23651APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pm ed Identification _
Building Address: Z,'J�a � �. �..�
PERMI TNO.
23651
rare Name me:
A
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
o car's Nanr: c ua.
re itm/ timer. Lk. o:
BUILDING-ELECTRICALPLUMBINC-MEIiAMCAL
CATILORY
CONTROL#
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:
PERMITIS5UANCE l �
LICENSED CONTRACTOR'S DECLARATION
I hereby aRirmthat l am hemsed under provisions of Chapter9(mmmen
Ingwilh Setl1on7000)of Dlvislon3 ofthe Busiormand Pmfesdons Code, and my
I=is in full( and effect. //Q
LlconeeC 1, LItM at'I
APPLIANCES -RESIDENTIAL
JOB ESCRIPaT.�ION
J
PANELS
Date Contractor
UP TO 200 AN'S
,
201-100DAMPS
CHITECPS DECLARATION
l understan myplaosuhaBbxaxdaspubllcrecords.
OVER 1000 AMT'S
SQ. FT. FLOOR AREA
S/SQ.FT.
SIGNSELECTRICAL
Licensed Professional -
SPECIALCIRCUIT/M15C
OWNER -BUILDER DECLARATION
CdNGw fart he
following reason. ( a p 7 tto Busher and Pro pmm s Code: My city or
Iwing rason.03acon731.5, B fromthed Professions
countywhkh requlreaa permittororstsucl, alter, Improve, demolkh,orrepair
ED I IV
�Mp, METER OR POLE INS(.
FINAL
anystrocture prior to its Issuance, also requirestheapplicant forsuch permit to
ilk a signed statement that he is licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9 (commencing with Section 7000)'uf Divi-
sion3oftheBuAnnsmdProfemtoruCWd )orthdhelsemmptthemfmmand the basis for the alleged exemption. Any violation of Section 70313 by any
applicant fora permit subjects the applicant to a dvil penaltyd nae more than
POWER DEVICES
TER
SWIMMING POOL ELECTRIC
\
OUTLETS -FIXTURES R.
L -
NEW RESIDENTIAL ELECTR SQFp
live I, as ed own r of the
he pr).
MI,acowner oftheproperty,orhe employees with wages their sole
STORIES
TYPE CONSTRUCTION
curoffendfor
r
mmpSec.70 , wRldotheworl4femons
'
sale (Set 7061, and Code:Tknotintended
an a law
Code: The Contractors Licethere
to f property
does not apply to an owner or property who builds or Improves thereon and
ow
who meelfor through hiaowne. thatsuch
OCC.GROUP
RES. UMTS
provemuch are not
Improvement( If,hoever,te building
offered oreak.If,h
TOT L:
Improvement beoldwlthlnoneyearo(comptetlon,theowner-buBderwlll have
wldvintended amyearofcmr er-gflderilIhave
trysyurden of proving that he did not build or Improve for purpose of me.).
U L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec.7016, Business and Professions Code.
QTY. PLUMBING PERMIT FEE
'
FLOODZONE
APN
PERMIT ISSUANCE 14-
The Contractor's License Law don out apply to an owner of property who
Improves thereon, and who centra for such pto)ects with a
cyBgact r(s) licensed pursuant to the Contractor's License Law.
U I am exempt under Sec. B & P C for this reason
ALTER -DRAW Is VENT • WATER (RMbuilds-or
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y_ N_
RECEIPT #
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby aHlrm that I have • certificate of consent to self -Insure, or a
certifirateofWorkeraCompeosatian Insurance ora certlfkd copythereof ISM.
3800, lab C.)
FIXESTURPER TRAP
SCIdOOL TAX Y_ N
REC EE'T #
GAS EA. SYSTEM -1 INCAOUTLErS
PARK FEB Y N
RFCEBT 0
Policy 0`
Com y
GAS EA.SYSTGI-0VER4(EA)
BUILDING DI VI SION FE ES
CertiBed copy 13 hereby furnished.
Certified copy k filed with the city Inspection division.
CREASE/INDUSTRL WASTE INTERCEPTOR
PLANCIiECK FEE
GREASE7RAP
CERTIFICATE OF EXEMPT ION FROM WORKERS'
PAID
COMPENSATION INSURANCE
(This stolon need not be completed If the permit Is forone hundred dollars
SEWER-SANHARY-STORM EA 200Fr
Date Receipt#
WATER HEATER W/VENf/EL[CTR
ENERGY FEE Y_ IN_
($100)mlca')
I certifythat In the perfornunceof the work forwhich this permit Is blued,
WATER SYSTEM/TREATING
1 shall not employ any person In any manner so as to become subject to the
Workers'Comperadlon laws of California. Date
PAID
NEW RESIDENTIAL PLMB. _SOFT.
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become sub)cct to the Workers'Compa cation provisions of the Labor
- Date Recei t#
TOTAL:
- BUILDING
Code, you must lerlhwlth comply with such provisions orlhk permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
Iherebyafflrm that there is a comtructlon lending agency forthe perfornry
onceoftheworkforwhichthispermitkk ed(See.30Y/,CIV.C.)
Lenders Nano
Lender's Address
I nrtifythatl have read thkappiicetionand statethat thealsmelnformation
with.1letyandrountyordlnances and nate laws
is m41dz.satnz��=Wf
_ T L
OTI
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relaldiogand herebyauthorlurepersamativetofthk
city mentioned property for impection purposes.
(emnity an d keep h " ew the City of Cupertino
ataintis contend expert which may In my aya a
agalor o the gran g of this permit.
1-71
ALTER OR ADDTO MECH.
Date Receipt#
AIR FIANDLINCUM7(fO 10,000 CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER IO,ODDCFM)
CONSTRUCTION TAX
S riot Contractor Dat
EXHAUST HOOD (W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUSMATE LS DI54 RE
HEATING UNIT (TO 100,000 BTU)
Date Recei t#
Will the applic or future bulldin copant store or handle Fevzrdous
rtsterkl as defined 6Y the Cupertl uhitlpal Code, Chapter 9.1 2, and the
Health and Safety CadeL+–�S,eaton 32(.)1
Yen No
❑Willthezpplicam or Pome buildingompa.t use equipment or devices
FIEATING UNIT (OVER 100,000 BTI!)
TOTAL
VENTILATION FAN (SINGLE RFSID)
ISSUANCE DATE
which emit haeardous air mntammants as defined by the Bay Area Air
Quality Management Dlatrict7
❑No
-
BOILER -COMP OHP OR 100,0(U BTI!)
BOILER -COMP (OVER 100,000 BTU)
4Yex
haveread the Emmaus materials equirenentsunderChapter6.95of
the Califemla Health & Safety Code, Sections 25505, 25533 and 25534.1
understand that lithe buildingdoes not corrently have a tenant, that it is my
J/"1
NEW RESIDENTIAL MECH. SQ.Fr
responsibility to notify the occupant of the requkements which must be met
prior to Issuance of a Certificate of Occupancy.%
(jpQ\/ 11\Ll/
my 1992
WM4—~
Owner or authorized agent "Date
TO
OFFICE COPY