24078APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification
PERMIT
Building Address
Loss D, . A �. �I��
ere came: C�,\S?We1 . 34Or_IG ane:
CITY OF CUPERTINO-BUILDING DIVISION/--�
APPLICATION / PERMIT
BUILDINGELECTRICALPLUMBING-MECHANICAL
L.
d
Contract 'eN Lie, No:
s
�+ H
CATFOORY
CONTROL.
rchitect gl eer. 1 Lk. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:
PERMITISSUANCE p
j�/j 1:1 1:1'LICENSED
! 2}
CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter9 (commenc-
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
PANELS
ingwlth Se on7000)o(Division3ofthe Businessand Professions Cade, and my
license ts In full form and affect.
LicenseChss Lk.M
Date Contractor
1`
201-IMOAMPS
ARCHITECTS DECLARATION
I understand my plana shall be used as public temnL.
OVERIOOOAMPS
SQ. FT. mbotzAREA
S/SQ. ET.
SIGNS ELECTRICAL s Q
Licensed Professional
SPECDILCIiCUIT/MISC
OWNER -BUILDER DECLARATION
I herebyaffiren that I am exempt fromthe Contnsor's License Law for the
TEMP. METER OR POLE INST.
following reason. (Section 7011.5, Business and Professions Code: Any city or
countywhichrequtresaper ttommtma,alter,Improve,demo)Ish,orrepair
nysmcture prlorto its Issuance, alsorequlrestheappileant forsuch permit to
file a signed statement that he It licensed pursuant to the provisions of the
POWER DEVICES
SWIMMING POOL ELECTRIC
Contractor'sLicense Law (Chapter9(commencing with Section 7000) of Divi.
sion3o(the Businew=dProfemiom Code)orthathelsexemptthamfromand
the basis for the alleged exemption. Any violation of Section 70ILS by anyOU7LE•ISSWLLCFfE4FU(1.UftES
mtha
applicant fora permit subjects s the applicant to a civil peruity not oren
VALUA]jON O
NEW RESIDENTIAL E•LECTR SQ.FT.
five F1I, asr..ed aof thepr.
property,or my employeewithwage• their sole
❑I,asownerll
ES
TYPE CONSTRUCTION
of
compensation, will Bothe work and the r
V not Intended or offered for
,structure
sale (Sec 70ty Business and Pro(essloro Code: The Contractors Lirewe Law
does not apply to an owner of property who builds or improves thereon, and
whodoessuch work himselfor through hlsownemployces, provided that such
OCC. GROW -
RES UNITS
Improvements are not intended proffered for sale.]( however, thebuilding car
TOTAL: _
Improvement Issold withlnoneyearofcompleion,theowner-bullderwill have
itrden of proving that he did not bund or improve for purpose of sale.).
61. as owner of the property, am exclusively contracting with licensed
contract. to construct the project (Seo 70sK Business and Profenlons Cade:
QTY. PLUMBING PERMIT FEE
FLOOD TONE
APN
PERMIT ISSUANCE
The Contnsor's License Law don not apply to an owner of property who
build• or Improve thereon, and who contracts fee such pXokea with a
shpt[+sore) licensed pursuant to the Contractors License Law.
I_J 1 am exempt under Sec B At P C for this reawn
ALTER -DRAIN le VENT- WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, CONI.
DRAINS.
SANITARY Y N
p
Owner Data
WORKMAN COMPENSATION DECLARATION
❑I her a(flrm that 1 have a certificate of consent to self -insure, or
certificate ofWm1u,rs Comp,.ianlydurxnreara certified copythereof(Sec.
Lab C.)
Polis
Polity
b7K'IVRFSS PER TRAP
SCHOOL TAX Y_ N_
RECENT NM
GAS F.A.SYSTEM-1 WC40UTLEIS
PARK FEE Y N
RECEIPT N
M
Co����mppppury
GAS EA. SYSTEM -OVER 4 (EA)
BUILDING DIVISION FEES
WCertificd copy 6 heed with the
Certified copy as feed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GRE.ISE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
vdV
I GREASE TRAP
COMPENSATION INSURANCE
(This section receives becomplsed lftFe permit isfurane hundred dollars
Date RCCfI t7i
SEWER,SAND'ARY-SIbRM EA. MFT.
WATER HEATER W/VENT/ELFLTR
ENERGYFEE Y N—
e
31 I0)orban.)
IreN that In the performance o(the work for which this permit is issued,
WATER SYSTEM/.TREATING
I shall not employ any Person in any manner so as to become subject to the
Worken'Compensationlawsof California. Date
PAID
NEW RESIDENTIAL PWEL SQyr.
Applicant
NOTICE TO APPLICANT: If, after making this Certificate o(Exempt10n, you
should become subject to the Workeei Compewtion provisions of the Labor
Date Racei tN
TOTAL:
BUILDING 'E
do
Code, you must forthwith comply with such pecvidov or this pemdt shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
-
SEISMIC FEE
I hereby affirm that there lsacadtruclon Lending agency for the perform
anceof the work forwhich this permit B Issued (Sec. 3097, Clv. C.)
Lender. Name
Lendae.Address
I ertifythat I have read thlaapplicatbnand sate thatthe above information
1.correct. I agreeto comply with all city and county onances and state laws
Nl
TOTAL,
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT PEE
MECHANICALFEE
PFRMITISSUANCE
FEES PAID:
relating to building cord roclum, and hereby authorize representative of this
city to enter upon the above-mentioned property for inspection purpoen.
(We) agree to save, indemNfy an d keep harmless the City of Cupertino
ag Inst lfabilltLeud
s, jgments, costs and expenses which may In anyway same
ALTERORADDTOMECH.
Da[e Retei (#
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
ag t said City In con.V re of the granting of thlgpe It.
.s i
AIR HANDLING UNIT (OVER 10,Ino CEM)
CONSTRUCTION TAX
Igwtore P kam omrasor Date
EXHAUST HOOD (W/DUCT)
CONSTRUCTION TAX PAID:'
AlARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
DateRecei tp
Will the applicant or future building otzvpant store or handle hazardous
material as defined by the Cupertino Municipal Cade, Chapter 9.1$ and the
Health and Safety Cod n25532(.)7
❑ YeNo
Willthe appiien r(u ure building occupant use equipment or devices
1 IFATING UNIT (OVER 100,000 STU) _
TOTAL:
3
VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
which emit hazardous air contamltunts as de0md by the Bay Area Air
ality Management District?
'
A' D
PAI
6`i
BOILER -COMP DEB'OR 100,000 BTU)
Yea x(IJo
j ,�h.dthehafirsrtuterials,equim"nhunderChapier6.95of
BOILER -COMP (OVER 100,000 BTU)
the California Health k Safety Code, Sections 25505,25533 and 25534. 1
and erstand that if the bu llding does not comently have a tenant, that it Bmy
p�ra - t(o
AUG '1992
NEW RESIDENTIAL MECEI. SQIT.
res edibility to nslfy the occupant of the requirements hich Stine met
1 �7:
prise olauanre ofa rtl(i ofOttvpancy. Q
'Ell If Ur vurcn 11140
ISSUEDBY:
Ow•nero u ori agent Data
TOTAL:
OFFICE COPY