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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pm'eet Identification
BuBding Address:
PERMITNO.
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23131
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CITY OF CUPERTINO- BUILDING DIVISION
APPLICATION / PERMIT
SUILDINGELFiCTRICA ING-MECHANICAL
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Architect/Engineer. Lic. No:
QTY ELECTRIC RMIT
BUILDING PERMIT INFO
' OtITIE
$
Address: Ll F�j
PERhITISSUA
a-FFEE
l/SL �11
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under p.WonsofChapter 9(commenc
AI'I'IlAN DENTIAL
OB DFSCKITION
n
Ingwith 5ection7000)of Dlvlmoo3ofthe Buslnessand ProfessionsCode, and my
license is in full force and effect.
License Class LIC#
I
Date 'ContractorAMPS
}
1 -IOW AMPS
ARCHITECTS DECLARATION
I understand my plans shall be used as public mrords.
Llrensed Pmfeninal
OVERIWOAMPS
SQ' FL FLOOR AREA
i 11 1
b
$/SQ'Ff'
SIGNSELECTRICAL
SPECIAL CIRCUIT/MISC
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
—SIJ
TEMP. METER OR POLE INST.
following mason. (Section 7031.5, Business and Professions Code: Any city or
county which requires a permit to comatmd, alter, improve, demolish, or repair
any structure prior to Its Issuance, a Iso require; the a pplicant for such permit to
file a signed statement that he b licensed pursuant to the provisions of the
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETSSWITCHESFIXTURES
Contractors License Law (Chapter 9 (commencing with Section 7000) of Divi-
slon 3 of the Businessand Professions Cod0orthat he b exempt therefromand
the basis for the alleged exemption. Any violation of Section 70315 by any
appHcantfora perrok subjects theappllcant too civil penalty of not more than
VALUATION
1 OQ �s
five hundred dollars ($500).
�1, as owner of the property, or my employees with wages as their sole
NEW RESIDENTIAL ELECTR SQFI.
STORIES TYPECONSTRUCTION
compensation, will dothe work andthestrocture b nm intended or offered for
sale(Sm.7NM Business and Professlons Code: The Contractors License Law
does not apply to an owner of property who builds or Improves thereon, and
who doessuch work himselforthrrugh his own employees, provided that such
improvemenuarenotintendedorofferedforsale.ILhowevepthe Wlldingm
Up
TOTAL: a,�.
Improvement baold withinoneyearofcompletbn,the owner-builderwill have
ttr�urden of proving that he did not build or improve for purpose of sale.).
"I, as owner of the property, am exclusively contracting with licensed
rumracmr to construct the project (Sen. 7044, Business and Professions Code:
The Contractor's License Law don no apply to an owner of property who
Wilds or Improves thereon, and who contract for such jo jeab with a
tnctor(s)Ucnsedpuruanttothe Cantrctors License Law.
f I am exempt under Sec. B k P C for this reason
AtImpubla
/ f'�a ws
UE j (�"' G
QTY. PLUMBINGPERMIT
PERMIT ISSUANCE .V
ALTER -DRAIN (EA)
FEE SUMMARY
BAC]( FIAWPROTFLT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
SANITARY RPLQIT' N
Owner ' Date
WORKMAN COMPENSATION DECLARATION
❑1 hereby affirm that I have a mniHcale of consent to self -Insure, ora
cenificateof Workers''Compeutlonlmnnmoramrtilled mpythemcf(Sec.
3800, Lab CJ
FIXTURES. PER TRAP
SCHOOL TAX Y_ N_
RECEIPT I
GAS pA gySl.Fl f -I INC.60UTLEfS
pAAK FEE Y N
RECEI r 0
Contin a
Cc
GAS EA. SYSTEM-OVER4(EA)
HUI LDING DIVISION FF. ES
copy is hereby fumbhed.
iPrtified copy b filed with the city impection division.
4-Y CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASE/INDUSIRL WASTE INTERCEPTORE_�'SEISMICr
PLANC14ECK FEE
PAID___
GRElSE1RAP
SEWFRSANITARYSTORM EA 200FT
COMPENSATION INSURANCE
(Thbsectlon need not be completed I the permit is forone hundred dollars
(SIM)or lea,.)
I certify that in the peAarmanm of the work forwhich this permit b issued,
Date Recti tic
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y_ N_
WA.� SYSTEM./TREATING
I shall not employ any person In any manner so as to become subject to the
Works%Compensation lzws o(Califomla. Date
PAID
-�_
NEW RESIDENTIAL PLMB. SQFT.
Applicant
Date Remi tin
NOTICE TO APPLICANT. -If, after making this Certificate of [Exemption, you
should twcomceubFe to the Worker' Compensation provisions of the Labor
TOTAL
6 71
BUILDING FE
Code, you most forthwith comply with such provisions or this permit shall be
deemed revoked.ars-.
CONSTRUCTION LENDING AGENCYEE
Ihereby affirm that there b a construction lending agency for the perform
ce of the work for which this permit is issued (Sec. 3097, Cie. C.)
Lender's Name
Lenders Addrem
I certify that I have read thio application and mate that the above infomation
iscorrect. i agree tocomply with all city andmcruntyomdinances and state laws
izereprentativraofthis
relatingtobuildingnsbuction,and herebyauthorsi
citytoenteruponthe above-mentioned property for inspection purposes.
(We) agree to save, indemnify an d keep harmiess the City of Cupertino
against liabilities, j dgments,consandexpenses which may lnanywayaccrue
TO ''sk
<t
ELECTRIC FEE
�(, u
PLUMBING FEE
12.
QTY. MECHANICAL PER T FEE
MECHANICALFEE
13.0
PERMITLSSUANCE ��O()
FEES PAID
f'-�
F �V a 37
/
1 ALTER OR ADD TO MECH.
V
Date Receipt#
AIR HANDLING UNIT (T010,
CFM)
SUBTOTAL:
ago ince said City In consequenceof the n' gofthle permit. a�
f p 1{� �{/f a ��'//'y
Signature fAppecant/Contra Date /
AIR HANDLING UNIT(OVER 10, CFM)
CONSTRUCTION TAX
\
E(HAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS ERIALS DISCLOSURE
Will the applicant or future buil ing occupant more or handle hxnamous
, HEATING UNIT (TO 100,000 BTU) ,0
Date. Recei t#
material as defined by the Cupertino Municipal Code, Chapter 9.17, and the
I lealth and Safety CodeSection25537(a)7
Yes [n No
WIIltheapplicant or form, building occupant useequipment ordevices
}[PAYING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN(SINGLERESID)
ISSUANCE DATE
which emit hazardous air contaMwntsas defined by the Bay Area Air
Quality Management Dimret7
Yet
4 YetF. No
read the hazy us materials requirements under Chapter 6.95 of
the Cellornla Health k Safety Code, Sections 25505,25533 and 25534. I
understand that if the building does not currently have a tenant, that it is my
pp�� �k
y' A f D
JAN 1 1992
BOILER -COMP DHP OR 100,000 BTU)
BOILER-COMP(OVQ2100,000BN)
NEW RESIDENTIAL MECH. SQ.Ff
raponsiblllty, to notify the occupant of the requirements which most be met
prior to Issuance of a Certificate of Occupancy.
CIIY UP CUPbh I INU
ISSUED BY:_ � 0f UGL•
Owner or authoowd agent Date
TOTAL: 3,VU
OFFICE COPY
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