29105APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL I PERMIT NO.
. BUILDING DIVISION APPLICATION/FiERMIT PLUMBING - MECHANICAL. O
BUILDING PROJECT IIIENTIFICA 5'PION _ J
BUILDINGADDRISS: I I SANITARY NO, APPLICA'DOW SUBMITTAL DATE
PHONE:
rQ Qi �� rAQo� w 79 ❑ Consultant Fees Paid by Applicant (Initial)
I hereby
M. that I am licensed under provisions of Chapter 9 (commencing QTY ELECTRIC PERMIT
with Section '1000)of Dr,ki 13idduc Bmine,sad Prslbs,ion,Code, andmy liana), PERMIT ISSUANCE
In full peace and effect.
License Class Lice
Date - Commerce APPLIANCES -RESIDENTIAL
ARCHITECTS DECLARATION PANELS
1 pndroar n l ruffian, shell he used as public Frank
UP TID 200 AMPS
OWNER -BUILDER DECIARA'I'ION
1 hereby affirm that 1 am exempt from the Commerce, License Law f n flue
following reason. (Section 703 1 S, Business and Professions Code: Any city or county
which requires a permit to construct, ober, improve, demolish, or repair any stmemra
prior to its issuance, also requires the applicant for such permit in file a signed statement
that he is Ilccnral putauvnt to the provisions of the Contractor's License Low (Chapter 9
(commencing with Section 70p of Division 3of the Business and Professions Adelor
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any split eam Ibr a permit subjects the applicant in it civil penalty of
not more than five hundred dollars ($5IX).
❑ I, as Owner Of the property, or any employees with wages as their sole compensation.
will du the work, and the structure is not intended or Offered for sale (See. ]BGq nosiness
and Findanions Cade: The Contractors License Ww, does not apply to an owner of
proper who builds or improves thereon, and who does such work hi itself or through
his own employees, provided Nat such improvements are not intended or offeteJ for
sale. If, however, the hot i lding or improvement is sold within one year of completion, the
owner -builder will have the burden of proving that he did not build or improve for pury
µnee of sale.).
D I, as owner nl'tho property, um aseu,i vel, cataract log with licensed contractors to
conswet the project (Sec. 7014, Business it Professions Cade:) The Contrsemr's Li-
cense Law does not apply to an owner of property who builds or improves thereon, and QTY.
who contracts for such projects with a contractions) licensed pursuant) the Contramnr',
License Law.
D 1 am exempt under Sec. B & P C for this reason
Owner Data
WOR KER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following decimations:
I have and will maintain a Certificate of Consent to self -insure for Worker's Compete
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
weak for which this permit is iswad.
1 have and will maintain Worker's Cnnnµa,atien Insurance, as required by Section
.1704 of the Labor Code, for be performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number are:
Cartier: Polley No.:
CERTIFICATEOP BXEMPr10N FROM WORKERS'
COMPENSATION INSURANCE
('Phis sation need not be completed ifthe pemnit Is for one hundred dollars ($ UM)
or less.)
1 certify that io the pednrmanee of the work for which this pertain is issued, Isiah
not employ any Person in any manner so as to become subject to the Workers' Comfort.
0,Z sation Laws of California. Date
Z Applicant
y NOTICE *1'0 APPLICANT. If, after making this Certificate of Exemption, you should
abecome subject to the Worker, Compensation provisions of the Labor Cody you must
fai In", ith comply with such pro visions or this permit shall be dcemed revoked.
Uz CONST itdome I, aamm LENDING AGENCY
U � S Ifothereby whichirm the Nem isacd(Sec. 097.Cis. agency for the performance of
� Lye the work for which this permit is issued ($cat. 309]. Civ. C.)
G U Lender, Name
} Lenders Address
1 certify td 1 have rad this applicationand sOno that the above information is
iF. V) coned. l agream comply with all city and county ordinances and gate lows relating to QTY.
L% building construction, and hereby, amhorne represeaneives of this city to wmoponth,
ubnveenentioned property for inspection pur uvoc.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
Iiahii ti s.ludgments, costs and expenses which may in any way accuse against said City
prance of the granting of this permit.
APP .1 ANT UNDERSTUVS AND WILL COMPLY WITH ALL NON -POINT
V HA] )OUS MATERIALS DISCLOSURE /
Will the applicant o nutrebuildingoecnpant,toreorhandlehaannlousmaterinl
in defined by the Cupertino `M'unicipal Code, Chapter 9.12. and the Babbitt oil Safety
Crude. Section 25532()'!
¢- / — o
❑ Yes
� Will the applicant Or future building Occupant use equipment or devices which
emit herardme, air contaminants as defined by the Bay Area Air Quality Management
District?
u
(] Yes
I have mad the hm ucous materials requirements under Chapter 6.95 of the Cali-
f a Health &Safety Cede, Sections 25505. 25533 and 25534.1 understand that if the
,'[,am�)r$ ng does not cures iy have v tenant, the, it is my responsibility to notifythe.anpan.
'I I!, mum, mems h It must he met nritA. issuance oft Cmi9cumn/Oo,uni.
SIGNS ELECTRICAL
SPECIAL CIRCUrUMISC.
TEIs1R. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL. ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIALELECTR SQ FT.
011e
u
PLUMBING PERMIT
El ❑ U' ❑
PERMIT ISSUANCE
FEF.
• JOB DESCRIPTION
RESIDENTIAL:
D SFDWL 0 KITCHEN REMODEL
Ll ADDITION El PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
D INTERIOR El CHIMNEY REPAIR
IMPROVEMENT
D BATH REMODEUREPAIR 0DEMOLIT[ON
DOTHER
BACK FLOW PROTECT. DEVICE
DRAINS- MOOR, ROOF ARBA, COND.
FIXTURES -PER TRAP
PLUMBING PERMIT
FEE
PERMIT ISSUANCE
<
ALTER -DRAIN & VENT -WATER (IIA)
BACK FLOW PROTECT. DEVICE
DRAINS- MOOR, ROOF ARBA, COND.
FIXTURES -PER TRAP
GAS -EA. SYSI HM -I INC.4 OUTLETS
J
I
GAS - EA. SYSTEM -OVER 4 (EA)
GREASI9INDUSTRL W STE INTERCEPTOR
ORPSE 'I'RAP
SEWER -SANIT `QS RMEA. 200 FE
WATER SERVICE
NEW RESIDENTIAL PLMR. SQ. IT.
MECHANICAL PERMIT I FEE
PERMIT ISSUANCE
AISF.R OR ADD TO MECH.
AIR HANDLING UNIT OD 10.000 CFM)
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUST HOOD(WIDUCT)
HHATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER (0.000 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER -COMP DHP OR 100,000 B'I'U)
BAILER -COMP (OVER 1 W.Otlo BTU)
COMMERCIAL:
CNEWBLDG/ADDITION DDEMOLITION
❑TIINANT ElFOOD SERVICE
IMPROVEMENT
D OTHER
ry Vow
)YI tell -yr -4
SQ. FT. FLO ANE LSQ. FT.
PAID
DEC 2 0 1995
CITY U1 L;Urt:KIINO
STORIES
BUILDING DIVISION FEES
PLANCHECK FEE
ENERGY FEE
GRADING FEE
SOILS FFR
PAID
Dote Raeiµ e
TOTAL:
BUILDING FEE
SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECI IANICAL FEB
I HOUSING MITIGATION FEE I .. I
I I NEW RESIDENTIAL MECH. SQ. IT, I I
PAID
Date Roo N
ISSUED BY:
OFFICE
ISSUANCE DATE