23972APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project IdentificationPERMIT
Building Address: SL ��
NO.
23972
nems one:
C ors ante: Lie. No:
CITY OF CUPERTINO-BUILDINCyD1V1 OD'
APPLICATION / PER I
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V U l O
BUILDING-ELECTRICALPLUMBIN -ME CAL
CATEGORY
CONTROLa
Ito /Engineer. Llc No:
QTY ELECTRIC P FEE
B DING PERMIT INFO
PLUMB
Add.: /
PERMITISSUAN
ElCONTRACT
'SrUECLARATiON
I hereby affirm that l son licensed under provisions of Chapter 9(corrmme
ingwith SeMon7000)of DlWslan3oflhe Buslnese.rd Pref sedomCode,and my
If... Is in full force and affe t.
License Class �Lk.N
AP NC LA
JOB DESCRIPTIOpsowN
1 LLLL
/fie
( `
P
Date
ID7-ID00 MI5
_ContnRo
ARCHITECT'S EC R N
Iunderstand myplansshall beused aspublic records.
OVER1 AMPS
SQ. FT. FLOOR AREA 4/
SIGNS ELEC C LJJE
Licensed Professional
L E
SPECIALC T MLSC
OWNER -BUILDER DECLARATION
I hereby afRrmthat l am exempt fromthe Contractor. License law for the
,4 D s
p /1
TEMP. RPOLE S`�'PUT
following reason. (Section 7031.5, Business and Professions Code: Any city or
rountywhichmqutr sapermittommtmd,altegimpmve,demolish,ormpair
ER
anystmcture pdorto its Lssuance,alw requimtheappBcant forsuch pemNtto
file a signed statement that he V licensed pursuant to the provisions of the
POWERDEVICES
C. trader'. License Law (Chapter 9(comonneing with Section 70W)o(Dlvl-
slon3 ofthe Basions antl I'rofemiom Code) orthat he V exempt therefromand
gW�IN,yING LELFCTRIC
A
the basis for the alleged exemption. Any violation of Section 7031.5 byany
applicant for a permit subjects the applicant to a civil penalty of not more than
UTLE TCHFSFTXTURES /fel
C.�
NEW DENIAL ELECTR SQTT.
five hundred dollars($SM.
❑I, as owner of the property, or my employees with wages as their sok
STORIES
TYPECONSTR KTION
mmpemati.r': do the work, and thestuctus, is not Intended or offend for
sale (Sec. 70K Business and Professions Code: The Contractors License Law
does not apply to an owner of property who builds or Improves thereon, and
docs such work himself or through his own employees, provided that such
OCC.GROUP
RIS UNITS
Improvements are not intended oroffered forxle. If, however, thebulldingor
Improvement lswld wlthinone)Barofcomple iomtheowner-buBderwill have
QTY. PLUMBING PERMIT FEE
t"rdan of proving that he dm net bulla or improve for purpose ofuk.).
U I, a, owner of the property, am exclusively contracting with Rmnsed
contractors to mnstuct project ect(Sec. 7004, Business and Professions Code:
FLOOD ZONE
APN
PERMIT ISSUANCE .�
The Contractor's es the Taw does not apply et an owner of property who
Wild, or improves themuand who macrons !w such ptojecb with a
UB1tactor(g .censeunder pursuant to Me Contractor's License Law.
LI I am exempt under sec. B & r c for cob mownOUTSIDE
ALTER -DRAIN & VENT- WATER (EA)
FEE SUMMARY
BACK FLOW PROTFLT.DEVIGE
FFES
DRAINS FLOOR ROOF, AREA, COND.
SANITARY RECEII'N
OwnerDate
,�/ WORKMAN COMPENSATION DECLARATION
1J/ 1 hereby affirm that I have a certificate of consent to self -mum, or a
cenificat..dworkea'Compensattot imuranmora mnifind copythereof(Sce.
3800, LbG
pttSppR TRAY ��
SCHOOLTAX Y N
RECEIPT N
GAS EA. SYS`rEM.1 INCA OUTLETS
PARK FEE Y N
RECEIPT N
Policy Y
Com
GAS EA. SYSTEM -OVER 4 (EA)
BUILDING DI VISION FEES
�Cenlfed ropy is pled with thee city Inspection division. d copy is hcrcby mr h
®Conii/l city
CREASE//NDU5TRL WASTE INTERCEPTOR
PLANCHECK FEE
l
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
COMPENSATION INSURANCE
(Thlsse Man need not be completed If the permit isfor one hundred dollars
SEWER -SANITARY -STORM EA. 700FI.
Date Remi t#
WATER HEATER W/VENT/ELCCTR
ENERGY FEE Y_ N_
($140)or1C .)
I codify that In the performance of thework for which this permit m hued,
WATER SYS.II N/TREATING
I shall not employ any person in any manner an as to become subject to the
Workers Compensation Lws of Callfomia. Date
PAID
NEW RESIDENTIAL PLMB. SQFT.
Applicant
Date ReceI t#
NOTICE TO APPLICANT: If, after making this CeMflcate of Exemption, you
should become subject to the Workers Compersatlon provisions of the Labor
TOTAL:
BUILDING FEE 971,
Code, you =at forthwith comply with such provisions orthis permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
Ihereby affirm that there is a mmtruction lending agency for the perform-
ELECTRIC FEE k,,aaa
ance of the work for which this permit is hued (Sec. 3097, Civ. CJ
Lenders Name A//u
Lender's Address
leertifythatl lout mad atmnandsatethauheabovelnfor tion
ismrmct. I agreemcomplywith all Myand countyordlnanansand state laws
PLUMBING FEE /'�
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relating to building construction, and hereby authorize representatives of this
city to enter upon the above-n-antioned property for inspection purpose,.
(We) agree to save, Indemnify an d keep harmless the City of Cu peMno
agaimtllablllUes,pdgmem,costsandexpensea which maylnanywayacceue
Date Receipt#
ALTER OR ADD TO MEGA.
AIR HANDLING UNIT (TO t0,000CFM)
SUBTOTAL:
.gam, Id -m once of the acting of this permit.
/ �y/
4W S 7
R HANDLING UNIT (OVER IQODOCFM)
MR
CONSTRUCTION TAX
Slgtuturco ant/Contra or ate
IXHAIISTHOOD(W/DUCT)
TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,000BTU)
HEATING UNIT (OVER IOO,OOD BTU)
Willtheapplicant or future building occupant store or handle hazardous
material as de0ned by the Cupertino Municipal Code, Chapter 9.1 7, and the
Hesllhand SafetyCcdc on 75537(a)7
E -1 Y- 0151.
Will the applicant or future building occupant use equipment or devices
Date ROCeI f#
TOTAL
VENTILATION FAN(SLNCLE REBID)
ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management Dist 7
��
P A ID
PAID
{J
BOILER-COMP(3FI'OR 100,0(D BTU)
BOILER -COMP BU)
Yes Nom tedaLrequimmnNunderChapter6.95of
4ycrcadthehaza Ip
the California Health & Safety Code, Sections 75505,75533 and 75534.1
understand that if the building does not currently have a tenant, flut It b my
JUL 90
N ]Llnrs
gixiC
NEWRESIDENIIALMECH. SQ.FT.
responsibility to notify then pant of the requirements which must be met
CITY
pri e a wteofOaupan
---- �t9L�II/Vl
V I Qj-
ISSUEDBY:��
Owner ora o - geneC ale
TOTAL
OFFICE COPY