30382 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY Z
1 CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 3038/}�(
2
BUILDING DIVISION APPI.ICA'170N/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DT1
C qOW ER'S AME: PHONE: CONTRACTORS NAME: LI NO: "L
NIC COM'HOLp
CIET CDENGINE R: LIC NO. ADD S: ❑
`ONTACT: TDe PHgONE:
`/ BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION. QTY ELECTRIC PERMIT FEE ❑
1 hereby affirm that I an licensed under provisions of Chapte1.9
9lcommencius
JOB DESCRIPTION
�d'Z withll Race]000)of Division3of th<Rusiness and Professions Code.ad mylicenxis RESIDENTIAL'
WOO
full Class effect. PERMIT ISSUANCE
aUV License Class Lica ❑SFDWL ❑KITCHEN REMODEL
inQi Ume Contractor APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
(_Dm ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT ❑STRULTURAL
O Z=Z 1 understand my phos eball be used as public records
UPT02MAKIP5 MODIFICATION
FBF-W Licensed Professional 11 INTERIOR ❑CHIMNEY REPAIR
OWNER-BUILDER DECLARATION 20l-1000AMPS IMPROVEMENT
—y W< I hereby affirm that I am exempt from the Contractor's License Law for the N
0 AMPS ❑BATH REMODE REPAI ❑DIiMOLITION
X a U following reason.(Section]031.5.Business and Professions Code M city or count
Iy131yF Y Y y I L ❑OTHER
F
0.5 which requires a permit to construct,area,improve,demolish,or repair any stmcmm
prior to its issuance.also requires the applicant for such Permit file a signed.statement
InI IT/MISC.
C�Qf that he is licensed pursuant to provisions of the Con,ranors License Law(Chapter
�IYQp (commencing with Scaion]f1W)of UiviaionJ of the Business and Professions CaJe)or
TEMP. O LE INST. COMMERCIAL
1 E O C that he is exempt Ihereliom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION 0 DEMOLITION
X,-,m Section by any applicant for a x,mot subjects the applicant to a civil penalty til EVICES
FZ]' not mote than five hundred done,P$5W). ❑TENANT ❑FOOD SERVICE.
F.=0 E]Los awncrof,ha,mr,myor myenphoyas with wagesa.uheir solecompensoion, GPOOLELE IMPROVEMENT
aF. will do Ne work,and lhestmame is not intendedoruffcred lafxale(Sec.](H4,Bmincsa ❑OTHER
3 w and Professions Code:The Contractors License Law does not apply,,an owner of -SWITCHES-FI RE pmpeny who builds or improves thereon,and who docs such work himself or throughhis own employees,provided that such improvements arc not intended or of'ered for IDENTIAL ELECTR Q FT.
sale,If.however the building or impravemem issnld withinone yeirrofcampletiotb, SQ.FT.FLIOR AREA E/SQ.FIT.
owner-builder will have the burden of,ra,,i.g Ihm he did nm build nr improve Ila Aur '
µ+se of sale.).
❑ I,as owner of the property.and exclusively conlonaing with licensed contractors la TOTAL: SEP 91996
consumer ar
cl the p.,j.t(Sa.](IDL Biness and Profceniona Cnd,)Do,CarnsO sLi-
cemuLawdaearolapply in an ownelyd pfopeny who huildsor im,socsnmmtm,and QTY. PLUMBING PERMIT FEE
whocomfaals forlorn 1-jest,withvGIDtinao,(,)licunscd pmrstrina I,the Contractors
License Law. I'ERMI'r ISSUANCE o( , s-, `-x" `"'t.,toIsm exempt under Seo. ,B&P C for lbs s ruuson
ALTER-DRAIN&VENTWATER(EA)
Owner pate - VALUATION
WORK COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I henehy anion under penalty of perjury one of the following declarations.
I have and will maintain a Certificate of Consent to self-insure for Worker's Crimper- DRAINS-FLOOR,ROLE,AREA ON .
smion as pmviJed for by Stttinn J]W n[IM1c Lobar Cndu,for the perfnrmuna al'the STORIES TYPE CONSTRUCTR]I
work for which this panni,is issued FIXTURES-PER TRAP
have and will maintain Worker's Compensation In.srmnce,as required by Section
]WoflM1e Labor Code.for the performance oflhe work for which this permit is issued GAS-EA.SYSTEM-I INC.40UTLETS
i My Worke's Cam motion ser ce c d Policy ntimbcf are v� ��.��a�/ OCC.GROUP APN
Carier:� rPnliN No:
� GAS-EA.SYSTEM-OVER 4(EA)
'RTIFICATEO EXEMPTION FROM WOR_E'.�RS'
j COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR
or less.)(This section need not he completed f,he permit is fortune hundred dollars(Sign GREASE TRAP BUILDING DIVISION FEES
I certifythat in the performance ofthe work for which this PLANCUECK FEE
R .it SEWER-SANITARY-STORM EA.200 FT
not employ any person in any...act..,ns hecome mbjea to the Worker'Cnmpcn-
Zsodic Laws of California.DateENERGY FEE
zO APPlicant WATER HEATER W/VENT/ELECTR
_ GRADING HE
y NOTICE bj APPLICANT:If,after making this Certificate of the
Exemption,you should WATER SYSTEMT]EATING
E" become subject m the Worker's Compensaion previsions of the IaMr Cede,you most
fordoohcomply with such provisions or this,crab,shall be deemed revoked. WATER SERVICE 50145 FEE
7z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID
V Q (hereby grim that for
hen is a construction agency forthe permance of Data Receipt It
the work for which this permit is issued(Sec.3097,Co.C)
Q ULenders Name
Lender's Address r0 AL:
I cenify,hm I have read this.,Turk m and a im that the abuse information is TOTAL. BUILDING FEE
V? comet.l agree to comply with all city sed county ordinances and state laws tenting m QTY, MECHANICAL PERMIT
iJ Z building construction.and hereby aumodze representatives ofthis city to enter upon the FEE SEISMIC FEE
above memha ted property far inspection purposes. PERMIT ISSUANCE
(we)ogre m save,indemnify and kap intimates'the City of Cupertino against ELECTRIC FE
liabiliies.judgmems.costs and expenses which may in any way acme against said City ALTER OR ADD TO MECH.
on consequence of the Starling of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT pIRHANDLING UNIT TO IO,000CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10.000 CFM)
Signorina 01 AppllcannCortmcmr Dae EXHAUST HOOD(W/DUCT) CONSTRUCf10N TA%
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION IN
Will the applicant or future building occupant sure or handle hazallous material HEATING UNIT(TO I OQO(10 BTU)
as defined by the Cupertino Municipal Code Chapter 9.12,and the Health and Safety
Coda,Section 25532(a)] L HEATING UNIT(OVER 1011,000 BTU)
17Y. �No
VENTILATION FAN(SINGLE RF,SID) PAID
Will the applicant of fmbuilding occupant tau eAiof devices which Dom Receipt p
mit hazardousntm
air coinams a as JcOncJ by the Bay Area
Air r Quality Management BOILER-COME(3HP OR IBU.00p BTU)
>isuim? _ TOTAL:
❑Yea �Nn BOILER-COMP(OVER IW,000 BTA) ,
I h:rvc reuJ the hazardous nwmrinLs rcyuirancnL.under Chupmr 695 of the Cnli AIR C(1NDITIONER
fomia lieahh&Safely Codc,Scc,inns 255(1,5,255]3 unA 255JJ,I undctsmnJ Ihm iT the ISSUANCE DATE
buildingdrcsnot cnrzcmly M1;rvca,enanl,0+m it Lr lay rcsµn+aibililywna,il'y the tucupanl N13W RESIDENTIAL MECH. SQ.I'T
of Ute quimmm�s which must ltt nlG,riormisemmce ofnCrniEc eaT Oav nosy,
O n rued vgcnt
TOTAL: ISSUED BY:
OFFICE