30283 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
.CITY�OF CUPERTINO BUILDING-ELECTRICAL. PERMLTNO, 83
30283 0 ^
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. "�(1 L yV(J{
BUILTHNG PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUHMLTTAL DATE
O D L R W -? 'L
OW E 'SNAME: IN tI r-t HOtyf �` CCONTRACIOR'S NAME: LIC NO:
MWQFS=
NIC CONTROL#
4 CHITECT/ENGINP.f:R: LIC NO: ADDRESS:
FCONTA�: PHONE: BUILDING PERMIT INFO
❑ Consultant Fines Paid by Applicant(Initial) BLDG ELE PLUMB MECH
LICENSED CONTRACTORS DECLARATION - QTY ELECTRIC PERMIT FEE � ❑ ❑
y affirm that I um licensed under prov s ons of Ch pt 9( omen.ng JO DESCRIPTION
,QeeZan mflbsi m 3 of the Business and Professor Cod d ry licenses RESIDENTIAL'
1�. 0 IeIfevt PERMIT ISSUANCE
U� Lic,4 ❑SFDWL ❑KITCHEN REMODEL.
WContractor APPLIANCES—RESIDENTIAL. ❑ADDITION CI PLUMBING R17-PIPLz
ARCHITECTS DECLARATION - El MULTI-UNIT El STRUCTURAL
PANf:1.5
ZpyZ IundersanA my plums shall he used as public records �/` �� MODIFICATION
OZ..-0 OTTO 200AMPS' IM4S'I hSHOR ❑CHIMNEY REPAIR
F4 aii Licensed Professional � 201-EMAMPR IMPROVEMENT
bg OWNER-BUILDER DECLARATION OVER IOW AMPS ❑BATH REMODEL/REPAIR ❑DEMOLITION
C' I hereby affirm that I am exempt from the Contractor's License Law for the
following reason(Section]031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL OTHER
which
473 LL 1"' which northeasta permit to comarucr,alter,improve,demnlish,or repair any suuaure
I.-t0 prior to its issuance.also requires the applicant for such permit o file a signed statement SPECIAL CIRCUTUNUSC.
that he is liccn'sed pursuannprevisions o the pvisions of the Contractors License Law(Chapter 9
��C0O (commencing with Section 7")of Division 3mf,ha Business and Pmf.d.re,Cri or TIME MITER OR POLE INST. COMMERCIAL:
that he is exempt therefrom and the basis for the alleged exemption.Any Atlantan of ❑NEW BLDG/ADDITION ❑DEMOLITION
W^tory, Sectio]031.5 by any applicant for a permit subjects the applicant to a civil penally of MOWER DEVICES
not more than five hundred dollars 15500). ❑TENANT ❑FOODSERVICE
� < I,as owner ofthe properry, employees with wo es as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
Q ❑ th pc Y Yg pBusi
11 dathe work,and the wheatsis not intended or offered tarsale(Seepply town Business [I OTHER
Sand Professions Crs at The Cnntacmos License Law rices not apply a if owner of Ol1TLF.TS—SWITCHE. — UNES
r
property who builJs or improves thereon,and who does such work himself ar through
his own employes,po vided that seek improvements are not intended or offer.]lin IN HW RESIDHNTIAL SQ PT.
sale.If,lmwwer,the building or improvement is sold within one year ofcompleinm,the My FT.FLOOR AREA $/SQ.FT.
wnerhnilder will have tha
e burden of paving that he did not build or Ima
pve lr
in pa
pose of sale.), G,
1.
/I
❑ I,as owner of 0¢property,non exclusively contracting with liecused contractors to TAC: LqLl
ennsnnet the project(Sec.](144.Business and Pmfeasimns Coda:)The Contractor's U.
centa,LowduesnotapplyItanowneref'pnopenywhoholdsa,improve,thanotnind QTY, PLUM G .RMIT FEE JUL 2919
who caramels for such projects with a commnr(s)licem
licensed pursuant the Contmor's
License Law, PERMIT ISSUANCE 6
Fl Sec. ,B&PCforthRtancom ^^'
mer Date ALTER—DRAIN&VENT—WA ( WV`ZCHjjff UATIDN
WORKER'S COMPF.N, TION DECLARATION BACK ROW PROTECT.DEVICE I'
• IherebydBraunderpenohy
I have oftierlury one of the(allowing duleatimns:
❑ ve and will maintain o Cenifcate of Consent toself-insure for Worker's Compete DRAINS—FLOOR,ROLE AREA,COND. STORIES TYPE CONSTRUCTION
cation,u provided for by Section 37M of the labor Code,for the penomence of the
work for which this payout is issued FIXTURES—PER TRAP
1 have and will maintain Workers Compensation Insurance.as required by Section
37M of the Labor Coastforthe performance of the work for which this Permit is issued. GAS—EA.SYSTEM-I INC.4 OUTLETS - OCC.GROUP APN
My Workers Compensation Insuance carrier and Policy num#are:
Carie,. Policy N., GAS—BA.SYSTEMOVER 4(EA)
CHRTIFICAI E OF EXEMPTION FROM WORKERS'
COhIPHNSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR
(Thisxeclinn need not he completed ifthe permit is formic hundred dollars($100) BUILDING DIV ION FEES
or less.) GREASE TRAP PLANCHECK FEE
Icartoyin,,perFy thatsam he ativoinrnanwe nnans..he wmkfor which jeci toper Wodesvmtl,I shot]apon. SHWER—SANITARY—STORM IA.200 Mn
amt employ any person in any anomer sec us to become subjecun the Waken Compcu- ENERGY PF.E
O ,z annual Laws of Culan nen.Dam WATER HEATER WNENT/ELECTR
Applicwn GRADING I.\
h NOTICE 10 APPLICANT,If,aIle,making this Ceriticate pf Exemption,you should WATER SYS TEMRREAM G
("! become suhjecl It the Worker's Compenounar provisions of the Labor Code,you muss SOILS FE
Lyk7 forthwith comply with such provisions of this permit shall be deemed revoked. WATER SERVICE
Q
� PAID
Q Ihereby affirm that is a construction lending agency for the performance of m
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIALPLMB. SQ.FT
V
Receipt#
U. '+ the work for which this Permit is issued(Sec.309],Co,C.)
U.(~ Landers Name _ TOTAL:
L) Lenders Address TOTAL:
yI specify that I have octal this application and stere that the above information is BUILDING
Li cored.I agree to comply with all city and... oNinances and sum laws rtleting rn CITY MECHANICAL PERMIT FEE
L) z building construction,and hereby nuthimre represenutivesofthis city recantation the SEISMIC F .
above mentioned pmpmy for inspection purposes. PERMIT ISSUANCE
(We)agree rosave,indemnify and kup hmmpe
less me City of Cunino againn ELECTRIC •li
liabilities.judgments,costs and expenses w hick may in any way accrue against said City ALTER OR ADD TO MECH.
in consequence of the gaming of this Permit PLUMBINt,FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIN HANDLING UNIT(TO 10,00(1 CFM)SOURCE REGULATIONS. MECHANICA E
Atli HANDLING UNIT(OVER 10mX)CFM) CONSTRUCTION\X
Signature of Applicam/Commetor Dane LXHAUSTHOOD(WMUC'I) HOUSING MITnrTXo FEE
HA'LARDOHS MATERIALS DISCLOSURE
Will the applicant nor noun building occupant stare or handle hazardous material I]HATING UNIT(TO 100,000 Bi IH -
as de0nul by the Cupenio,Municipal Cale,Chapter 9.12,and the Heath and Safety
Code,Section 25532(x)? I II'.ATING UNIT(OVER 1 KWO RTU)
❑Yes ❑No - VIiNTIlAT10N FAN(SINGLE RESID) PAID
Dam Reccip
Will the applicant or future building occupant use equipment Of device.;vi Management
•mit haadmm air comhminams as defined by the Bay Arca Air Quality Menagemeot BOILER—COMP CHIP OR 100,000 BTU)
Uisvicl? TO
NL
❑Yes ❑Nn BOILEk—COMP(OVER IIp,0)0 BTU)
I have road the hazardous materials requiamenra under Chapter 6.95 of the Cali- AIRCONDITIONER ISSUANCE DATE
furam Halth&Safety Code,Sections 25505,23533 and 25534.1 undersand that if the NEW RESIDENTIAL MECH. SQ.FT.
bathe re does nmts a Inch have a metpthino ismyresponsibilitycae ofymearancy. r
ofthe¢quiamemswhich must Isenonprix to issuancemy responsibility
Certificate 1. ofy the acem
Owner or antlmdxd agent Dam TOTAL: ISSUED BY: uOullp
OFFICE
I YARD
i.ecr
Floor Plan (ia s�alz) ;
1955 6dcrdlark ttty RECE Vp �
ED/
cq)eetivlo JUL 2 9 1996
BLDG. INSPECTION DEPARTMENT
OFFIG"E COPY CITY OF CUPERTINO
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