30375 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING ELECTRICAL PERMIT NO. 0
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL
IIIIH,Dvi G PRQIECI'IDENTIFICATION
375
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
oN2DvlA 8 uf96
OWNER'S NAME: PHONC: CONTRACTOR'S NAME: LIC NO:
.b aLL A 6- „, N/C CONTROL#
CHITECLfLIENGINEER: LIC NO: ADDRESS: ET ❑
e
DOW041V—IN —76 r✓ Llffoeh /LL ;qj,ef51Z
CONTACT. PHONE: BUILDING PERMIT INFO
It q97-6464- ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
N if1�s` 9 ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
ceZ
1 hereby iffrm that 1 em licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
with Section700E.I'DividmiTmObe1heinessand Professions Cwle,snit mylicence is •� RESIDENTIAL:
00ull PERMIT ISSUANCE d
W§ L License
effect. ❑SFDWL (D KITCHEN REMODEL
�UZ Litems Class Co.# APPLIANCES-RESIDENTIAL ❑ADDITION C1 PLUMBING RF.-PIPE
�QtY Dom Conaunor
ARCHITECT'S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
Z C to Z� 1 un cntgnit my plans shall he used esy blit sec.rds PANELS MODIFICATION
OZ- -1 14.O✓hAe DnW�7�.IL/h/ UP TO 200 AMPS
7,41:" Licensed Franconian %NTF.RIOR [I CHIMNEY REPAIR
201-1000AMPS IMPROVEMENT
y OWNER-BUILDER DECLARATION OVER Ifs10AMPS BATH REMODEUREPAIR [I DEMOLITION
y{xt,Vi I herehy affirm that 11. exempt from the Cssions is License Law for the
DJ ii: Following reams.(Section 7031.5.Business arm Pnsfessions Code:Any city or roumT SIGNS ELECTRICAL ❑OTHER
W O which rcquim a permit m conswct,alter,improve,demolish,or repair any ator cmre
prior to issuance,also requires the applicant for such permit to fee a signed statement SPECIALCIRCUIT/MISC.
that he is licensed pu.uantto 0 visions must Comm bie.License Low(Chapmr9
X00 (commencingwith Sanion7001 of Nisi.,O.Obe incsx and Professions Cole)or TEMP.METER OR POLI?I NST. COMMERCIAL:
d
that he is exam t the mm unit e s r the Real exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
B• Section7 yanyo lic.ntf a u is the applicant wacivil penmry of POWER DEVICES TENANT ❑FOOD SERVICE
��. not mo hon five bund do PROVEMENT
Q (]I,us weer of or my t swish wages as their sole compensation, SWIMMING POOL ELECTRIC
O will Jo wn nit the ret m intended ormfred for sale(Sce 7044,Business ❑ R
4'3$ and Profen Ic:Th.- actor's License Loss does i appdy m int owner of 6 OUTLE'T'S-SWITCHES-FIXTURES
propety, s ilds proves thereon,aad who does such work himself.r through
his own emplo s,provided Ihet such improvements arc not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sals.ILhnwevei,t building or improvement is sold within one year ofcompletion,the S'01<7.MOOR AA $)SQ.Pr.
ncr-builder will hove the burden allowing that he did not build or improve for par. 111
pose of x
❑I.esowner
wne am
wner(ifthe See 7044.Business
contracting with licensed cnmmces i. IOTA
construct the project
pply toren Businessroprty who builds
CMeJThoves cemse owner Ufpropeny wcesed pursuant
to
Committees
License
QTY. PLUMBING PERMIT FEE
who commna for such projects with a emtrecrnKs)licensed pursuant t.the Commcm(a TT
License Law. PERMIT ISSUANCE V
[D I am exempt under Sec. ,B&P C for this reason
Owner Dete
I ALTER-DRAIN&VENT-WATER(TA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one ofthe following declarations: -(. V 000
I have and will maintain a Cendiicate or Consenun self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND.
.tion,m provided fm by Section 3703 of the labor Code,for the performance of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP •'',
❑I have and will maintain Worker's Compensation Insurance,as required by Section
37W of the Lahr Cast,far the perfomance of the work for which this permit is inand. GAS-RA.SYSTEM-I INC.4 OUTLETS OCC.GROUP � Nm APN
CroWf rke Co. tion nsNfc}' Poliic,wcy No:304-95 OAS-EA.SYSTEM OVER 4(['A)
CERTIFICATE OF EXEMPTION FROM WORKERS' ,gc
COMPENSATION INSURANCE GREASE/INDUS'I RI.WASTE INTERCEPTOR BUILDING DIVISION FEES
(Phis sermon modem hecompleted Hart permit is Tomos hundmddollars(5100) GREASE TRAP I
or less.) PLANCHECK PER,.)
Icenil that in the performance ofthe work forwhich this x•
y the Workers
Counter- SEWER-SANITARY-STORM EA.300 Ff.
not employ any person in any mam¢rsn as m become subject the Workeri Counter- ENERGY FEE
Off$
more Lawsof Califmnia,Dal. WA'I ER HEATER WNENTTLECfR
Z O Applicant GRADING FEE
It) NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTENUTREATING
h^ become subject to the Worker's Compensation provisions of the Laho Code,you must SOILS IEE
forthwith comply with such provisions or this permit shall he deemed mocked. WATER SERVICE
Q
Catthe is.sm NLE.NDINGAGENCY NEW RESIDENTIAL PLMB. SQ.PT. PAID
V k Farr shich rat thatthemisacd(Site 0n len dm ng agency fm the performance of Date Receipt#
L4 Ei
the workforwhichthis permit is issurA(Sec.7097,Civ.C.)
O U Lender's Name D TOTAL:
Q. I landclAddress TOTAL:
certify that 1 have rend mi
chis npplicnn anA orate thin the above infmxt
nrien is � BUILDING FEE
V0.] coned.l agree to comply with all city and county ordin.ncex and state laws relating to QTY. MECHANICAL PERMIT FEE
V buildi,emeaumion.and herehymahmi.representatives ofdoicily toemarupon the SEISMIC FEE
above-mentioned property for inspection purposes.
(We)agree m save,indemnify and keep Intensities are City N PERMIT ISSUANCE Cupertino against ELECTRIC FEE s Qd
liabilities,judgments,cods and expenses which may in any way iceme against said City ALTIiR OR ADD TO MECA
in consequence of the grunting of this permit. PLUMBING FEE V
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITD`010.010 CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 100000 CFM) CONSTRUCTION TAX
Signature of Applicanl/Contracmr Date EXI IAUSTHOOD(W/DUCT) HOUSING MITIGATION FET.
HAZARDOUS MATERIALS DISCLOSURE.
Will Neappeicant infuture building sacupantnoresr handle hazardous mamtial HEATING UNIT LTD 100,009 BTIJ)
as defined by the Cupertino Municipal Cade,Chapter 9.12.and the Health and Sauty
Code,Section 25532md? HEATING UNIT(OVER 100.000,BTU)
❑Yes No VENTILATION FAN(SINGLE RESID) PAID
Dam Recciptp
Will theapplicantcontmorfsta a building occurpby
nt Bay A aAir enittdManaemes ent BOILER-COMPQHPOR 100,0f11BTU)
emit ictxxrdonx air conmminanu as def sed M1y the Boy Area Air Quality Management
District? IOTA �
[I yes No BOILER-COME(OVER 100.00E BTU)
I have real the lamNnus materials requirement under Chapter 6.95 of Ne Coli. AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Cade,Sections 25505,25533 and 35534.d understand that if the NEW RESIDENTIAL MECH. SQ.IT.
building does not currently have.mw that isms my responsibility to notify are executorsof the awhich must be p vmissuan de •ni0cae.f oey.
Owns rtauNoriuA agent •
Data TOTAL: ISSUED BY:
OFFICE