23177 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
Building Pro'en Identification
BulldingAsg, PP y cls P.
PERT NO.
MIPo 23177
n ame8: one:
u ,< Qb VXi N -IS 9 61 - 4U6
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATIONAPPLICATION / PERMIT
BUILDINGELECTRICAL PLUMBINC-MECHAMCAL
S-1 G•
cnntrsctar'a Name: Lk. N.:
c K o y MRS oN2> 2-0 b T
CATEGORY CONTROL #
I Architect/Engineer. �_ Llc. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Addrcas:�
Q� O 1:1 ❑
I�]
PERMITISSUANCE
LICF.NS ED CONTRACTOR'S OECLA RATION
Ihereectionnnlhatlam Bce3.fth.erprovislommf..i.Chapter .Cdommen
Inensei Section 7000)of Dlvlfect. Dho Bualnessand ProlnelonaCode,and my
License tsinfu-rorceyna c.
License Clq_ Llc,p
Date_/ 02 Cor /♦\'rapt
_7v
MPLIANCESRE90ENIIAL
JOB DESCRIPTION
G `
x
��
PANELS
N
A—RCHITSITECTg DECLARATION
201-IOOOAMPS
OVER 1000 AMPS
®FF. IIMEA.
$/SQ. Fr.
I understand my plans shall be used u public records
Licensed Pro(emw
lal _
OWNER -BUILDER DECLARATION
7 hereby a(Irm that I am exempt frumthe Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or
countywhich requires a permit to romlruct, alter, Improve, demollsh,urrepalr
anystructure prions its haseme,al,orequires theapplirant forsuch permit to
ilk a signed statement that he B,licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9(commencing with Section 7000) of Divi.
of the Bi strumend ProfmatonsCode) or that he is exempt themfmm and
SIGNS ELFiCTRICAL
TER
SPECIAL CIRCUIT/MISC
TpaP.METFROR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRICslon3
VALUATION .
the bask for the alleged exemption. Any violation of Section 7011.5 by any
applicant for a permit sub*U the applicant to a civil Family of not more than
OUTLETSSWITCHESH%7URES
live hundred dollars ($500).
❑ 1, as owner of the property, or my employees with wages as their sok
NEW RESIDENTIAL ELECTR SQ'FT'
STORIES
TYPE CONSTRUCTION
compereatlon,will clothe work and thestructure is not intended or offered for
sale (Sec 7044, Buskeea and Professlom Code: The Contractors License Law
dont not apply to an owner of property who builds or improves thereon,and
who doessuchworkhlmself orthrough hlsownemployees, provided lhatsuch
OCC.GROIIP
RES. UNITS
Improvements are not Intended oroffered for sats. IL however, thebullding or
Improvementkmidwlthln omytarofcomplmi Ntheowner-bu0derwili have
tl ,clen of proving that he did notbuddorimproveforpurposeofuk.).
LJ L as owner of the m ng with licensed
property, am exclusively Business
mnLicen the project (See. Business and Pro(esskm Code:
TOTAL:
QTY, PLUMBING PERMIT FEE
PERMIT ISSUANCE
FLOOD ZONE
APN
TheconContractor's apply who
That Cantnctori Llcenee Lawon, does nal apply tct an owner E property with
W Ilda or Improve thereon, and who contracts for such ploJects wish a
cgR(1amaddeempt pursuant to the Contractor's License Law.
LLII I am exempt under See 0 A P C for this reason
ALTER -DRAIN VENT- WATER (Eta
FEE
BACK FLAW PROTECT. DEVICE
OUSUMMARY
EFEIS
DRAINS FLOOR ROOF, AREA, COND.
pgg TRAP
SANITARY Y N_�
BBCFS'I. p
Owner Data
WORKMAN COMPENSATION DECLARATION
pI hereby affirm that I have a mdfllcate of consent to
50100E 7A% Y N_ln
self -insure,
re, or •
cmIflcaleofWorkers'CoxnN.lon lmamm.m.carifled copy thereofeice.
3600, Lab C.)
Pdiay II
Com any a GLS ti
RECEIPT N
GAS EA.SYSTEM-1 INCA OUTLETS
PARK FEE Y N
RECEITT x
GAS FA. SYSnM.OVER 4 (FA)
BUILDING DIVISION FEES
Certified copy ts filed
Certified ropy k (Iled wi1M1 the airy Inspection division.
the city
CREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECKFEE
GREASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Ihlssection need not Mcomplcmd If the permit k forms, hundred dollars
(5100)orless3
I cenot that In any person
I shall not employ any penton In any manner n as to become wbject to the
In an thework so as tobea meemnit ie o the
Workcre'CompensaUon Laws of California. Date
PAID
Date Recti t#
SEWER-SAMTARY-STORM EA.700FT.
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N
PAID
WATTR 5Y5IMMEATING
Applicant
NOTICE o APPLICANT. If, after making thio akse pro o(Exl of the Labor
Code,shoulbeton<forth to the Workers' CompemvHonpmthis pof the Lab or
Cade, you must forthwith comply with each provisional or this permit shall be
deemed rooked.
Date Recei t#
NEW RMDFNTIAL PLMB. SO.FT.
TOTAL:
I G FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby aflmn Muttherc tsamnslructlon kndingagency for the perform,
once of the work for which this permit la Issued (Sec. 3097, Cie. C.)
TOTAL:
ELECTRIC FEE
Lmdera Name
Lnrdcr'e Address
I cenilythatl Na ereadthinappB tlonandtlatethattheabove Information
Is ormot. l agree to comply with all city and county ordinances and state laws
QTY, MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIf1SSUANCE
FEES PAID.
relating to building construction, and hereby authorise representatives of this
cityto enter upon the above-mentioned property for inspection Eau rpose.
(We) agree to save, IndemNfy an d keep harmless the City of Cupertino
against liabilities, judgments, masand expenses which may In mywayacoue
aga Inst mid City In consequenn of the gra ming of this permit
ALTERORADDTOMECH.
AIR HANDLING UNIT CEO 10,000 CFM)
Date Recel t#
SUBTOTAL:
AIR HANDLING UNIT(OVER I GEDO CFM)
CONSTRUCTION TAX
Sig atureofAppBont/C.mmctm Date
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,ODO BTU)
Will the applicant or future building occupant store or handle hasardms
matcrialm defined by the Cupertino Municipal Code, Chapter 9AZ and the
Health and Safety Codlon 75537(a)7
RYes jfj No
Ill theappllcant or future building occupant use equipment ordevlces
which emit hecardmis air coriaminams m defined by the Bay Arca Air
Quality Management Dist 7
n Yea No
21 el,
ea of
ayeread the outmode,
requirements5533
Date Receipt
HEATING UNIT (OVER 100,000 BTU)
TOTA
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
BOILER-COMPOIIPOR 100,000 BTU)
BOILER-COMP(OVER 100,000 BTU)
the r Health &Safety Code, Ssalom 2ment 75533 and 75534. 1
Se and
NEW RESIDENTIAL MECH. SQ.FT
understand that lflhe building does not currently have a tenant that it k my
responsibility to notify the occupant of the requlremenls which most be met
'JAN 13 1992
prwrt us sofa difleateof Occupancy.
aS
CI(Y
ISSUED BY
Owner or author♦ ate
TOTAL:
OFFICE COPY