23228APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Protect Identification
Building Address , ,a T�
16L�aJ n/V...1���`J
PERMIT NO.
23228
wners came:
WARR&J +C/47-AuuA FAnI
CITY OF CUPERTINOLBUILDING DIVISION
APPLICATION / PERMIT
BUFLDINGELECTRICAL PLUMBINGMECHAMCAL
Z_o.>_q 2'
Cmumutnr,Name: Lic.No
CATEGORY CONTROL # -
Archimet/Engineer: Lie. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMITINFO
Address:
PERMIT ISSUANCE ��
MLLII
1�] ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirmthat lam licensed under provisions of Chapter9 (corn
mmc
'ngwith Section 7000)of]AWsion3a(the Businewand Pmfes msCode, and my
license is in full fora andPANELS
LicenseCbc. #x
Date —Contractor'
ARCHITECPS DECLARATION
Iunderstand my pbrs shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
Ihereby affirm that am exempt from the Contractor's LicenJIw the following reason.(Section 7031.5, Bslness and Professions Codtyor
county which requires a permit to construct, alter, Improve, demolish, or repair
any structure prior to its Issuance, a lou requires the applicant for such permit to
file a signed statement that he Is licensed pursuant to the provisions of the
Contractors License aw(Chapler9(mmme cftBwlth Section7000)cf the
'on3 of the Business and ProfessionsCede)orthat he b e mmpttherefmmand
the basis for the alleged exemption. Any violation of Section 7031.5 by any
appllant for a permit subje is the applicant to a civil penalty of not more than
Liv ndred dollars (850.
ant owner of the property, army employees with wages as their sole
mpensat0"Busdess and Pr and (hes Code:
Ie (Sec 7f144, Business and Professions Cade: The Contractors Llarse Law
contractor License Law
does not apply to an owner of property who Wilds or Improves thereon, and
who doessuchworkhim 1forthrough hisownemployees, provided that such
Improvements arc not Intended oroffered forsale. ILhowevegthebuildingor
improvement issold withinoneyearofcomp101ogtheowner-builderwill have
the4urden of proving that he did not build or Improve for purpose ofsakJ.
u I, as owner of the property, am exclusively contracting with licensed
contractors to ronstron the project (Sec. 7014, Business and Professions Code:
The Contractor's Lima to Law does not apply to an owner of property who
Wilds or Improves thereon, and who comncts for such Inyjects with a
cott.[actor(a) Ilcend pursuant to the Contractor's Llrense caw.
IN I am exempt under Sec. , B & P C for this reason
APPLIANCES -RESIDE
ON
`
1 PS
qVMI000AMIS I
SQ. Fr. FLOOR AREA
V �+
f/SQ. FT.
1 e�
14 PAPE
OR POUR ]NST.
WER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
NN
OUTLETSSWITCHESHXTURES 1
NEWRESIDENTIALELECTR SQ.FC.
STORIES
TYPE CONSTRUCTION
,
SO
'^
p
K/
I
p
TOT
QTY, PLUMBING. PERMIT �E -
PERMIT ISSUANCE
ALTER -DRAIN & VENT - WATER (EM G
FEES
RY
BACK FLOW PROTECT. DEVICE
OLE SI UE FEES
DRAINS FLOOR RODE, AREA, COND.
I'L\.fURFS PER TRAP �r
SANITARY Y N_
RECEIPT at
Owner pate
WORIOs1AN COMPENSATION DECLARATION
❑I hereby affirm that I have • certiftate of consent m sell -Insure, ora
certifiate of WorkeWCompensation Insurance ora certlEfoopythenof{Sec.
lab GJ
SCfIOOLTAX Y N
RECEIPT #
GAS EA. SYSTEM -I ING4 OUTLETS
PARK FEE Y N
RECEIPT #
Policy p
Felt,
Cam any
GAS EA. SYSIEM-OVER 4 (TAI
BUILDING DIVISION FEES
ffCertifted copy V hereby furnished.
Certified ropy is filed with the city inspection division.
CERTIFICATE OF EYEM PTIONFROM WOR KERS'
COMPENSATION INSURANCE
(I'hlssection need not be completed If the pemnit is forom hundred dollars
(9100)arless.)
repermit_
I rtify that In the performance of the work forwhich this permit is issued,72
I shall not employ any person In any manner so as to become subject to the
Workers' Compensation laws.( California. Date
Applicant
NOTICETO If, Certificate
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE /
/ `
PAID
Date Rccef t#
I GREASE TRAP
SEIVER-SANITARY-STORM EA 2001r
WATER FIFATFR W/VENT/F7,[CTR
ENERGYFEE Y N
-
PAID
Date RCCeI t#
WATER SYSTEM/TREATING '
NEWRFSIDENT[ALPLMB. AFI'.
APPLICANT: after making this of Exemption, you
should becomesuLject to the Workeri Compensation provisions fthe Lobar
Code, you =at forthwith comply with such provisions orthis permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
Ihembyaffirmthat there is a construction lendingagency forthe performTO
once of the work for which thio b permit issued (Sec. 3097, Civ. C.)
aegil
I<nder'a Nm
Lender's Address
I nertifythat I havereadthis appllationaMstate thattheabove information
is correct. l agree to comply with all cityand county ordinance and sate laws
elating to Wilding construction, and hereby authortce representatives ofthis
city to enter upon the above-mentioned property for Inspection purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cupertino
against liabilities, judgments, cossand expenses which may In anyw.yaccrue
against d inconsequenceofth an tingofthispernot.
�— _
TOTAL:
BUILDING FEE
SEISMIC FEE
ELECTRIC FEE
^`
PLUMBING FEE
QTY, MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIFISSUANCE
FEES PAID:
Date RCCCI t#
P
-
ALTERORADDTOMWFL
AIR HANDLING UNIT ((010,000 CFM)
SUBTOTAL:
NR HANDLING UNIT (OVER 10,000CFM)
CONSTRUCTION TAX
ignarure of Applicant/Contact Data
HAZARDOUS MATERIALS DISCLOSURE
Will thea applicant or future building t atom or handle hazardous
PP B o Pa"
material as defined by the Cupertino Municipal Cod, Chapter 9.17, and the
Health and Safety Code Section 25532(a)7
F1 Yes NN.
Will the applicant or future building occupant use equipment or devices
which emit harandous air contaMmnts as ciefined by the Bay Area Air
Quality Management District?
Ihxvereadtheha No so materials requirements under Chapter 6.95 of
the Cahfornla Health&Safety Code, Sections 25505,75533 and 75534. 1
understandthatlithe building does not currently have a tenant, that it 6 my
responsibility to notify the occupant of the requirements which must be runt
Into issuance of a Certificate of Occupancy.
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
Date Recei t# J_
HEATING UNIT Q0100,000 BTU)
HEATING UNIT (OVER 100,000 BTU)
TOTAL. "[♦
VENTILATION FAN (SINGLE RESID) -
ISSUANCE DATE
/�
PAID
D
e -
FED 1�
03 `teal �
1992
ISSUED BY:V W s t Mal I
BORER -COMP OHP OR lOQO(D BTU)
BOILER-COMP(OVER IW,OW BTU)
NEW RESIDENTIAL M tTL SQ'FT'
Owner or authorized agent Data
TOTAL: