22917APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — uSE RAIL PAINT PFN ANI V
Building Project Identification - - -- — _
Building Add...: tv, .-- �--c -°
-- - - -- -- PIiI(MIT NO.
22917
� (; w <,,� ens:
(08 %-77�
-
CITY OFCUPERTINO- BUILDING DIVISION
APPLICATION / PERMIT
BUILDINGELFCTRICALPLUMBING- MFGFIAMCAL
A Ti
C
° °`•N ue.N
SciuLit y pTul�aJ !o Yy3
CATEGORY
CONTROLp
A M1lteet /Engineee - d � Lie. N.
.Pnifil�C I) /'LM4
.Q
-'i' r'' 4ELECTRIC PERMIT •' •i'
", ^,FCE '
,
•:i "BUILE]INCFERMITINFO '
�,,/
Address: /(Ri a4✓Yl Ui
PERMTTISSUANCE -
-
❑ a
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l son Bcensed under provisions ofChapter9 (commence
ingwlth Sedion7000)of Di ision3ofthe BuslnessandP.fe.IonsCode,an
license lain full fora and effect.
LlcenaeC LIc.#
Date3 ...Contraetor
J ARCHITECPS1RL`hARATION
I understand my plans shall be used as publierccnrds
APPLIANCES RESIDENIAL
_
PANELS
- JOB DESCRIilON
IF /_
X11-1000 AMPS'
OVERI000AMP5
SQ. FT. FLOOR AREA
'
A'`E � +
^ R
Y
S /`.Q. FT.
'
Licensed Professional
OWNERe BUILDER DECLARATION
7 hereby affirm that I nm exempt from the Contractors Professions License
Code: law (or the
foilowingreason. (SeWoermi1$Bustructandmprove, Code: Any tlty or
county cture requlresa permit Issuance, o requi alter, a improve, fors loth, or permit to
any atruMVrepaler tells hatt he6 elsose,i Funniest to the rovisihpermite
file a signed statement that he V Bansed pursuant to the provisions; of the
Contractors License Law (Chspler9(mmmentlng with Section 7000)°( Dial-
s1on3of the Budnessand Pro( nsiow Code)orthat he is exempt therefromand
the basis for the alleged exemption. Any violation of Section 7ML5 by any
applicant fora perm¢ subjects the applicant to a civil penalty M not morcthan
five hundred dollars (5500).
I,asonerofthe property, or my employe with wages
171 w rs ges as their sole
compensation, wllldothe work, andthe structure issue Intended or offered for
.sale (Sec. 7044, Business and Professions Code: The Contractors License Ls v
does not apply to an owner of property who Wilds or Improves thereon, and
who does such work hlmseiforthrough his own employees, provided that such
improvemcntsare net intended Oro(ferctl (w role. Ithowevegthebulldiagor
Improvement heold wllhinoneyearofcomplNlon, theowner- builderwill have
t rden ofpsevingthat he did not build or improve ferpurpose ofsale.).
LL as owner of the property, am exclusively contracting with licensed
contractors to constmct the project (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an -owner M property who
Wilds Or Improves thereon, and who contracts for such pkojects with a
on cher(a)Rmne pursuanttothe Contmdor'e License Law.
LJ I am exempt under Sec B & P C for this reason
SIGNS ELECTRICAL
SPECIALCIRCUIT /MISC
TEMP. MEIpB OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
O[JfLETSSWITC}I15FIXTIJRFS
#�sf
nA
TION
, lr
EW RESIDENTIAL ELECTR `•Q:Fr.
STORIES • -
TITECONSTRUCTION
`
-0CC. GROUP
'
RFS. UNITS
QTy'.
- TOTAL:
t'(,]?WmBING PERMIT',, i +,
PERMIT ISSUANCE
ALTER -DRAIN & VENT- WATER (EN
'';FEE`,.
H'�D lONE
APN
BACK FLOW PROTECT. DEVICE
t ^ +. FEE SUMMARY 't{
2' FEES
Owner Date
DRAINS FLOOR ROOF, AREA, COND.
FIXTURFSPER TRAP
GAS EA. SYSTEM -] INCA OUTLETS
_SA
SANITARY Y JN
RECEIPT#
WORKMAN COMPENSATION DECLARATION
01 hereby affirm that I have a metiBote of consent to self - insure, or a
certificate. (Wtrkers^ Compensation Insurance or a certified copy the.( (Sac.
3800, Lab Q
Policy #
SCHOOL TAX Y N
RECEIPT# '
PARK FEE Y N
RECEIPT #
Co ny
�(CortlBed copy V hereby furnished
nceatlnea copy v race with the ary wpactl °n arol.mn.
the city
r CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed lithe Permit is forone hundred dollars
fS100)etifyt3
I shall not that In the pensen in any manner an xt hto b this penult c Issued,
1 shall not employ any person In any manner ao as to become subject to the
Workers' Compensation laws of California. Date
Applicant
Applicant
NOTICETOMPLICANT; It after making this Ccrtiflrate of Gemption ,you
CZ,I,dbe — ol,ject tothe Wurkers'Comperaatlon provisions ofthe Labor
Cod°, ymu swat (atthwith comply with such provision orthle permit shall be
deemed revoked. -
CONSTRUCTION LEIJo ten AGENCY
I hereby affirm okfor w there b e const Is Issu d (Sec. agency for the perform
area Na a for which this per Mtbbsued (Sec. 3097,Civ. C.)
Sander's Name -
Lenders Address
I ceelfythatl have read thisappBatio.. ad Ante that the above information
is worect. I agree to comply with al city and county ordinances and pate laws
relating to building construction, and hereby authorize representatives of this
city to enter upon the above - mentioned property for inspection Purposes.
(We) agree to save, indemnify as d keep harmless the City or Cupertino
against hablitbes, judgment, costa and'expenses which may in anywaynccme
against said City In consequence of the granting of this permit.
\%
CAS G.SYS[Qd- OVER4(FA)
CREASE /INDUSIRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
PLANCHECKFEE
PAID
Date Recei t#
GREASE TRAP
-
SEWER - SANITARY -STORM EA. XOFT.'
_
WATER HEATER W /VENT /ELECTR
ENERGY FEE Y _ N
PAID
Date 'Recei t#
-
WATER SYSTaf /TAE47ING
NEW RESIDENTIAL PLMB.__SQ,FT,
TOTAL:
J ING ' '
TO
SEISMIC FEE
ELECTRIC FEE
QTY.
MECHANICAUPERMITi
PERMIT ISSUANCE
'ALTERORADDTOMECH, -
AIR HANDLING UNIT (TO 10,000 CEM)
-
•'.'FIB'.-
PLUMBING FEE
MECHANICAL FEE
FEES PAID:
Date Receipt#
SUBTOTAL.-
AIR HANDLING UNIT (OVER ]O,000CFM)
CONSTRUCTION TAX
9gratam of Appllcant /Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazartlous
material.. defined by the Cupertino Municipal Code, Chapter 9.1 7, and the
❑ Yeed Safety C°de+� —Se saloon 25532(¢)7
Will the Sppliesen or future building omtpant use equipment or devices
which of[ hauMous air corn entrants as defined by the Bay Area Air
Qu 1hy Management Dwret?
q Yes Fl No
have read the huar�i ous materials requirements under Chapter 6.95 of
the Califrnia Health &Safety Co de, Sections M505, 75533 and 25534, I
understand that lfihe Wilding does not cu rrently haveatenant, that itbmy
responsibility is notify the occupant of the requirements which must be met
prior to Issuance of a Certificate o(Oceepanry.
EXHAUST HOOD (W /DUC'D
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 10),000 BTU)
Date Reeel I#_
UNIT 1M ilan BTU)
TOT
FAN fSINGLERESID)
ISSLLA� DATE
F4
29 1991
b
®M•
(a IP�I{
BYA�
BOILER-COMP OR 100,0(0 BTU)
NSOILER-COMP(OVE�RJ00,090
(OVFR IfilOW BTU)
T METH. SQ.FT.TINY
- , -
TOTAL :
ISSUED
Owner or agent - Data
OFFICE COPY