23975APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Address:23975
2I OCQ-7 2OSO,2 N%Q e_
PERMIT NO.
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CITY OF CUPERTINO-BUILDING DIVISION/�
APPLICATION / PERMIT
BUILDING-ELECTWCAT PLUMBING-MECIIAMCAL
APPLICATION SUBMI I I AL DA FE
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Contractor's Name: ' Lic. No:
oblic Cot'y* �R)7
I
CATEGORY CONTROL
BUILDING PERMIT INFO
Architect/Engineer. LIc No:
QTY,,-. ELECTRIC. PERMIT.` ;
Address: P,a , 60'f %` `LQ. S. Gi�.�i1S
_FEE
PERMITISS'UANCE
.
D El
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(mmmene
Ing with Section 7DW)of Division 3ofthe Bualnessand PmfessionsCode, and my
license Is in s form and died.
Licensep.'F..y�♦1
LicenCam Ue.N
Date Contactor
ARCHITECTS DECLARATION
Iundentand my plain dull be used upublicrerord s.
Licensed Professiorul
OWNERI am -BUILDER DECLARATION
License law fort he
Iwingrasorm n.5=on731.5,Bxempt fromthe essad Professions
fallowingreuon.(Se Uon703WBms eland Profenlonse=le hnydtyor
cauntywhich requlma permN toronstruct, alter, Improve, demolish,orrepair
anystm=mpeortaia Wuance,ais mmquimlheappbcantforsuchpermitto
file a signed statement that he is licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9 (commencing with Section 7000) of Divi-
sion3ofthe Buslnessand Profmiom Code) orthat he is exmpttherefromand
the basis for the alleged exemption. Any violation of Sectionpenalty net co by any
applicantudfor a permit subjects the applicant to a civil perulty o(nd rrorethan
live hundred owndoler of the pr .
�I, as owner of the propdrty, or my employees with wages as their sale
compensation, will do the work and the structure is not intended or offered for
xle (Sec 7064, Business and Professions Code: The Contractors License Law
does not apply to an owner of property who builds or improves theme,and
whodoessuchworkhincxlf orthrough hlsawnemployees, provided that such
improvements am not intended oroffered forsale. If, however, thebuilding or
Improvement issold within owyearofcomplelb themnervbufiderwill have
thLI;urden of proving that he did not build or improve for purpose of sale.).
U ( as owner of the property, am exclusively contracting with limned
to ronslrutt the project (Sec. 7044, Business and Professions, Code:
The Contnctorb License law does near apply to an owner of property who
Wilds or Improves thereon, and who contracts for such ptofects with a
cgB[pec, ctm(s) licensed pursuant to the Contractors License Law.
I_I I am exempt under SB & P C for this reason
APPUANCESRFSIDENTIAL
JOB DFSCRII'TION
V
1�1��
PANELS
UP TO 200AMS
7014(XI)AMPS
OVER IOOO AMPS
� ��
p,�
S/BQ. FT.
SIGNS ELECTRICAL a
SPECIALCIRCUIT/MLSC
TpMg METERORPOLEINST. -ADOE•
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS SVH'CHESFIXTURES
VALUAIJQCJ_
^ , iJv
NEW RESIDENTIAL ELECTR SQ.FC.
STORIES
TYPE CONSTRUCTION
TOTAL:
QTY, PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER -DRAIN &VENT- WATER (EA)
CC. GROUT'
RPS. UNITS
MIN
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
DRAINS FLOOR ROOF, AREA, COND.
FIX�PER .�P
SANITARY Y N
RECEB'T N
Owner Date
WORKMAN COMPENSATION DECLARATION
01 hereby affirm that I have a certificate of consent to self lesure, ora
certificate ofWerken Compensationlnsunnceuacertlrind copy themof l5ee.
3800, Lab CJ
Policy p
SCIdOOL TAX Y N_
Rh)rE1 NN
GAS EA. SYSTEM -I INC4 OUTLETS
PARKFFE V N
RCB'f N
GAS EA. SYSTEM -OVER 4 (EA)
Caron
B UIL UI NG DIV] SION FC ES
art
Certified copy is hercbyth the cityed.
Certified copy Is Wed with the city inspection division. �
CCRTIIICATE OF EXEMPTION FROM WOR KERS'
COMPENSATIONINSURANCE
IThaxctlan need not W completed edift Rthe permit islorone hundred dollars
(5100)orless')
IMOB that in he perfar roof (heworkforwhichlhlsparmtisissved,
I shall not emplo a 'pmol 1 any manner m u to be me eubled to the
Workers Co. li IlfornIs, Date"' — `C
Applicant_
NOTICE TOM 7C if, er making lhsCertilica of Exemptifryyou
should Wmme subject to the Workers'Compensatbnp visions o(the Labor
Code, you must forthwith comply with such provisions lrthis permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there Is a construction lending agency for the perform
ante of the work for which this permit is issued (Sec. 3097, Civ. Q
Lender's Name
lander'sAddmas
I certHythatl have read thisappbcationand statethat the above information
cermet. lag. to comply with all ctyand rountymcilnancesaod sate laws
relating to building construction, and hereby authorize repruentatives of this
city to enter upon the above-mdntloned property for Inspection purposes.
(We) agree to save, indemnify an d keep harmless th City of Cupertino
liabilitl s,' dgmena,"sand expenses which In any wayamue
XtSUBTOTAL•
said Cl n o a(thegmrtingcfthla It.
GREASE/WDUSIRL WAS IT INTERCEPTOR
PLANCHECK FEE
PAID
Date Recei t#
,
GREASE TRAP
SEWER-SANITARY-STORMEA.4(IOFT.
WATER HEATQ6 W/VENT/ELLCTR
ENERGY FEE Y N
PAID
Date Recei t#
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB.SQFI'.
TOTAL:
UI
r�
SEISMIC'
TOTAL:
ELECTRIC FEE
QTY. MECHANICAL PERMIT- FEE
PLUMBING FEE
MECHANICAL FEE
PERMITISSUANCE
FEES PAID:
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,ODOCFM)
Date Recei [#
AIR HANDLING UNIT(OVER I0,000CFM)
CONSTRUCTION TAX
SlgrutureofApllcant ontradfr Data
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
I Iealth and Safety Cade Section 25537(x)7
n Yes
Illthe applies sat or future Wilding acmpant use equipment or devices
which emit banrdausair contaminants as defined by the Bay Area Air
Quality Management District?
P4 Ye 4 No
h read Healthe h ar feta Code, Se rcons 25SnaundeandChapter 2554.1 of
the Callfoma Health &Safety Code, Stolons 2550.5, ti537 and 75536.1
understand that lithe building does not currently have a tenant, that it is my
responsibility to notify the occupant of the requirements which must be mot
prior to Issuance of a Certificate of Occupancy.
EXHAUS'THOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT(TO 100,000BIL1)
Date Recei t#
HEATING UNIT (OVER 100,000 BTU)
TOT
VENTILATION FAN (SINGLE RESIU)
ISSUANCE A
JUL �� �Ny
�a77�
1992
"r ur f oretlI
ISSUED BY:
HOLLER -COMP DID OR 100,0W BTT!)
BOILER -COMP (OVER 100,000 BTU)
'
NEW RESIDENTIAL MECH. SQ.FI
Owner or aulhodud agent Data
TOTAL:
OFFICE COPY