S0388 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL vSUTNO.
BUILDING DIVISION APPLICATION/PF,RMIT PLUMBING-MECHANICAL J 0 J V 8
BUILDINC PROJECTIDEN'ITF'ICATION
BUILDING ADORES � � r SANITARY NO. APPI.ICA'1'ION SUBMITTAL DATE
BUILDING
NA ' 1'HON CONT G 53Rd
j� N/C CUNTROLN
�JARCHITEC ENGINEER: LIC NO: [$Jit ,A ❑
t
CONTAcf: `/moi ,_fyyx0NE: �/J 'BUILUING PERMIT INFO
;✓/ `/6? ❑ Consultant Fees Paid by Applicant(Initial) BLDG IiLE PLUMB M[
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby affirm that I oro licensed unJer pmvisinns of Ch-Pool 9 Bvotmencing
OaZ with Stttion 70(110 Division 3 ofthe Business and msm CW un my license is RESIDENTIAL:
W O PERMIT ISSUANCE
Fa W� in full force unJ ❑SFDWI. ❑KITCHEN REMODCI.
¢UU License Claz Le,# APPLIANCES-RESIDENTIAL ❑ADUI'TION [I PLUMBING RE-PIPE
F Z ty Dmc TECT*S ECL
Nod C..TBCT$DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
F,an an PANEfS MODIFICATION
Ot•+Z 14 Z I understand my plans shall be used as public records UP TO 201 AMPS
❑_ INTIiR10R [-I CHIMNEY REPAIR
W Limnrsd Pmfes,waid 201-100AMPS IMPROVEMEMt' []SWIMMINGPOOLS
'W,1$j OWNER-BUILDER DECLARATION OVER 1000 AMPS O BATH REMODEDREPAIR ❑DEMOLITION
C a Q I hereby affirm that I am exempt from the Contractor's License Law fnr the
x�x 06,U following reason.(Section 7031.5.Business and Profusions Code:Any city interiorly SIGNS ELECTRIC"ELECIRIC
❑OTHER -
1+13W v1i wbicM1 requires n permit m um.nruct alcor,intpnrve,demolish,or repair anY swnure
I�"u•�; prior to its issuance.also requires the applicant for such lrcrmin9 file asigneJ statement SPECIAL CIRCUI
P50
W} that he is licensed pursuant to the provisions ofthe Commemrs License Law(Chapter 9
W aa0 C0 (commencing with Section 9000)of Division 3 ofthe Business and Profesxime,Cadd or TEMP.SIFTER ORCOMMERCIAL:
t1 y m¢' That he is exempt therefrom and the basis I'nr the alleged exnnption.Any violation of ❑NIiW BLDG/ADDITION ❑DEMOLI"PION
iC W Section 90315 by any epplicant far o permit xUbjcn,flmt,,Ii,am mo civil per.111 f IVIWBR DEVICES ❑'fl?NANT ❑FOODSERVICE
FZ} not more than five hundred dollars Stan). IMPROVEMENT'
�=QO ❑1.as owner of the progeny,or my employees with wages as theirsole cnmpsmmion, SWIMMING POO
F• will do the work.and thesweture is not intended or offered for sale(See. Business ❑OTHEk
lay^m arse Pr9fesnlnne Code:The Conuo um''s License Law docs not apply to an owner of (1UThETS-SW I'r
proper who builds or improves themon,and who dos such work himself or thmupM1
his own emplovees,provided that such improvements am not intended m oRcmd fur NEW RESIDENTI .
rule.If,however.the building or improvement is soldwithin one year of completion.the SQ.FT.FLOOR AREA SISQ.FT
ow cr-builder will hove the burden of proving that he did not build or improve for pur-
pnnenfxde,, CEIVED
L as Owner of the property.a exclusively mntmning with licensed cmnraaon nr L'
construct the project(Sec.7011,Business and Professions Cade:)no Commons',Li- : g
Li-
came Law does not apply to an owner of progeny who builds or impawcx thereon.and QTY. PLUMBING PERMIT FEE SEP 3 O 1997
who contracts Ibr such projects with a commmo0s)hroo,ed pursuant m the Commmor's
License Law. PERMIT ISSUANCE
1 am exempt under Sec. .B&P C for this reason
ALTER-DRAIN&VENT-\YATER IEA) B VALUATION
Owner Dat°
WORKERS COMPENSATION DECLARATION BACK_FLOW 11110TECI'.DEVICE
I hereby affirm under Penalty of perjury one of the following declarations
❑Thave=it will maintain a Certificate ofConwill tolf' re for Workers C Igen DRAINS FLOOR.ROOF.AREA,COND. STORIES 'TYPE CONSTRUCTION
,atioa.ax provided far by Section 3900 Of the Labor Cadr,fill am performance'If the
tars - h'h h:hamo, J FIXTURES-PPR TRAP
I' J 'll t Workers C p f 1 : - 1 JbyS Unr
L0 fthe Lalxm Cod f It fomvi fill rk far which this permit i. .sued GAS EA.SYSI'hM-I ING1OlTTLIa'S OCC.GROUP MIN
My Mork Icon s r ad"Pow,pntphrl�yy{ O/
Cartier oliev Nb GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICAI E OF EXEMPTION FROM WORKERSGREASFIINDUS'I'RL WASTE INTERCEPTOR
C(1MPENSA'DON INSURANCE BUILDING DIVISION FEES
(This section need not becomplemJii thclameal lsformehandredddlarslSHO) GREASETRAP
PLARCHECK FEE
m lessl
l certify that in the perfynnance of the work for which this permit is issued,lukAl $EWLR-SANITARY-S"TORM118A.2IX1 FT. ENERGYIYE
not anpiny any perwm in any I nes so nxmhemme nuhj«t nr the Workerz'Cmnpcn-
Z Sat Laws of Culdcon Date WATER HIiAI'ER W/VI;NI'/ELIs.CfR GRADING TEE.O Applicant 1
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NATER SYSTEMi BEATING SOILS RiE
f~ ^ become subject to the Worker's Compensation provisions of the Labor Code,YOU must
fnnbwithurmply withsgamishall be doraedrevokeJ. WA'T'ER SERVICE
p PAID
...NSTRUCr10th LENDING AGENCY NEW RESIDENTIAL PLIIB. SQ,En Date c at
1..7 O I hereby affirm thin them is a comm ction lending agency for the prommormac of
W �+ the wail for wM1ich this person is issued[Sac.31197.Civ,C.1 "� 'IOTM
O F•t IsnJer's Name 'TOTAL:
} LSI Isndcr'x Address BUILDING FEE
4 I certify that 1 have mad this application and nate that the above information is
Fh correct.I agree nr comply with all city and county ordinances and state law's relating to QTY. MECHANICAL PERMIT FEE SEISMIC IFE
V�. building construction,and hereby omhon-mpresentativesofthiv city mcmeruponthe -
alxrvomemmned properly fill inspection Plel osee. PERMIT ISSUANCE. � / ELECTRIC FELE
DAO agree to save,indemnify and keep hamdc the City of Cupertino against
Iiahilitics judimconv coos and expenses which may in any way timem against said City ALTER OR ADD TO MSCI L PLUMBING FEE
in consequence of the granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1,NON-POINT AIR HANDLING UNIT lrO 10,000CFM) MECHANICAL ITE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,0X1 CFM) CONSTRUCTION TAX
Signature of AppliwnVContmcmr Dam IXI IAUST I IODD(W/DUCT) HOUSING birrIGADON FEE
HAZARDOUS MA'I'VRIALS DISCLOSURE -
Willtheapplicantorfuturehuildingnocupantxtomerhandlehumniousmaterial HEATING UNI'I'BTO I00.oK BTU) r
as Jchned by the CupenI Monte'
d Cole,Chapter 9.12,and the Health and Safely BLEATING UNI'I'(OVER 100.00DRIM)
Crile.Section 25532(a)n J,�(p
❑Yes I[l A'o VE NPILATION FAN(S]NO LE MEMO) PAID Doe: Rcaeipta
Will the applicant or future building occupant use equipment or devices which BUTLER-COMP(3HP OR 100.000ITU)
nit hams rlous air contaminants as defined by the Bay Area Air Quality Management TOTAL N
Diurnal" TOILER-COMP(OVER I(0.W0 BTU)
Yes
l have mrvl the M1mnNous mabnuls ¢unJer Chapter 6.95 of be Cdi- AIR CONDITIONER ISSUANCE DATE
reyu:remen
famia Heald&S Fry Cole,Sestinas 255LI5,3533 and 25531.1 utdemand tha if the NEW RESIDENTIAL MECH, SQ.EL i l (Ts _Cr
buiWingdee voeml ve a tenant,that it ismy reapomsilohly I Off thececupin G�
01 he, It.wh us(be met prior to ismencc at a Cenifie
O c autho- c gem ate TOTAL: /' .SU, BY: Q- T
OFFICE