19984APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building project identification
Building Address:
23S_7120 C IST e .
PERMITNO.
19 9 8 4;/
�
ante Q if es
CITY OF CUPERTWO-BUILDING DIVISIONlet
APPLICATION / PERMIT
_,Z� —
ce atle •N•nrIJcNu
O Ce) IjU4
CALORY
CONTROL Y
Architect/Engi Ik No:
QTY ELECTRICPERMIT. FEE
BUILDING PERMIT INFO
Address:
El El El ❑
PERMITI.RUANCE'
LICENSED CONTRACTOR'S DECLARATION
Ihereby.ffhm Nat lamllceveduMer pcovWoru of Chapmr9(commm
Ingwlth Se n7000ofDiv m3ofthe BuN mdPmfntl Code,and
Boers, is In full for¢ and effect
LlareeCt. Lk.11
Date Cormactor
ARCHITECT'S DECLARATION
I understand my plsmahall h used as public remNa
Licensed Pmimional
OWNER -BUILDER DECLARATION
I henebya(0nmthat lame xempt fr�mthe CoNnctore Ll¢ve LAwforthe
rmntywhkaxon.(ection mlttomairmas andPsnossuen Code: Any city
county hichnen.(Bectlon70315, Business.1m,urmbns e.14h,yatyor
or
preno,
any.tructure prior to Its leeusece,alsu mala ion the.ppg¢nt for such permit to
file a signed statement that he b Ooomad pursuant to the pruWbra of the
Comrseum: Llceree Law (Chapter 9 (commencing whh Section 7000) of DMv
siun3 ofthe Buslnwand Profmbn Code) orthat he is exempt therefromaM
the bells for the alleged exemption. Any violation of Section 70315 by any
applicant for s pemdt subjecta the applicant to a civil peruhy, arta more than
five hundred dollars (SM.
F1 1, as owner of the property, or my employes with wages a their auk
compewtlon, will do the work, and the structure b not intended or offered for
Mk (sec. 7011, Busbuas and Profmlon Code: The Contractors L oe. Law
don rout apply to an owner of property who Wlds or lmprovn thereon,and
who does such work hlmalf or through hls own employees, provided that such
Improvemow are rot intended oro/(enrol f¢ sok. IL however,the W ldleg or
Improvement bsuld whhlnoneyeiro(complabn,the owner -W Oderw U haw
Xt Men¢ofprovingthathedOrw Odorlmpmveforpurpoaeofsak.).
I� Late owner of the property, am exchulvely contracting wLLh Iben•ed
t s to construct the project (Sec 7014, Businessand Prambm Code.
The Cmucadm'• Leer. Lw don not appy to an owner of property who
Wilda, or Improves Merton, and who contracts fee such pTojeeb with a
c9lailsetm(a) 11cenued pursuant to the Contractors License Law-.
LJ I em e. 1.0 under Sec B 4 P Cfor this muton
4o
APPLIANCES-RESIDENTIALOB
[ION T
DE9[R"C21-
C il\Z", C —T l e
r
SI 1 -� �I V
PANES
— UP TO 2DD AMPS
-&M-15
OVERTWOAMPS -
SQ. Fr. FLOOR AREA
E D 1 N
�1 , TF
l7■ (7�
Aa /
f/9Q. FT.
SIGNSELDCTRICALF1 UK-
- SI'FJ,7ALCIRCIIIT/MLSC
7EMP.MEI'EIt OR POLE )NST. '�
ItiTJIFR DEVILS D � .
SWDRANG POOL ELECTRIC
OUTLETSSWITCFIN"rH)CIl1RFS
VALUATION
NEW RESIDENTIAL ELECTR SQ'FT'
STOEUES
TYPECONSIRLCTION
TOTAL
QTY, PLUMBING PERMIT FEE
OCC.GROUP
RES UM(S
FLOOD ZONE
A),N
PERMIT ISSUANCE
ALTER-DRMN&VENT - WATER PEN
FEE SUMMARY
BACKFLOW PROTECT. DEVICE
esse
DRAINS FLOOR. ROOF, AREA, COND.
SANITARY Y_ N.
R�EB'II
��Z7L-[OFD7{�e'.y7a
WORIO.EAN COMPENSATE A� N
[-]I hereby aHOm that I Tuve a ¢ cQ! @i est to self-I�nrt, ora
comf31M, ab of Workers'Cmnpemauonlrouran¢mat anHkd copy thenro/Cee.
31M,LabCJ
�� a
FDOMJRFS PFR TRAIT
SCHOOL TAX Y_ N_
RECEIPT If
GAS EA. SYSTEM -1 INCA OUILEPS
PARK FTE Y N
RECEIPT' 1
CAS EA. SYSITM-0VER 4 (FA)
Comm Csty
BUILDING DIVISION FEES
ICenNed copy Lr ffledbtretumecity
IiJ� CcrtlOed ropy 6 filed �Mth the city Irupttibn dlvlsion:
CERTIFICATE OF E)(iIM EON FROM WORKERS'
COMPENSATION INSURANCE
(IMssMbnneed n¢bec Dieted If the permit is for one hundred doBan
m°°)or lmJ
lam0yLou ft, the performance work for wlorwhlch this permit issued,is eaed,
I 1u nM empby any pennmt b any manners ate to become eubjea to the
Wmknn' Cmmpensatbn Laws o(C. Womb. Date
Applicant
GREASE/INDUSIRL WASTE INTERCEPTOR
P CHECK FEE
PAID
ate Recei f#
GREASE TRAP
SEWERSANH.ARYSMRM EA LI(BrT
WATER HEATER W/VENT/ELECTR
E'NERCY Y N
PAID
DateRegi #
WATERSYSIFMj[REATING
NEW Rk30EN'IEN.PUEB. SQF7.
NOTICE TO APPLICANT".H,.Resmaking this CoAtfiam of Exempt ion, you
mhmme subject to the Wor
shld klsbm of t
em' Compensation poevhe Labor
Cade, you must forthwith comply with such provielon or this permit shall be
doomed revoked.
CONSTRUCTION LENDINGAGENCY
Ihereby.ffirm tart there ba construction lending agency for the perform,
once of the work for which this permit ls burred (see 30Y7, Civ. CJ
lender: wn,e
Lord or'•Add rm
1 cMiythat I love read thbappllatbnand state thrtthe above Inlormnlm
bmrrm.l.grte tocomplywithaOchy•M countyonlNanmandsoulaws
relatingtobuildingenntrumm,.N hereby•uthorirerepresentatWeo(thio
city to enter upon the above-mentioned Property for inspector, Purpo. .
(We) .gree to mee, mdemNy an d k<ep harmim the city efCLpenlno
agaWtVabWtbs, ydgmerds, mstsaM npenen which mayN mywayaccroe
againut old CityGb Mmnueryerzz+(the granting of this pemW.
�a�G/ 9�ja/p.�
(-Datte
Nl .TOT
BUILDING FEE
EISMIC FEE
TOTAL
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL 'E
PPRMPrISSUANCE
FEES PAID:
,
ALTERORADDTOMECH.'
Date Receipt#
AIR HANDLING UNIT (TO 10,000 GEM)
SUBTOTAL:
AIR HANoulvc vNrr rovFRlo,000GFnn
CONSTR ON TAX
sgtalure of Appuant/ s
HAZARDOUS MATERIALS DISCLOSURE
WOltheappliantorfuture WOdingoaup.nt store or handle haaardous
material as defined by the Cupertino Municipal Code, Chapter 9.IZ and the
He❑ahh.m[ Soley Cure, SectlY.oon zs533a)r
Wllltheippl"menfutum Wlldingomvpantuseequiprnent ordevlc
which emit havrdnus air osntamW Ne as defined by the Bay Area Mr
Qna1By Managerry nt Dlstmt7
Y. I� No
have read the h mous materials requlremenb under Cha per 695 o/
the C.hf.UHeahh&Safety Cade,Sectbru75505,SS33and7S5M. I
understand that i/ the Wn building donot mrrentyve+te
hanant Is It my
roporalbility to really the occupant of tho rtqulrcments which at be met
prl¢to Issuance of aao1il teotOmnPancy.
EXHAUSTHOOD(W/DUCT)
CONST CTION TAX PAID:
- -
HEATING UNIT (TO 100,0)0 BTU)
ate Recei t#
HEATING UNIT (OVER 1W," BTU)
TOTAL:
VENTILATION FAN(ShWLE RISID)
ISSUANCE DATE
G /l FD
)MI
'
r)t7 'I<(„SWI
APR _
I City of furertinn
ISSUED BYj+ (Jc k!/� W
BOILER -COMP PFD' OR 100,0W BTU)
BOILER -COMP (OVER 10(),(C() M)
NEW RESIDFNRAL MECH. 5Q.ET.
Ownermautherimd•gent Date
TOTAL:
OFFICE COPY