.40UTLETS
OAS-EA.SYSTM.OVIR4PA)
OCC. GROUP
APN
CERTUICA 11 EXEMPTION FROM WOG'
Z
�2Applicant
COMPENSATION INSURANCE
(This when need not becomplemditthePermit is forone hundred dollars (5100)
or less.)
lecitif Ominthe if rmanceofthework f.rwhiehthis
y an the Werkeo' arram1
not employ any person in any mannermasmbecomesuhjenmthe Workers'Can m
pe
scion Laws of Culifomin. Dote
GREASPJINDUSTRL WASTE INTERCEPTOR
GREASE TRAP
SEWER -SANITARY -STORM EA. 200 FT.
BUILDING DIVISION MRS
,
PLANCIIECK FEE
ENERGY FEE ,
'WATER IiIiATER WNEM'IF.LEC'1'R
GRADING E
FE
rNi
abecome
0
UZ
U 0l
I1iF
O U
NOTICE, TO APPI.ICANT: If, .after making this Certificate of Exemption, you should
subject to the Workers Compensation provisions Of the labor Care. you mull
fimhwiih comply with such tumkiansor this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
rrat iso tilending agency for the performance of
the work for which this permit is issued (See 397. Civ. C.)'
Lenders Name
Lenders Address
WATER SYSTEM/TREATING
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
SOILS FRIT
PAID
Data Receipt
TOTAL:
Fy
.a V1
IJ Z
I certify that I have read this application and slam that the abuse information is
correct. l agree to comply with all city and county ordinances and state laws relating to
building consumption, and hereby outh.dze represenmtives ufthis city to enter upon the
QTY, MECHANICALPERMIT
FEE
BUILDING FEE
SEISMIC FEE '
above-mimionrd.,.,city for inspection purposes.
(We) agian to save, indemnify and keep harmless the City of Catania again.
PERMIT ISSUANCE
PERMIT
FEE
ImbilidcajaAgmcms, costs and expenses which maytn wayaccmeagatnst said City
' nsequcnce of the gaming oflhis permit.
ALTER OR ADD TO MLCH.
Irk
PLUMBING FEE CCJJ
APPLICANT UNDERSTA S AND WILI fPLY a 9TH ALL NON -POINT
SOURCE REGU},tW NS
AIR HANDLING UNIT LTO IO,lXO CFM)
MECHANICAL FEE
p A
��" ate'/��
J'a'
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
5ignamra mi picant/C mmelor Date
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUC[')
HOUSING MITIGATION FEL?
Will the applicant or future building Occupant stow or handle hazardous material
HEATING UNIT(TO 100,000 BTU)
as dermad by the Cupertino Municipal Code, Chapmr 9.12, and the Hcahh and Safety
Code, Section 25532nd?
HEATING UNIT (OVER IOf" BTU)
❑Yes I]No
Will the applicant or future building ache ]t on ea Air Qnt or devices which
.nitiet'i us air contaminants as defined by the Ray Arca Air Quality Management
Dish cR
❑Yes NO
VENTILATION FAN (SINGLE RESID)
BOILER -COMP (3HP OR 100,000 BTU)
BOILER - COMP (OVER I00,00I BTU)
PAID
Date Receipt it
TOTAL.
I have mad the Mzmdous materials requirements under Chapter 6.95 of the Cali-
y p
Tania Health & Safety Code, a ttinas 255(15, 35539 and 25534.ility u anif, tJ that if the
building ]res not currently have a mama, that o is responsibility ca o Ne.ccupom
AIR CONDITIONER
NEW RESIDENTIAL MUCH. SQ. FIE
ISSUANCE, DATE,
'
oI We reyuiremmau which mull be met nor to Of 11 CeniOcum of (lttapnncy.
ua ce Of11 at
,
ISSUED BY:
Owner or athorized_igent Date TOTAL:
OFFICE