24145APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification
Building Address: OS'q 8 0�
PERMIT NO.
.. 24145
G ante: �W � / one:
CITY OPPLICATION / DINGPER DIVISION
APPLICATION /PERMIT
A A A
� ^
(i
Con1tatlor'"'"•: Lie. No:
BUfLDINGELECTMCAL-PLUMBINGMECHAMCAL
CATEGORY
CONTROL p
Architect/Engineer. Lie. Na
QTY ELECTRIC PERMIT - FEE
BUILDING PERMIT INFO
Address:
PERtMITISSUANCE
❑ ❑ ❑
LICENSED CONTRAROR'S DECLARATION
Ihereby affirm that l%vishmsed under heBusi sand sof Chains ode,an en,
7000)of Dlvtslon 3o(thegusinesaand Professions Code, and my
time. Is In full force and effect.
AI'PLIANCESRESIDENTIAL
—�
PANES
JOB DESC
pPs�
' `V
Ikons
License Clan
, 1
Date - ConMactor
Cont
r
201-1000 AMPS
ARCHITECTS DECLARATION
Iunderstand my plans shag be used as public records.
Licensed Professional
OVER 1000 AMPS
SQ. FT. FLOOR AREA,
E D I N
S/SQ.FL.
SIGNSELECTRICALF1
OWNER -BUILDER DECLARATION
I hereby afOren that I am exempt from the Contractor's License Law for the
SPECIALCIRCUIT /M75C �1 1
MPU
': .: -
TEMP. METER OR POLE INST.
POWER DEVICES DAT
following reason. (Son 70315, Bualn. and Profession. Code: My city or
countywhichrequiresapermittommtruct,siter,mpmve,demolish,orrepair
any structure prior to its issuance, also requires the applicant for such permit to
file a signed statement that he is Harpursuant m ed pursuathe provisoes of the
Contractors Llcerue Law (Chapter 9 (commencing with Section 7000) of Divi-
slon 3ofthe Buslnessand Profeniom Code) orthst he is exempt therefemand
the bash for the alleged exemption. Any violation of Section 7031.5 by any
applicant fora permit subjects the applicant to a civil penalty of not more than
f ve h dred d°Ilan (6500).
as owner of the property, or my employees with wages as their sole
m pnsatlon,willdo the work, and thestmature is not intended or offered for
q �y
/
SWIMINGPOOLELECIRIC'
OUTLETSSWITCHESFIXTURES
VALUTA ,N
NEW RESIDENTIAL ELECTR SQ.FT.
gTOw'S TYPE CONSTRUCTION
sale (Sec. 7044, Business and Profeaskm Code: The Contractor's License Law
does not apply to an owner of property who builds or improves thereon, and
who does such work Nowell or through Meown employees, provided that such
improvements are not intended oroffered formic. If, hcweveq thebullding or
improvement Resold withinoneyearofcompletioNtheowner-W Hderwill have
t rden of proving that M did not build or improve for purpose of sale.).
L as owner of the property, am exclusively contracting with 1—n—pEgMpp
contractors to construct the project (Sec. 7044, Bunem and Profruser s Code:
al
TOTAL:
QTY. PLUMBING PERMIT FEE
ISSUANCE
C. GROUT' RES. UNITS
FIODDZONE APN
The Contractors License law does not apply to an owner of property who
Wilds or Improves thereon, and who contracts for such pWjecie with a
,}Rf churls) hansed pursuant nothe Contractor'sLicense Law.
LII am exempt under Sec. B & P C for this reason
ALTER -DRAW & VENT
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
OUTS I DE FEES—
Owner Date
WORKMAN COMPENSATION DECLARATION
hereby affirm that I have certificate of consent to self -losers, ora
certificatecertificate u(Workere' Compensatioo n Iwuranre ora certified copy thereof
3800, GbCJ
I'ollryp
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y N
RECD
'by
FD(TURES PER TRAP
SCITOOL TAX Y N'
ENT RECM
GAS EA. SYSTEM -1 INCA OUTLETS
_
PARK EEE Y N
RpCpyfp
mCy
rifled copy V hereby furnished.BUILDING
[—]Cenlfied copy is filed with the city impecion division.
GAS EA. SYST[MAVER4(EA) ,
GREASE/WDUSIRL WASE INTERCEPTOR
DIVISION FEES
PLANCHECIC FEE
GREASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thissectionneed not W eempleted if the permit bforonehundrcd dollars
(6100)orlessa
lartify thattsthe perfomuna ofthe work for whld this permit lalwned,
Work not employ any person f any manner ro u to become subject to the
W plicae Compensation Gevs of GHfomfa. Date
Applicant
NOTICETOAPPLICAM:IL after making this Certificate of Exemption, you
should homers subject to the W°rkeni Compersatlon provblom of the Labor
Code, you moat fort hwith comply with such provisions or this permit shall be
deemed revoked.
PAID
Date Recei t#
SEWER-SANITARY-SIORM EA. 200FP.
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N
PAID
Date Recei t#
WAT R SYSTI M/7RIEATING
NE'WRESIDENTIALPLMB. SQFT.
TOTA
BUIL TNG •E
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the perform-
ance of the work for which this permit ts issued (Sec. 3097, Civ. C.)
Leaders NamPLUMBING
II<nd¢riAddress
I urtifythatl have read thbappHatlo... d Gatethatthe above Infornutlon
is coned.I agree to comply with all city and munty ordinances and state laws
relating to building construction, and hereby author'sm representatives of his
Hy to enter uPon the above-m.ficmdpropertyfor WpMionpurpma,
(We) agree to save, had actually ad
fy an d keep haren the City of Cupertino
against liabilities, pdgments, costs a rad expenses which may In any wayacaue
against said City in .ryuena the granting of this permit.
TOTAL:
SEISMIC FEE
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
FEE
PERMUL%*UANCE
ALTERORADDTOMECH.
AIR HANDLING UNIT (PO 1gODO CFM)
MECHANICAL FEE
FEES PAID:
Date Receipt#
SUBTOTAL:
-
AIRHANDLING UNTf(OVERiQ=CI•bt)
CONSTRUCTION TAX
`tea— t� � V/
olgnalumo p cant/Contrannr / Data
III HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100000 BTU)
Will the applicant or future building oxcupant store cur handle haurdous
materlalaadefinedbyth¢Cupertino Municipal C°de,Chapter9.l Z,andthe
health and Safety CHe Section 2M32(a)?
1:1Yes M No
Date Recej t#
HEATING UNIT (OVER WILLOW BTU)
TO
Will the applicant orfutumbuilding occupant use equipment ordevices
which emit havardous air contaminants as defined by the Bay Area Air
m
Quality Marageent District?BOILER-COMP
CP4 Yes No
I tech& ar usmode,btiona 25505, under 2553aChapter 6.95°!
the California Health&Safety Code, SeHore Sly
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
p D
OEN OR 100,000 BTU)
BORER-COMP(OVQt100,000 BTU)
NEW RESIDENTIAL MECH. SQ.FT
have a amass, that
that It Is my
undersmndthat i(the tify the ing occupoes not arreuirennnts which
respomibllity to notify the ocmpant of the rcquircments which must W rret
Prior to Wuance of a Certificate of Occvpa ncy.
r I'4 y/
/J�r2n51992
d56UEOBY ; `e W
-AUG
Ownermituth°rinedagent Date
TOTAL:
OFFICE COPY