20840APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification
Building Address:
3it. CatOL/-Al CLC
PFR ITNO.
O O A8LF 0
waters ane: one:
a Vy% "p
CITYOFCUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUR.DINGELECTRICAL-PLUMBINGMECHAMCAL
pT
(l/
ontMdm.aNaam� Lie. No:
V
CATEGORY
CONTROL N
Architect/Engineer. - LIc.Ncx
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address:
® El ❑ 1:1LICENSED
PERIATISSUANCE,
CONTRACTOR'S DECLARATION
I hereby a!lHmehat lam lknseduMerprovWons a(Chapter9(mmmee
ingwlth Srdton700D)of DlWalon3 ofthe Bustrese/'anddjProrofessionsCode, and my
Ilcense is in s fylce d� feM
L=Class
APIaLIANCESRESIDENTV+L
RDFSCRB'D
(tee
eh, �
pA�s
Date Contractor -
2071000 AMPS
ARCHIlECrS used as DECLARATION.
I understand my plane shall be used u public remrda
OVER1000AMPS /
SQ. FT. FLOOR AREA
S/SQ.FT.
SIGNS ELECTRICAL It
Llcensed Professional
gp-TIAL CR< T/M
OWNER -BUILDER DECLARATION
I herebyaffirm Hut I am exempt from the Controet.e.Limnse Taw for the
'
TEMP.ME7E4 POL MSf.
following reason.(Section 7031.5, Business and Professions Code: Any city or
countywhichrequl apemdttommt Lt,alter,Mprove,demolish,orrepalr
anystm=mpriarlaibl ame,alsorequtmstheappUa tfarsuchpermltto
file a signed statement that he Is licensed pursuant to the provisions of the
TOWERD
Contractor's License law (Chapter9(commencing with Section 7000)o(Diet-
sion 3 of the Buslnm and Profeeioru Code) or that he b exempt themfmmand
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant fora permit subjectatheapplicant to a civil penalty of not morethan
SWIMMING E C
- VALUATION
J
five hundred dollars($SM.
[:]Las owner of the property, or my employees with wages as their sule
WREST TR .FT.
STORIES
7YPECONS[RIX:TION
mmpensation,willelolhe work, and thestructum Is not intended or offered for
sale (Sec. 70K Rudneas and Profemlom Code: The Contracto/s Licensor Law
A
does not apply to an owner of property who Wilds or improves thereon and
whodoe such work himseRor through his own employee,provldedthalmrh
—DpCig�(
REi, UNgTS
Improvements are not Intended oroffered for sale. If, however, the build Ing or
T E R
Improvement Is sold within one year ofcompleHon, the owner-bu0derwill have
theWrdenof proving that he did not build or Improve for purpose of sole.).
0 L as owner of the property, am exclusively contracting with licensed
.at.&.. to construct the project (Sec. 70K Business and Professions Code:
QTY. PLUMBING PER FEE
NE
APN
PERMIT ISSUANCE
The Contractor's License Law don net apply to an owner of property who
Wilds or Improve thereon, and who contracts far such ptokcts with a
ctorW licensed pursuant to the Cmlractors License Law.
cgB(�ani
LJI am exempt under Sec. B & P C'far this ren
ALTER.DRAIN&VENT-WATE4(EA)
FEE SUMMARY
BACK FLAW PROTECT. DEVICE
OUTSIDE
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y_ N_r
RECEPT#
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have • certificate of content to self -Insure, m a
certificate ofWorkers'CompensaHanlmuranawaxrtifled copy therm((Sec.
C.)
�'S PER TRAP
SCHOOL TAX Y_ N_
RECETT N
GAS EA. SYSTEM -1 INCA OUTLETS
PARK FEE Y N
_ RECEB'r It
Policy3800,
0
Com any
Cu9p
GAS EA. SYSTEM -OVER! (RA)
BUILDING DIVISION FEES
Certified copy V herebytumie city
Certified copy b (Bed with the city Inspection division.
GREASEANOUSTR, WASTE INTERCEPTOR
PLANCHECK FEE
I GREASE TRAP
CERTIHCATE OF EXEMPTION FROM WORKERS'
PAID
SEWERgAMT•ARY-STORM FA HIOFr.
COMPENSATION INSURANCE
(This section need not be completed if tine permitr
is for one hundred dollars
Date Recti IM
WATER HEATER w/VENT/ELECTR
ENERGY FEE Y N
—.
(5100)or less.)
I cattily that In the performance of the work for which this permit b lnuM,
WATER SYSTEM/TREAl1NG
I shall not employ any person In any manner so as to became subpet to the
Wmkere Compensationlaweof CaHfomia. Date
PAID
Applicant
NOTICE 7o APPLICANT: If, carr nuking this Certnlpro is Exi of
should become subject to the Workers' Compensation provblom of the Labor
Labor
NEW RESIDENTIAL PLMB._SQYr.
Date Rece) tH
- TOTAL:
BUILDING FEE
Otl
Code, you moat forthwith comply with such provisions or this permit shall be
deemed cooked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
Ihercby affim that them orklorwhichtisprmtroRlon tendingCSxc.3 ,CIv.ncy rthe perform
once n'. Nwork lorwhich this perrtdt is IesuM (See 30Y/,Civ. C.)
Lender's Name
Lender's Add..
I certifythat] havereadthisappHothmand slatethat theabove Information
Ismnoct. l ogreetocomplywithallcityand countyardlnancesand Ratelaws
relating to building construction, and hereby authorize representatives of thisQ
city toenteruponthe' ve� otimud property for impaction purposes.
(We) agree to uv Nfy and keep harmless the CI
sgalnatliabilities, p e ich aya
agai Id Ci on urates o(1M thio
TOTAL:
ELECTRIC FEE
PLUMBING FEB
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
AL TERORADDTOMECH.
Date Receipt#
AIR HANDLING UNIT 10,ODO CPM)
SUBTOTAL:
-
AIR HANDLINGUNIT (OVER 10,000CFM)
CONSTRUCTION TAX
Sigto uo /ConlraRm ((
EXHAUST HOOD(W/DUCT)
CONSTRUCTIONTAXPAID:
HAZARDOUS MATCRIAdDISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Date Recei tin
Will the applicant or future building occupant store or handle hazardous
anterial as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Health and Safety Code Stolon 25532(a)T
❑ Ye No
Will the applicant or tore building occaspant use equipment or devices
HEATING UNIT (OVER 100,000 BM
TOTAL:
�
C
j
VFNRLATION FAN (SINGLE RESID)
ISSUANCE DATE
which emit hazardous air containment, as defined by the Bay Arca Air
Quality Management District?
Yn C1� No
1 hove read the hexarmes. materials requirements under Chapter 6.95of
the California Health & Safety Code, Sections 25505, 75533 and 25534. I
undcrstandttutifthe ig don not mnently haveat at, that it is my
PM� B,p .
`—M
-
AUG 2 1990
BOILER -CAMP OHP OR 100,000 BTU)
BOILER -COMP (OVET106,000 BN)
NEW RESIDENTIAL MECH. SQ.FT.
respomlbilitymnoll cmpan rcqulre.a hi musthe met
rior to lasso an
Ani
City Pp rlte)Orpnn •LLTfj)
)
3
ISSUED BY:
or aHeed agent f D
TOTAL:
OFFICE COPY