21008APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Address: / Q �.-t+ / ®Q
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PERMITNO,
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING-ELECTMCALPLUMBINC-MECHANICAL
(Sj
l� 1
c°"lradnr.Name: Lic.No:
B
CATEGORY CONTRC 111IOrJ43(_]
L
Architect/Engineer. k No:
QTY ELECTRICPERMIT FEE
-
BUILDING PERMIT INFO
Address:
PERMITISSUANCE
�]I
(�
LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm that l am Bcrosed under provisions of Chapter9(commen
Ingwith Sedion7000)ofDldsion3ofthe Businessand Pmfess maCode, and my
Ilcenre le In full fes a antl effect.
Licenses Clam — Lk.e
Date-/, p_Contradmr
APPLIANCESRESIDENIIAL
]OB DESCRII'ITON
`
' PANQ S
IDI -1 WO AMPS
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records
OVER 1000 AMPS
SQ. Fr. FLOOR AREA
8/SQ. FT.
SIGNS ELECTRICAL
Llrensed Professional
�•�n
SPp-CULCIRCUIT/hi LSC
OWNER -BUILDER DECLARATION
I herebyatfi mthatI am exempt from the Contractor's License Law for the
'4' U [T/j
TEMP METER OR POLE I
following renum. (Brute. 7031S, Business and Professions Code: My city or
cwntywhich requires a pernottecorstruct, alter, Improve, demollsh,or repair
anyctrocture prlorto its Issuance, also requires theappllcant for such permit to
Bk a signed statement that he is, licensed pursuant to the provlslors of the
Contractors Lice. Law (Chapter 9(rommencing with Section 7000) of Divi-
.ion3 of the Business and Pro(emlmuCode) or that he It exempt therefrom and
MOWER DEVICES
gWIMMING POOL ELECTRIC s'
VALUATION
the bash for the alleged exemption. Any Violation of Section 7MLS by any
applicant for a permit subjects the applicant to a civil penalty of not comethan
OUILE.ISSN7.ICI IESFl%TSJRFS t�
:..I•� {'` ^ —,..,
Lt J.L..�J
NEW RESIDENTIAL ELECTR SQ.FF.
five hundred nor thepro
1, as owner of the property, or employees m with wages as thele dale
SFOREES
TYPE CONSTRUCTION
compensation, do the work and the structure
he ata Intended or offered for
Iwill fiod
sale Bu sinessandf Code: The Contractors License Law
h
TOTAL:
does and
nota ply property
apply torn owner of(prough who nempor improvesyees,povided roryhat uch
who
who does suchments am nothimselfsed orough Meowne . If, ho e; pe°vided ilding or
improvementsarcnot Intended earofredfor sale.ILHowever, Elder ilI have
Improvement lssold within oneyearo(compldbrylheowner-bullderwlll have
OCC.GROUP
RFS UNITS
tlA.Ilurdenof pmving that he did not build or improve for purpose°fwk.).
L j L as owner of the property, am exclutively mntnding with licensed
eonlredre oto construct the project (Sco94, 70Business and Prolessiona Code:
QTY. PLUMBING PERMIT FEE
' �ays
PERMITISSUANCE
ra C -b
Fl-OOD TONE
APN
The Coatndorb Lim. Iaw does not apply to an ..or of property who
builds or Improves thereon, and who contracts for such ptojects with a
o�7Bt[+dor(s)licensed pursuant to the Cormadors License Law.
L lam exempt under Sec B k P C for this reasonOUTSIDE
ALTER -DRAIN VENT - WATER ERA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
FELS
DRAINS FLOOR HOOP, AREA, COND.
SANITARY Y_ N
RECFJPT p
Owner Data
WORKMAN COMPENSATION DECLARATION
❑1 hereby .(firm that I have a certificate of consent to self-inwre, ora
mdtftmteof Workere Comperustlonlmuranceoracertlfied mpythereo((Sec.
3800, Lab
IT FIXTURES' PER TRAP `I d
SCHOOL TAX Y - N_
RECEFF 4
GAS EA. SYSFQd-1 INC4 OUTLETS 1& xCp•
PARK FEE Y_ N
Polity p
M
BBCGAS
EA. SYSTEM -OVER 4 MA)
Com any
DING DI
BUILDING DIVISION FEES
Ihed
ID Certified copy ls herebytumecity
ID Certified copy I. filed with the city Inspection dlvlslon.
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
�''')
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
lonneed net becomplowd iftheperl isforonehundred dollarsSIl7RM
RhissedM
(810(coify that
n
I E) m IcsN the performance of the week (orwhkh this permit is blued,
I shall not employ any person In any manner so as to become subject to the
Workere'Compenaatlon Laws of California. Date
Applicant
Applicant
AI'I'LICANT:II, offer mrWng thio CertRlcate of Exemption, you
should become subjectto the Workers' Compensation provisions of the LaborTOTAL:
Code, you most fort hwith comply with such provisiam or this permit shall be
deemed revoked.
PAIDcapHHO r Q�Q
l
Date RCCei i{
�7�f;83
SEWER SANITARY EA. 20011'.
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y
PAI
D Zirtlil
���
WATER SYSTEM/TREATING x t
NEW RESIDENTIAL PLMB.SQ.Ff.
BU G ••E
SEISMIC FEE
619
CONSTRUCTION LENDING AGENCY
construction lending agency for the perform-
Hurebyaffirmthattherets r ce b bl
anof the work for which this permit heated (Sec. 3097, Cls. C.)
TOTAL: «%
ELECTRIC FEE
1
Lender'.Name
Lenders Address
I certifythatl have read this application and A tethatlhe above information
Is correct: Iagmeto comply with all city and county ordinances and slate lawsPERMIT
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
f00
MECHANICAL FEE
t,OO
ISSUANCE Gym
FEES PAID:
mixing lobuilding ronsrudion, and hereby authorize representatives of thls
cityto enterupon the above-mentioned property for inspection purposes.
(We) agree to save, Indemnify an d keep harew the City of Cupertino
'.
AL7EI9ORADDTO MECH, s _co
Date eeeiptp
SUB' OTAL:
against liabilities,' dgereets,rorts andexpendes which may in any wayaccrus
ag Wl Cit rens .non of he Bre rating of thio permit.
o /sr -90
Slgmtureof ant ontrador Data
AIR HANDLING UNIT 8010,000 CFM)
AIR HANDLING UNIT (OVER IO,ODOC)M)
CONSTRUCTION T X
EXHAUSTHOOD(W/DUCT)
CONST RUCIONT XPAID:
AZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (M 700,000 BTI!)
Will the Banl or future bu0ding occupant store or handle havrdous
matcra .fined by the Cupertino Munldpal Code, Chapter 9.1 2, and the
I leallh and SifetyCodt,�Soloo 25532(a)7
RYea IN No
illtheaizard i.ir ce t.romaing°uvpant use the Bay A or devices
which cout M.e.grrdousakrict? Mnanls as de❑red by the Bay Area At,
ClEality Management DISMd7
❑No
Date Ree' tN
IMATING UNIT (OVER 100,000 BTU)
RM as TQTAL
VENTILATION FAN (SINGLE RESID) [b
1$$17 DATE
OCT 1 s 199Q
BOILER -COMP Otm OR 100,000 BTU)
BOILER-COMP(OVQt 100,000 BTU)
haveVea
read the havrdouc materlab requirements under Chapter 6.9E of
the Califomla Health A Safely Code, Sed Ions 25505, 25533 and 25534. I
understa nd that if the building does not currently have a tenant, that it is my
ash �s�ss�}4s�
NEW RESIDENTIAL MECH. SQ.FI'.t:i�%f'"S
responsibility to notify the occupant of the requirements which roust be mot
t uanre ora Cedi cxteof Occvpaory.
ISSUEDBY:
a thoriud agent Date
TOTAL: al
OFFICE COPY