29224APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL PERMITNO,
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING - MECHANICAL
BUILDING pR(IJEC'1' FDFLNiTITCA'ITON
BUILDING ADDRESS: RANI'I-ARY NO I APPI ICATION SIINMITTAL OATF
^''''S)S� PHONE:
01 r1_�_M 1'� ❑ Consultant Fees Paid by Applicant (Initial)
' LICENSED CONTRAC UR'S DECLARATION QTY
1 hereby affirm the, I vet licensed under provisions of Chapter 9 (commencing
X00 with Section 7000)of Division 3 ofthe Business add Professions Code, and my license is
lyE�] in full force and e t.
Qil
<V W License Cl '� Lic.0 _
FF.. Date-I—Gmwetor
Fprn ARCHITECTS DECLARATION
z O 1 understand my plans shall be used os public records
OZ Q
Mal Licensed Profctaxam l
_l OWNER -BUILDER DECLARATION
I hereby affirm that I um exempt from the Contractor's License Law for the
Xa 1 U U following reason. (Section 1031.5, Business and Profession Code: Any city or county
41 4 which requires u permit to construct, alter, improve, demolish, or repair any structure
FSO prior to its issuance, also requires the applicant for such pardon to file o signed statement
of that he is licensed pursuant o the previsions ofthe Callowness License Law (Chapter 9
(commencing with Section 7(M) of Division 3 of the Business and Professions Code) or
d q o pOE that he is exempt therefrom and the basis for the alleged exemption, Any violation of
�y Section 1031.5 by vnyapplicamfora permit subjects the applicant to a civil pvociyof
+ F z Y
no'
more Nan five hundred dollars ($500f
}qsee
0 1. as owner of the pmpeny, or my mrployces with wages as their sole compensation,
' CO will do to work, and testruaure is not intended or offered for sale (Sm. 1041, Business
W 3 and Profexsions Code: The Contractor's License Lew does not apply to an owner of
property who builds or improves thereon, and who does such work himself or trough
his own employees, provided that such improvements one, not intended or offered for
sale. If, however, the building or improvement is sold within one year of completion, the
owner -builder will nave to burden of proving that he did not build or impfove for pur-
pose of sale.),
❑ 1, m owner of the property, am exclusively contracting with licensed correlations to
container the project (Sce, 9044, Business and Pndessions Code:) no Contmeters Li -
move Law dons not apply to an owner of pmpeny who builds or improves thereon, and QT V
who contracts for such projects with v connotations) licensed pursuant to the Contractor's
License Law,
I am exempt under Sec. ,B& P C for this reason
Owner Dme
WORKER'S COMPENSATION DECLARATION
I hereby affirm under poorly of perjury one of the following declarations:
1 have end will maintain a Craniums ofComm.uo self -insure for Worker's Compen-
sation, us provided for by Section 3100 of the Latin, Code, her the performance of the
work for which this permit is issued,
❑ 1 have and will maintain Worker's Compensation Insurance, as continued by Section
3100 of the labor Code, for performance ofthe work for which this per it is issued.
My'
W ���pgy_tyn ecce carierli, Noy numbcgetk xrf;
Carver AA//��NN'' kZ LSV J
CI?RTIPICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
LTM. announced not be completed ifte permit is farone hundred dollars ($IPU)
or less.)
I certify that in the p anceof the work for which thea theta is issued. I shall
not employ any person in anyy maromvnner'so as to become mhjecuo the Workers' Cnmpn-
O z 'sation Laws of California. Date
Z 2 Applicant -
pr NOTICE TO APPLICANT. If, after making this Car ifiom of Exemption, you should
Fa^ become subject to the Worker's Compensation provisions of to LeMm Code, you must
LLI forthwith comply with such provisions or this permit shall be deemed revoked.
a. Q
U z CONSam,do eis.construction
ON LENDING AGENCY
LL. I for Which
thi Net mere is m constm .30 lending agency forte performance of
fs H the work for which this permit is issued (Sm. 300. ON. CJ
Q U Lender's Name
Lenders Address'
fir+ 0. 1 certify that I have read this application and state that the above information is
F Vy comet. l agree to comply with .11 cityand countyoninvncesandmate laws relmingm QTY,
V Z building construction, and hereby authorize representatives of this city tomaorupon the
above-mentioned Final for inspection puttoses.
(We) agree m save, indemnify and keep harmless the City of Cupertino against
liabilities, j udgments, costs and expenses which may in any way accrue against said City
in consequence of the emitting of tis
APPLICANT UNyEQSTANDS LL COMPLY WITH ALL NON -POINT
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building rccupnnt mare or handle hazaNaus material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code. Section 25532(a)?
❑Yes [:1 No
Will the applicant or future building occupant use equipment or devices which
it hazardous air contaminants as defined by the Bay Area Air Quality Management
otrim?
❑Yes Fl No
I have read the ha ourimx m t,rd, requirements under Chapter 6.95 of the Cdi-
fomia Health & Safety Cale, Sections 25505, 25533 and 25534.1 understood tat if the
building does not currently have a aerial, that it is my responsibility to notify the occupant
of the requirements which must be met prior to natural of a Certificate of oampeal
Owner or authorized agent Date
L
MECHANICAL PERMIT FEE
❑ ❑ 2� ❑
ELECTRIC PERMIT FEF,
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL ❑ KITCHEN REMODEI,
❑ADDITION R*MMBING RE -PIPE
❑MULTI -UNIT CSTRUCTURAL
MODIFICATION
❑INTERIOR E) CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEUREPAIR ElDEMOLITION
❑ OTHER
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL.
PANELS
UPT0200AMPS
2)1-100 AMPS
OVER INMAMPS
SIGNS ELECTRICAL
SPECIAL CIRCIJUUMISC.
EXHAUST HOOD (W/DUCD
TEMP. METER OR POLE INST.
COMMERCIAL:
❑NEW BLDG/ADDITION C1 DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
TITER
POWER DEVICES
SWIMMING POOL ELECT RIC
OUTLETS - SWITCHES -FIXTURES /
VENTILATION FAN (SINGLE RESID)
NEW RESIDENTIAL ELECTR SQ Pf.
TOTAL:
HOILER- COMP (OVER 100,(0 BTU)
SQ. FT. FLOOR AREA
R' r•, � i
AUG 13 1991
$/SQ. FT.
TOTAL:
PLUMBING PERMIT FEE
PERMIT ISSUANCE
ANTER -DRAIN &VENT -WATER (EA)
kilt QI VALUATION ss
RACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF AREA. COND.
STORIES
TYPE CONSTRUCTION
FIXTURES -PER TRAP
GAS-EA.SYSTF.M-1 INC.40UTLBTS
OCC, GROUP
APN
GAS -HA. SYSTEM -OVER 4 (FA)
GREASUINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
GREASETRAP
PLANCHECK FEE
SEWER - SANITARY - STORM EA. 204 FT,
ENERGY FEE
WATER HEATER W/VENTAILEMR
GRADING FEE
WATER SYSTEMO BEATING
SOUS FEC
WATER SERVICE
PAID
Date Receipta
NEW RESIDENTIAL PLMB. SQ.E-n
TOTAL:
MECHANICAL PERMIT FEE
BUILDING ME
SEISMIC IEE
PERMIT ISSUANCE
ELECTRIC ME
ALTER OR ADD TO MECH.
PLUM BING FEL'
AIR HANDLING UNIT (TO I L000 CFM)
MECHANICAL FEE
AIR HANDLING UNIT(OVER 14009 CFM)
CONSTRUCTIONTAX
EXHAUST HOOD (W/DUCD
HOUSING MITIGATION FEE
HEATING UNIT OD IW," BTU)
HEATING UNIT (OVER 100,000 BTU)
PAID
Dole Receipt M
VENTILATION FAN (SINGLE RESID)
BOILER - COMP (SHP OR 166,00) BTU)
TOTAL:
HOILER- COMP (OVER 100,(0 BTU)
AIR CONDITIONER
ISSUANCE DATE '
NEW RESIDEWIAL MECH. SQ. FT.
OFFICE