19986APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN.ONLY.
Building Pro eet Identlneattan
B. Ming Add.:
ae35oo at zstc Pe
PFRwT NO.
19 9 8 6
M�as
G V_O
CITY OF CUPERTIN6BUILDING DIVISION
APPLICATION / PERMIT
BIIILDINGELECTIUCALI'LUMBINGMFLFiANICAL
Contractor: Name: Lk. Nu
CATEGORY
CONTROL I _
ArchRed/Engineer. No:
QTYELECCR[C PERMIT FEE
BUILDING PERMIT INFO
Address GOq Vt -
F
�2s�
oLUPFRMITISSUANCE
❑ X ❑ ❑
LICENSED CONTRACTORS DECLARATION
O
I hereby kmaff7000) of
amlkmaedhe under Btuarwt lonand PrfeselosCoce, and m
bigwltFSecibn force afdoffon ofth<Buelwaandl'mfnelwCode,and
Livenbin full fora and dfea.
Lineae Clam LILT
Drte CamrcnRor'UP
ARCHITECPS DECLARATION201-1000AMPS
Iundemssmdmyphnah.Bbeusedaspubac,roads
Lk:necd Profewbal
hatIam B ILI)ERmptfro DECLARATION
I herebyafOrm thatIunexemptfromthe LARA111O Llar�Lw(othe
eouowingreuon. (Seca n 7031 pemittocoainsandr,bnp uConk Mytlepair
muntywhichr .(Sk Ipermit S, contact, alter,wmlun Code:emulAmy city or
anystm=mpA toitn ame,aL requlmtheappUantfaeudtpe tto
file a signed statement that he b p
Beeed pursuant to the pmvleiamu of the
Contractor's Lkenelaw(Chapter9(mmoencing orh Senbn 9000) of Divi-
aum 3oftbe Business and Profes mCode)orthathehexempttheefromamd
the basis for the alleged exemption. Any violation of Section 7MIS by any
fora pert subjects the appBcant to a civil pmatty d not moa than
applicantmi
Iiv�huns owns of thepro
U I, d owner of the property, or Cry empbyen with wage u their role
mmperuatlon,willdo tha world andthe.truciurc b wt welled or offend for
sale ISee. 70K Busnees and Prof®lona Code: The Comractae. LIanx Law
does not apply to an owner of property who build. or imprwesthereon, and
whod«esuhworkhl Uorthmughhi..nempinyms,providedthatsuch
] pmvcmenbarenotintendedorofferedforeak.ILhowever,thebalbingm
Impmvcm mbaddw hlnomy rofcompletbs,tbe Omer-wMerwWhave
ov
L"relcoof proving that he did wild or Improve for purpose ofule.).
L_j L as owner of the property, am e.e ely mmtracting with IbenM
mntncimeto mmutruct tha proJed (See 7011, Bninrssand Pof.lon Code:
The Cnot actor's Lkrns, law dram not applY to an owner of property who
or Improves thrones, and who mntecte fee such plojcm with a
egWartor(s)Deemed pomsuant to the Conwdor'sLleree Law.
LJ 1 am exempt under Sec B h P C for bb reason
APPLIANCESRFSLDLNML
BDESCRR'rpN
-rip
1�r^F1- (� L�•�� .
I'ANEIS
TO 2DOAMPS
OVER 1000 AMPS
SQ. FT. FLOOR AREA $/SQ. FT.
LED I N
PATER
-
ON
SIGNSELECIRICALOWNIER.
SPECIALCIRCLIT/ML9C
— '1"FAOR POLEINSf.
1'OWF.R DEVICES
gymggNG POOL ELECTRIC
DAM
011]LEI '.7.�Hi]SFl%7lJRES
NEW RESIDFMIAL EIECER SQTT.
STORIES
=CONSTRUCTION
TOTAL3fl
QTY. PLUMBING PERMIT FEE
OCC. GROUP
RES.UNITS
FTDOD ZONE
'1IT1
PQiMITISSIlANCE
ALTER -DRAIN 4 VENT- WATER IRA)
SUMMARY
BACK FLOWI'RQfFGr. DEVICEFEE
DRAINS HOOK ROOF, AREA, CONTI.
SANITARY Y N
. Rpr�.
Owner Data
WORIOstAN COMPENSATLON DECLARATION
❑I hereby affirm Co 1 have o artlf. of cemm�t to self -]we, or a
MID, Lab of Worken'Compevatlon Inuranaora artifkd espy thereof (sec.
3800, Lb CI
mley R
p�S, PER TRAP
SQiOOL TAX Y_ N_
RECFd
GAS F.A. SYSTEM -1 INCL OUTLETS
PARK FEE Y_ N_
N
RECERar Y
GAS E.A.SYSTEM-0VER / (F.V
Com nay
BUILDING DIVISION FEES
Gem Lfiedmpybfikd fumbhed.
CedWed espy b filed'Mti the efty Inpecibn dfvWon.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
CCM. lesion need neat be completed If tM perMt b (sou hunded doBan
a100)o. tem3
o the pare. I an lhewerk sor wMcbeeom emJl le blued,
] a.. t1hatemploy
I shag not empty any TAw3 In any manner at ss to become eubjett to the
W pllean Compenaatbn lawn o(GWmnh. Date
AppOont
NOTICE TO APPLICANT: IL after raking this Certiflnte of Exemption, you
,bald become subject to the Worten' Cemp monfen provbbm of the labor
Code, you must forthwith comply with ouch proWsion or thio permit Wil he
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hemebyaffirm that throe is a mntruction lending agency for the perform
ana of the work for which thio permh b boredSec ( 3091, Clv. C.)
Lendar:Name
Leoder:Addmes
Lartlfy Alhaworedthbappliatbnardstatellattheaboveinfor ion
bconer . l agratneemplywxhail dty.M muntyomdlnanmand stau,l. .
mlating to wilding cora rudlor, and hereby authorize repreeentatluis of thb
city to enter upon the above.mentbed property fee kapedbn purpoaa.
(We) ages to save, Irdemnify an d keep harmless the City of Cu p"tb'o
against llabditln,0dgments, costa and experuea whkh may in any way amrue
ago ins asid City 1m mneequenoe of the gram log N this permit.
GREASE/WDUSML WASTE INTERCEPTOR
PLANCHECK FEE
p'plp
Date Recel t#
GREASC RAAIa
SEWFFSANITARY STORM EA 20WT
WATER HEATER W/.VENT/o-Lr['R
E'NERGYFEE Y N
PAID '
Date Real t#
'
WATTR SYSIFIA/TR TING
NEW RESIDENTIAL PLA/& SOFT.
TOTAL:
BUILDING FEE
SEI MIC FEE
TOTAL:
ELECTRIC FEE
Q Q
-
QTY. MECHANICAL PERMIT FEE
PERMIT ISSUANCE
PLUMBING FEE
MECHANICAL FEE
'
FEES PAID; -
,
ALTERORADDTOMECH.
AIR HANDLING UNIT CrO 10,000 CFM)
Date Receipt#
SUBTOTAL:
AIR HAN13ulvc Darr (OVER lo,InocEM)
CONSTRUCTION TAX
Sigatu re of Applicant/Contractor Date,
HAZARDOUS MATERIALS DISCLOSURE
WW the appllnntorfuture wilding oavpant Toe or hand le h.d..
material u defined by the Cu Perrino Municipa l Code, Chapter 9.12 and the
HIlthand Safety Code Seetion7 24)7
YrjNo
n Wthc applkantmfutue w0ding oavparA use equlprnmi or devious
which rout hazandoua air mnlamlanb ae defined by the Ray Area Air
Quality Mamagemrod Wtriet7
4YnhavcmNo dtheha .m trio b Yq IrtmenbunderChapterG9 0(
the Ghfemb HeallhkSafety Code,Senbn25505,25533and2S53/. T
umdb
mmd that if the wilding doero
s t currently have a tenant. that k bon
mopoaibilfly to realty the o pant of the requirements whkh must be met
pmrto a da Certtficateof Occupancy.
wee, or;
Pvnermauth agent Date
EXHAUST HOOD(W/DUCT
CONSTRUCTION TAX PAID:
HEITRNG UNIT (TO 100,000 BTU)
Date Recei I#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
-
'?CAB
/CA3O
VFNIILATK)N FAN!SINGLE RESID)
ISSUANCE DATE
P_ 40
APR 2 s '1990
�LI �b
BY OE l�(
OE
ISSUED BY: L+L
BOILER -COMP OHIP OR 100,0(0
30I1CILCOMP(OVFRIM,0008I11)
NEW RMDENIIAL MECH.' SQFI.
_
MORAL:
OFFICE COPY