23273APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Add.:
PERMIT NO.
n �I n
73
aai67 s�- o���
232
wneva one:
CITYOF CUPERTINO�BUILDING DIVISION
APPLICATONIPERMIN
7
CLk. No:
Arc Ract/ gineer. Lie. No:
BUILDING-ELECTWCATePLUMBING.MF MCAL
CATEGORY
CONTROL M
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address
PLUME M�H
❑ 11 ❑
PERhITISSUANCE
LICENSED
ED CONTRACTOR'S DECLARATION
that
IMreby eeflon7000)o DiviWam m3ofthesed er "mmandPmfeWonsns 9(comm.
Ingwlth Section 7000)ofgvislon3o(rhe Busleessand Pro(esslonsCade, and my�
license Ism o d d(cer.
APPLIANCFSRESIDENfUL
JOB DESCRIPTION
A
PANELS
Limn CW LI[.R
Date CoMnctor(�%�
ARCHITECT
I understand my place shag be used as public recoNs.
201'1000AMPS
OVERIOOOAMPS
SQ. FT. FLOOR AREA
$/SQ.FT.
SIGNS ELECTRICAL
Licensed Prefesslarul
SPECLILCIRCUIT/MLSC
OWNER -BUILDER DECLARATION
I herebyaffirmtlul I. exempt fromthe Cordeadora Limn. law for the
TpT{p METER OR POLE INST.
following reason. (SMIon 70115, Business and Professions Code: Any city or
=nlywhichrequire*apem Wwmu d,alter,bnprove,demoiish,currepair
anystmctum prmrto its Wuance, also requlreatheapplicantforsuch permit to
file a signed statement that he Is licensed pursuant to the provbiov of the
Contractor's License LAw(Chaptarl) (commencing with Section 7000) of Dial-
slon3 ofthe Businmand Pmfnalom Cose)orthat he is exempt themfmmand
the basis for apermRed exe prion.the pAnyvicant oation civil of penalty of nm room than any
the beaapplican for the alleged exemption. Any ablation of Section 70315 by any
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
meq/ VALUATION
NEWRIESIDENTIALELECTR SQ.FT.
five hundred dollars($500).
I, as owner of the property, or my employees with wages as their sale
STOW
TYPE CONSTRUCTIONF1
compensation, will do the work and the structure is not intended or offered for
.lo (Seo 7064, Business and Prefemioru Code: The Contractors Llceme law
does not apply to an owner of property who builds or Improves thermn,and
doessuch work himself or through his own employees, provided that such
OCC.GROIII'
RFS. UNITS
Improvements am not intended oroffered formle. If, however,thebullding or
TOTAL:
improvement isseddwithlooneyearofcomplMlon, theowner-buaderwlll have
tlwkurden of proving that he did nm build or Improve for purpose admin.).
u L as owner of the property, am exclusively contracting with licensed
contractors to consumer the pmject(Sec. 7040 Business and Profmbro Cade:
QTY. PLUMBING PERMIT FEE
FLOOD ZONE
APN
PERMTTISSUANCE
The Contractor's License Law don nor apply to an owner of property who
Wilds or Improves thereon, and who contracts far such pFjeda'with a
cgatpdor(s) licensed pursuant to the Contndars Liamue caw.
LI I am exemp under Sec B h P C far this ...
ALTER -WATER (FA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
DRAINS FLOOR ROOF, AREA, COND.
SANITARY . Y_ N_
RECEB7 M
Owner Date
WORKMAN COMPENSATION DECLARATION
hereby affirm that I have a certificate of consent to self -Insure, or a
rtifimte of Workm'Comperaation Insurance or a certified ropy thereof 03ec.
3800, L. C.)/, acs A 1o7QO3
PolicyB LWT
FO(TURES PER TRAP
SCHOOL TAX Y N
RECEIPT N
GAS EA. SYSTEM -1 IJC.60IlILETS
PARK FEE Y N
RECEIPT M
Com env_ �yop
GAS EA. SYSTEM -OVER 4 (EA) �
BUILDING DIVISION FEES
CertlRad copy hem furnished.
am
ed copy is (fled with the city IropMion division.
GREASEANDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
SEWER -STORM EA 200FT
COMPENSATION
Ohiasectlon need nd Wcom becomplMed Ithe permit is(or ono hundred dollars
Date Recei t#
HEATER W/VE}IT/E7.ECTR
ENERGY FEE Y N
(SI00)orine.)WATER
I eenilythal Inthe perfomunceof thewmk forwhich lets permit le blued,
WATER SYSTEM/TREATING
I shall not employ any person In any manner n as to become subject to the
Work� Comperu tionfawso(Callfomia. Date
PAID
Applicant
NEW RFSIDENTfAL FLUID, SQ.Fr.
Date Reuel til
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should became subject to the Workers' Comperuatlon provisions of the Labor
TOTAL:
-
BUILDING-
d
Code, you must forthwith comply with such provisons orthis permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
a
I hereby affirm that there is a construction lending agency for the perform
anm of the work for which this permit is Issued (Sec. 3097, Civ. C.)
lender, Name
Lendee.Addreu
I eartifythat I have read thisapphatlanand statvthatthe above Information
iscorred. l agreetocomplywithallcityand munlyordmanresand state laws
relatingtobullding construction, and herebyauthorizerepresentativesofthis
citytoenterupontM above-mentmaedproperty(orlmpectlonpurpossa.
e to save, indemnify and keep harmless the City of Cupertino
ago tlla lilt�a.Pdgnmmte,cmm.a exp .a which maylnanywayamrus
zg t s d Inconaequen of the gr of this permit.
^//
TOTAL:
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMITISSUANCE
.
FEES PAID
(Q\ Z
ALTERORADDIOMECH.
Date Recei tN
AIR HANDLING UNIT (TO 10,000 GEM)
SUBTOTAL:
AIR HANDLING UNI'T(OVER 10,000 CFM)
CONSTRUCTION TAX
S tumof Applicant/Cont tar Data
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARD S MATERIALS DISCLOSURE
HEATING UMT(TO 100,000 BTU)
Date Recei tN
Will the applicant or future building occupantstone or handle hamniom
material as defined by the Cupertino Municipal Code, Chapter 9.17, and the
Health and Safety Cade 37(a)7
❑Yes
Will the applies building occupantuseby equipment or
HEATING UNIT(OVER 100,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RESIq
1$SUANC�E DATE
hamrdntormlure
Ana Air
whkheMnaement air contaminants unbas dented by the Bay Area Alr
Quality Management District?
'PYen
QY+ Y4 1 �./
BOILER -COMP O}I'OR I00,IX0 BTU)
BOILER-COMP(OVER 100,000 BTU)
hase madthebaaa oils rrute Ial m-quimm.n und,rCh.pter G95of
tet California Health k Safety Code, SCerk)re 75505, 75533 and 75534. I
JUN 12 1992
NEW RESIDENTIAL MECH. SQFT
understand that lfthe building does not currently have a tenant, that it is my
res tyro nmdy the occupant of the requirements which mast he met
p into les a oda CertlficaI of¢p�om ry.
CII Y Ur UILIeCfililiv
'
ncrorauthorimdagent va Data
15SIIED BY:
TOTAL:
OFFICE COPY