23421APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
Building Project Identification
PERMIT NO.
Building Address:
-
23421
' one:
Illy ate. 6YC /U �CI� 2CS- 0
CITYOFCUPERTINO-BUILDINGDIVISION
APPLICATION I PERMIT
BUILDINGELECTRICALPLUMBINGMECHAMCAL
A A A
Cont, ctor's Name: Llc. No:
?
�t / /t, eG 632/4_
CATEGORY
C
Archftect/Engineer. Lic. Na
QTY • ELECTRIC.PERMIT FEE
BUILDING PERMIT INFO
Address
PERM ITISSUANCE
LCF
L9 ElLICENSED
CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chaptei 9(commene,
Ingwlth 1 f.117000)ofdaffeon3o(the Businessand PmfesaonsC,.de, and my
license is In toll fo and offal.
Liam.o.. Lle.p
APPLIANCESRFNDENTIAL
JOB DESCRIPTION
PANELS -
Date / Contractor
701-1000 AMPS
ARCHITECPS DECLARATION
I understand my plane shall be used as public records.
Licensed Pmfessioral
JOVERlMOAMPS
SQ. FT. FLOOR AREA $/SQ. FT.
01%—
77L�. I�a6
SIGNSELECTRICAL
SPECIALCMCUIT/MLSC
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt fromthe Contractor's License Law for the
following reason. (Section 70715, Business and Professions Code: Any city or
countywhich requires a permit to mnstruc t, alter, Improve, demolish, or cepalr
/
L
^^
'(ySTp METER OR POLE INST. '
anystmt mpdortoltslamance,alsomquireslheappllrantforsuchpert tto
file a signed statement that he is licensed pursuant to the provisions of the
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS-SWITCHE&FIXTURES
Contracture License Law (Chapter 9(oarrom Ging with Stolon 7000) of Divi-
'on 3 of the Businessand Professlow Code) orthat bola exempttherefromand
the basisfor the alleged exemption. Any violation of Section 70315 by any
appl cant for a permit subjects the applicant to a civil penalty of not more than
five hundred dollars(SM.
F1 1, as owner of the property, or my employees with wages as their sole
VALUATION qhl
O oO
NEW RESIDENTIAL ELECTR FT.
_SQ.FT.
STORIES Jr
TYPE CONSTRUCTION
compensation, will do the work and the suuc um is not intended or offered for
sale (Sce. 70" Beat., and Pwfeslom Code: The Contractors License Law
does not a pply to an owner of property who Wilds or improves t hereon and
whodoessuchworkhimself orthrough his.wnemployeas, provided that such
Improvements are not intended oroffered for sale. If, however,thebuilding or
TOTAL:
improvement issold within oneyearofcompletlon, the owner-builderwlll have
the Burden of proving that he did not Wild or Improve for purpose ofsale.).
❑ f as owner of the property, am exclusively contracting with licensed
contractors to coatruct the project (Sec. 70JA Business and Professions Code:
The Commences License Law does not apply to an owner of property who
builds or Improvn thereon, and who contacts for such pT.jets wfth a
an (a) licensed pursuant to the Contractor's License Law.
L� I am exempt ..our Sec. B & P C for this reason
QTY. PLUMBING PERMIT
E 1,•(�
G�
PERMITISSUANCE
ALTER -DRAIN & VENT -WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINSLOR, A, FOROOF, ARECOND.
FIXTURES.
SANITARY Y N_
RECEIPT X
.
Owner - Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificate of consent to self -Insure, or
mnifimteofWorker Compo timin mnmwamdifled copytheroof(See.
3800, fab C)
Poliry X / 2 7 6 K 3 3— ?�
SDTCOL TAX Y_ N_
RECEIPT N
CAS EA.SYSrFAi-1 INC.40UTLE15 -
PARK FEE Y_ N —
RECEIPT X
CAS Ek. SYSTEM -OVER 4 (EA)
Co any-YA-/�— f-illo�/%�
BUILDING DIV] SI EES
laboxf
MCcrofied copy is hem tumecity
❑Certified copy la(ilre with the city inspection division.
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECK Fr
/!/1//COMPENSATION
CERTIFICATE OF EXEMPTION FROM WORKERS'GREASETRAP
PAI
zi
INSURANCED,
(fhissection need nae W completed If the permit la foram hundred dollars
SEWER SANITARY STORM EA 2(IOFTPa
WATER HEATER w/VENT/D.ECTR
ENERGY FEE Y N
.
(5100)., less.)
I curtify that In the perfomvno, of the work forwhich this permit la issued,
WATER SYSITA(/TREAIIN'G
I shall not employ any person in any manner so as to became subject to the
Workers' Compensation Laws of California. Date
PAID
NEW RESIDENTIAL PLMH. SQ.Ff.
Applicant
Date Reeel t#
NOTICETO APPLICANT: If, after raking this Certificate of Exemption, you
should become subject to the Workers-Comperwtion provisions of the Labor
TOTAL:
BUILDING FEE
Code, you most forthwith comply with such provisions orthis permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I herebyaffirmthat there isamvwctim lendingagency forthe perf.w,
once of the work for which this permit Is Issued (Sec. 3097, Clv. Q
Lender. N.cm
Lenders address
I certilythat I have read thisappBrationand catethatthe above Information
iscorret:] agree to complywith all city and county ordinances and mate law.
relating tobuilding mnsuution, and hereby authmae, repromutative. of this
city to enter upon the above-mentioned property for inspection purposes.
(We) agrm to save, indemnify an d keep harmless the City of Cupertino
against habilities,)adgments, was and expenses which may in anywayaccme
SEISMIC FEE
TOTAL:
ELECTRIC FEE
PLUMBING FEE
QTY. I MECHANICAL PERMIT FEE
MECHANICAL FEE
71 A /3D
77
PERMU15SLIANCE
ALTERORADDTOMFLH.
Date Reeeipl#
AIR HANDLING UNIT( TO 10,"CFM)
SUBTOTAL:
agaiw said City In con.ryuence .(the granting of this permit
AIR I-]ANDUNc unrr (ovER lotno cFM)
CONSTRUCTION TAX
Signs. -o( Appumnt/contractor Data
EUHAusrHooDfW/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicent.,fare. building occupant Mercer handle havnlou,
HEATING UNIT (TO 100,000 BTU)
-
Date Recei t#
material as defined by the Cupertino Municipal Code, Chapter 9.17, and the
Health and Safety Cade Section 25532(a)?
❑ Yes MN.
Will the applicant orfuture building occupant use equipment or devices
HEATING UNIT (OVER 100,000 BTU)
'
TOTAL:
VENTILATION FAN (SINGLE RFSID)
ISSUANCE DATE
which emit harardous air contaminants as defined by the Bay Area Air
Qua illy Management District?
4 Yes F 1 No
have read lhehazarii ous materiab requLments under Chapter 6.95 of
Pl A' D
T M
BOILER -COMP GHP OR 100,000 BTU)
BOILER -COMP (OVER 100,000 BTU)
-
the California Health& Safety Code, Sections 75505,75533 and 25534. ] y
understa no that if the bu lldin does not current) have a tenant, that it ism
MAY ' 1 1992
NEW RPSI DENIAL MECIdL SQ.FT 1
resporuibility to notify the occupant of the requirements which must be met
prior to issuance of a Certificate of Occupancy.
CI YO�r,' %k�/ vrrThI INV
ISSUED BY1y
Owner or authorized agent Date
TOTAL: }]
—�
OFFICE COPY