23897APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project IdentificationPERMIT
Bmlamg Address: O— �(�Ky G�.
�'•`p1C
NO.
23897
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CITY OF CUPERTIN4BUILDING DIVISION
APPLICATION I PERMIT
A A
Cono-attorawme: le. N.
RICALPLUMBING-MFLHAMCAL
CATEGORY
CO L6_
Archite t/Engineer. Lk No.BUILDING-aE
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address:
PERMITISSUANCE
(�;;r
LIN
LICENSED CONTRACTOR'S DECLARATION
Ihercbyaffirm that l am Bcenud under provisions of Chapter 9(Commenc.
ingwith SMian7000)of Dlvision3ofthe Busimnsand ProfeslanaCodgandmy
license is in full force and effect.
APPLIANCESRF.SIDENTIAL
JOB DESCRIPTION
PANELS
LicenseClass Lie#
� s
Date Contractor
201"1000 AMPS
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
OVFRIo00AMPS
SQ. FT. FLOOR AREA $/SQ, FT.
SIGNS ELECTRICAL
Limned Professional
OWNER -BUILDER DECLARATION
I hereby alfinnthat I am exempt from the Comtt
raor's License Law for the
SPECIAL CIRCUIT/MIST
gib1P METER OR POLE INS!.
followlegressen.Ckelon7BT15, Business and Profesnbm Code: Anydty or
County which requires a permit to Constr ud, alter, Improve, ciemalbh, oreepair
anystmchim jamarto its isuance,ahm requlrestheapplicant forsuch permit to
file a signed statement that M Is licensed pursuant to the provision of the
Contactors License Law (Chapter 9(Cornewmang with Section 70M) of Divi-
sion3 of the Business and Prohnsim sCode) or that he is exempt therefrom and
the Lasts for the alleged exemption. Any violation of Section 7MIZ by any,
applicant for a permit subjects the applicant to a civil penalty d not morethan
five hundred dollars (8500).
F1 1, as owner of the property, or my employees with wages as their sole
Compensation, will do the work, and the structure is not intended or offered for
POWER DEVICES
SWIMMING POOL ELECTRIC
SOUTLETS-SWITCHEFIXTURES
VALUATION
V��s
NEW RESIDENTIAL ELECTR SQ,FL
SCOWFS
TYPECONSTRUCTION
sale (Sec. 7044, Business and Profession Code: The Contractors License law
does not apply to an owner of pmpeny, who Wilds or improves thereon, and
who doessuchworkhimselforthrough hisownemployees,provided thatsuch
OCC
—RES RES.IINITS
Improvements arc not Intended or offered for sale. If, however, the building or
improvement is sold within one yearofcompletion, the owner -be Oder will have
t nolpmving that he did not bund or Improve for purpose of sale.).
ce owner of the Property, am exclusively Contracting with licensed
cion to rorulmct the project (See 7M4, BwNess and [Profession Code:
Th tractor's License law does not apply to an roowner d property, who
Wilds or Improves thereon, and who Contracts such projects w'th a
.dcv(.)licensed pursuant to the Contractor's Lt... Law.
eqB LJI am exempt under Sec. B & P C for this reason
CITY. PLUMBING PERMIT FEE
PERMIT ISSUANCE #s/4
� V (/
-
ALTER -DRAIN &VENT- WATER (EA)
pLOODIDNE
ApN
BACK FLOW PROTECT, DEVICE
FEE SUMMARY
Owner Date
WORKMAN COMPENSATION DECLARATION
k.' ❑1 hereby alOrtn that I have a CortlRaee of consent to self-Inwreor.
certiBateofWorkers Comperoationlnurance oracenlfied ropy thereo((Sec
3800, lab C)
Policy Is
' D R F, COND.
_
Q
SANITARY Y_ N_
RFLQPI' N
SCIi00L TAX Y N
RECEIPT#
- I
G 1 6
PARKFFE Y_ N
RFCIIPT N
Cam any
�CertiBed Copy 6 hereby furnished.
❑Certified ropy is tiled with the city inspection division.
GAS EA. SYSTFM-0 a IL
—
GREAS/ 1411
BUILDING DIVISIO FEES
PLANCI ICK FEE 4/y�
•�
GREASE TRAP
CERTIFICATEMPE SATION IN FROM WORKERS'
COMPENSATION ba c. ATION INSURANCE
R)mlettion need net Wcompleted tithe permit latoxone hundred dollars
($100imlyth
Illnor thato the performance dthe work for which this permit Is lamed,
I shall not employ any person in any manner so as to become wbject to the
Workers' Compensation Lawn o(Call(omla. Date
Applicant
`Q
PAI
t Remi t#
SEWER -SANITARY -STORM EA. 200FT.
WATFRHFATFR W/VENT/ELECTR
ENERGY FEE Y N
PAID
WATER SYSTEM/,CREATING
NEW RESIDENTIAL PLMB. SQ,FT,
NOTICE TO APPLICANT: If, after making thio CerlRiate of Exemption, you
should became sub)eer to the Workers Compensation provisoes of the Labor
Code,you It forthwith Comply with such pewialom orchis permit shall be
deemre
ed voked.
Date Remi t#
Is TOTAL:
BUI IN FE
CONSTRUCTION LENDING AGENCY ceEISMIC
therem
Thereby work Is antrottionlendingagenryfarthe peAn ort
onof the work for which this permit isaed (Sec. 3097, Cl,ClCJ
Lenders Name
Lenders Addresa
1 ochuythat I have read this application and etatethatthe above Information
reCorrctt. Iagree toComplywitho, all city.rddherb County thom mpreesand 4softhilam
relating to building Controttion, and hereby authorize representatives of this
city to enter upon the abovcmemload property for WpMlon purpose.
(We) agree to save, Indemrafy an d kap harmless the City of Cupertino
agalnstllabilitiesJudgmants, mete and expenses whlchmayln anywayamme
against said City In ronsequerwe of the gra ting d this permit.
1
TOTAL:
FEE _
ELECTRIC FEE
QTY. MECHANICAL PERMIT EMECHANICAL
PERMIT ISSUANCE
PLUMBING FEE ' V
FEE
PAID -
FEES— n v
Date Receipt#
ALTERORADDTOMFCH.
AIR HANDLING UNIT(TO 10,
SUBTOTAL:
AAHAND NG UNIT (OVFR1 CRM)
CONSTRUCTION TAX
S' plant/ o tractor Date
HAZARDOUS
EXHAUST HOOD(W/DICT)
CONSTRUCTION TAX PAID:
MA ERIALS DI OSURE
Willtheapplimet or futambuildingoxvpantst reorhanllehazardous
materialasdeMed by the Cupertino Municipal Code, Chapter 9.12, andthe
FlealthaSafetyCod a Seniors 15532(x)?
F-1 Yea M No
Date Recei t#
HEATINGUMT(TO 100,000BTU)
HEATING UNIT (OVER IOg000 BTU)
pr
TOTAL: p.
mes
Willch emit haramintorr onetamilding ocmpantuse the Bayequiprrs,nitArea devices
Q..InyMt bg,,m ous air mntaMvnb as de0ned by the Bay Arca Air
QualitY� anagemcnt DistrlNo
haveread the hazzr us materials requirements under Cha pier 6.95 of
the c lifomin Health&Safety Cade, Section 25505, 25533 and 25534. 1
understand that if the building does not mhave a tenant, that it is my
re,ponsibilit to notify the ocmpant of the requirements which must be met
pdoff ran of ificate of panty.
�
i
VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
D
P'1renlly
AUGr y 1992�
Clfi' j-'�
urINV
V
BOILER -COMP tlt0'OR 100,IXD BTU)
BOILER -COMP (OVER 100,DDO BTO)
NEW RESIDENTIAL MECH. SQ.IT
or such i agent ate
ISSUED BY:�_/fin
70TA1,:
OFFICE COPY