23092APPIICANTTO FILL IN INFORMATION WITHIN REP LINES —USE BALL POINT PEN ONLY
Building Project Identlfla Ion t�a�
Building Addreaa: , �.1 a, ftD Sys 3 8
PERMIT NO.
23092
caner, ante: MAM0 AM 'er OIL ane.
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDINGELECIRICA PLUMBING -MECHANICAL
Cjjqq(4pptradarsN.me: LIc.N.
a•/ A—S41,/210
CATEGORY CONTROL#
Archins /Engineer. - Lie. No:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address:
❑ ❑ ❑
PERMITISSUANCE
LICENSED CONTRACfOR'S DECLARATION
I hereby affirm that lam Rcensed under pervialoneofChapter9(rommm
Ingwllh Smtion70 U)of Divtsion3 ofthe Busioessand ProlesslonsCode, and my
111, Infull �Lifect
CU X 6 7
APPLIANCFSRESIDENTIAL
JOB DESCRIPTION
PANELS
Date ContnRorUP
T02DOAMPS
201-1000 AMPS
ARCHITECPS DECLARATION
OVER IOW AMPS
SQ. FT. FLOOR AREA $/:Q. FI'.
to d my plans slplt Vas p� rds.
SIGNSELECTRICAL
,e
AA" -TT
Licensed Professional
IV . A D 'w'
SPFCIALCI2CUIT/MISC
OWNER -BUILDER DECLARATION
I hereby affirm that l am exempt fromthe Contractors License Law for the
following mason.(Section 7031.5, Business and Professions Code: Any city or
h,orrepair
19\VI ,v
Nj P T E R
TEMP. MRTEROR POLE INST.
-GOcountywhichrequiresapermittommtmMalter,impmve,demil
anystructure, priorto Its Luuance,alsorequlresthe applicant for such peroutto
file a signed statement that he Is Hcensed pursuant m the proublons of the
Contractors License Law (Chapter 9(commencing with Section 7000) of Divi-
eion3ofthe Businessand Pmfessims Code)orthat he Is exempttherefromand
the basis for the alleged exemption. Any violation of Section 70315 by any
applicant for a permit subjects the applicant to a civil penalty of not mare than
five hundred dollars ($500). �
owner of the property, or my employees with wage. as their
POWER DEVICES
K �
ATE
VALUATION '
SWIMMING POOL ELECTRIC
OUILETSSWITCHCSFIXNRES
NEW RESIDENTIAL ELECTR SQ.FI'.
STORIES
TYPE CONSTRUCT' ION
mmpcnaatfon, will do the work and the strueNrc Is not Wended or offered for
sale (Sec. 7044, Business and Pref.lans Code: The Contradoes License Law
does not apply to an owner of property who builds or improves thermR and
who doessuch work himself orthrough hlsawn employees, provided that such
OCC. GROUP
RIS. UNTT5
improvements am not Intended oroffered forsale. If, however, the building or
improvement Is sold within oneyearofcompletion, the owner-bullder wHl have
TOTAL:
the*rden of proving that he did not build or Improve for purpose ofsale0.
I, as owner of the property, am exclusively contracting with licensed
contractor to construct the project (Sec. 7044. Business and Prefesalonv Code:
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
FLOODZDNE
APN
The Contractor's License Law does net apply to an owner of property who
Wild. or improves thereon, and who contra far such pkojems with a
re+ctor(a)Ilcensed pursuant to the Contractor's Lim.. Law.
I ' 1 am exempt under Sax,B k P C for this reason
ALTER -DRAIN &VENT- WATER (EA)
_,BACK FLOW PROTECT. DEVICE
FEE SUMMARY
FFrq
DRAINS FIDOR ROOF, AREA, GOND.
pp(TURES PER TRAP
SANITARY Y N_
RECEIPT #
Owner Date
WORKMAN COMPENSATION DECLARATION
❑t hereby affirm that I have a mrtllleste of consent to self -insure, ora
SC1{ODL TA% Y_ N_
oarifmteofWorkers Compenaation Insurance ora cortified copy thereof (Sec.
MOD, Lab C.)
RFDRI f X
CAS EA.SYSfQ.f-1 INCd 01717,675
PARK FEE Y N
Policy X
RING #
GAS EA. SYSTEM -OVER 4 (EA)
Com any
DI
BUILDING DI VISIONITES
gedifted copy 6 herebyfurnished.the cid.
ertified copy Is tiled with the city Im)xRiOn division.
CREASE/INDUSIRL WASTE INTERCEPTOR
PLANC14ECK FEE
CREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Qhlssenion need not becomplated tithe permit Isforone hundred dollars
PAID
Date Remi t#
SEWER -SANITARY -STORM EA. 2WFT.
($100)orless3
I c<rtifythat In the performance of the work for which this permitb Issued,
I shall not employ any person in any manner ao as to become subject to the
Workers Compensation Laws of California. Date
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N
PAID
WATER SYSTEM/TREATING
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the Workers' Campnsation provisions of the Labor
Code, you roust forthwith comply with such provisions orlhis permit shall be
deemed revoked.
Date Recei l#
NEW RESIDENTIAL PLMB. SQFT.
TOTAL:
BUILDING
- - TOTAL:
SEISMIC FEE
ELECTRIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there Is a construction lend Ing agency for the pedorrry
ance of the work for which this permit eund (Sec 3097, Civ. C.)
a la
fender'. Name
tenders Address
I mrfify that I have read the.pplication and pate that the above Information
Iscamod. l agree to comply with all city and county ordinareasand mate laws
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE S:0Q
FEESPAID:
relating tobullding commander, and hereby authoilae "FI-1tativea of thIs
city to enter upon the abovementioned property for inspection purposes.
(We) agree to save, IndemNfy an d keep harmless the City of Cupertino
against liabilities, judgment,mmsand expenses which may In any way accrue
City In consequence of the grant Ing of this permit.
y � 01 � �_�I_ZFI
ALTE20RADDIOMECH.
AIR HANDLING UNIT (TO 10,000 CFM) ', UD
Date Receipt#
SUBTOTAL:
AIR HANDLING UNIT (OVER 1gODO CFMI
CONSTRUCTION TAX
Signature of Applicant/Contractor Date
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
UNIT (TO 100,000 BTU)
Will the applies at orfumure building occu pant atom or hand le haeardousHEATING
material as defined by the Cupertino Municipal Code, Chapter 9.1 2Z and the
Health and Safety Cod�S ,Hoo 25532(a)7
❑ Yrs No
Date Recei f#
IDEATING UNIT (OVER 100,0W HIM
TOTAL:
0
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
Ap
111991
rIJ�a
Wllllheappllant future building occupant use equipment or devices
which emit has rdous air mora Wnana as defined by the Bay Area Air
Quality Management District?
4 Y s he r.o
Maseru lealth& Tet model neons 25555533 aChapter.1 of
the California h Safety Code, rre 25505, and 25534. I
MOILER -COMP OHP OR 100,000 BTU)
BOILER-COMP,(OVIR 100,000 BTU)
NEW RESIDENTIAL MECH. SQ.I'T.
at lithe ing u
of currentlyhave
the requirmentshichthat ltIsmy
a tenant,
undenandmhat iftify
oesant
DEC
respomibility to notify the occupant o! the requirements which most be met
the occu of
prior to a eofaCertlR/cate of/Occupancy. �,a
�F
I
(v
CIIv U{rs Cuptr{IBVU
ISSUED BY:
I I
Owner or authodud agent Date
TOTAL" 011
OFFICE COPY