21789APPLICANT TO FILL IN INFORMATION WITHIN REDLINES -USE BALL POINT PEN ONLY
Building Project Identification
Building Address: y o� r
70 2l 4r."I �n
PERMIT NO.
89
21789
n s amc:I.I n - hone:
)% W)Q/f•IQn -' j4sf(y.;a'J3
--
CITY OF CUPERTINO-BUILDING DIVISION -
APPLICATION /PERMIT
BLELDING-ELECTRICAL-PLUMBING-MECHAMCAL
•-ZG_,�' -
(,
C
Cont dors ams: - Lic No:
rfPy „ u ` n /
- .JGI�f S -/ �(7
CArr RY CONTROL
Architect Engineer. Lie. Nin
."pTY s h ELECTRIC PERMIT FEE -
` -BUILDING PERMIT INFO
Address: ,'
t
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
Iherebyaffirm that l'cum Bcensed underprovuloneof Chapter9(rommenc
Ingwith5 ion7OM)ofMMMon3ofthe BuWl and Profs ionsCodgandmy
license is In fuB o d effect
License am Lisp 93 / _
Date a Contrado
APPUANCESRESIDENTIAL
-
PANELS
JOB DESCRIPTION
,•p/ ( 5.��.cr
2(11-1(DO AMTS
ARCHITECPS DEC RATION
lundemtandmyplimshallbeusat pubbcmm a. -
OVER 1000 AMPS
SQ. Fr. FLOOR AREA
$/SQ.FT.
SIGNS ELECTRICAL '
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or
countywhich requires a permit to com uct, alter Improve, demoluh,orrepalr
anystmeture priorto Its esuance,abo requirestheapplicant forsuch permit to
file a signed statement that he u licensed pursuant to the provisions of the
Contredarb License Law (Chapter 9(commencing with Section 7000) of Divi-
sion3 of the Business and Pred.kors Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 70315 by any
applicant fora permit subjectathe applicant to a civil penalty of not more than
five hundred dollare ($500).
as owner of the pro
Qproperty, or my employees with wages as their sole
compensation, w111dothe work. and theetrocture is not Intended or offered far
-
SPECIAL CIRCUIT/MISC
TEMP. METER DRPDLE INST. '
POWER DEVICES
SWIMMING POOL ELECTRIC
OVTLE7SSWI FI
VALUATION
NEW RESIDEN77LTR
A [Cl, SQ'FL
S7OII ES
TYPE CONSTRUCTION
'
sale(Sec. 7044, Busmessand Professions Code: The Contmet.e.Licerse Law
'
does not apply to an owner of property who Wilde cur Improves thereon, and
whodoessuchworkhmfforthroughhlsownemplayees,providedthatwch
improvementaam not lntendedoroflered(create. If lunuever,thebuiidinger
Improvementusoldwthinoneyearofcomplelb theowner-bullderw111haLe
thr-*rden of proving that he did not build or Nnprove for purpose of sale.).
IJ L as owner of the property, cam exclusively contracting with licensed
contractors to consW ct the project (Sec. 7044, Business and I'mfesiov Code:
the Contractor. License Law does not apply to an owner of property who
Wilds or Improves thereon, and who contracts for for such ptajewith a
co,a1LlTactor(q licensed pursuant Rothe Contactors urease Law.
1_I I am exempt under Sec _ B 4 P C for this, reason
TA
QTY, ".';PL CPE IT ii •'FEE "
1'gRMR ISSUA D
0
ALTER-DRA VENT- WA 2 CEA
-
OCC. GROUP
Ri'S UNITS
.
h7AOp ZONE
APN
BA OTFLT. DEVICE
.t •a'. FEE SUMMARY, -
OUTSIDE rill
Owner Date
R, ROOF, AR[A, COND.
PERTRAP �
SANITARY Y N
RECFIT N
i WORKMAN COMPENSATION DECLARATION'S -
�i herebyo'(or em that 1 have o certificate of consent to self -insure, ora
1380,Lab of Worken'CompematloQn in�surance ora certified ropythereof (Sec.
3800, Lab C.1
Pa11cyY f%O
SCIi00L TA% Y- N
RFGEII'I' N
GAS, SYSTEVf-1 INCA OUTLETS
PARK NS Y_ N
RWE
Cam and Q
[ZCertlfled copy is herey(umci
�CertBied copy lefiled with the city
ty Inspection division. '
GAS EA. SYSTEM -OVER
GREASEANDUSTRL WASTE INTERCEPTOR
DING DIN
BUILDING DI VISION FF.
PLANCI'IECKFEE
ES
GREASE TRAP • a'
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE-
(This section need not W complded If the pemdt u for cam Fundrcd dollars
' (f100)otify(h
I certify that In the pedomanceof the won' ve as nch this permit le tassel,
l shall not employ any person le y manner w xs to Eject to the
Workcre' nsa of Csllfornia. DatApplicae'
1�t-�H
PAID
Date RCCCI t#
SEWFR-SANITARY-STORM EA. ZOORT. a O O
WATER HEATER W/VENT/ E.ECTR
ENERGY FEE Y N
PAID
Date Reeei t#
WATER SYSTEM/TREATING
+�
NUIIC^
N077CE30 MI'L1CA :IL aster kingth ertlfl te`o/ExempOo ,you
should become subject to the Workers Compensation Previsions of the Labor
Code, you most forthwith comply with such provisions or this permit shall he
deemed revoked.
NEW RESIDENTIAL PLM.,. SQ.FL
TOTAL:
-BUILDING -E
I hereby affirm that there u a construction lending agency for the performFEE
ance of the work for which this permit is Issued (Sec. 3097, CIV. C.)TOTAL:
-- CONSTRUCTION LENDING AGENCYMUNIT(TO
E
lender. Name
--
have read thisappBatlonand ststethetheabovelnfemnsulanVcorrect.
QTY:L PER MIT '.
ME:
FEE,DLendersAddmas
CALFEEIcedilythatl
(agnate to complywith all cityand countyorinancesand stale laws
to building construction, and hereby authonec representatives of thiscity to enter upon the above-mentloned property for Wpection purposes.
agree to save, Indemnify an d keep harmless the City of Cupertino-
against liabilities, jud menu,coat. and expenses which may In any way somas
agai C y nssryenceofthe granting&thls permlL
E.(We)
O 10,000 CFM)
:relating
ReceiptH
.SUBTOTAL•
AIR HANDW NG UNIT (OVER IO,ODOCFM)
CONSTRUCTION TAX
(
Slg tore of ppllant/Contractor Dal
EXHAUSTHOOD(W/DICT)
CONSTRUCTION TAX PAID:
HAZARDOUS) ATERIALS DISCLOSURE
EiFATING UNIT (TO IOO,ODO BTU)
Will the applicant or future b hding ooupantstore or handle hzrardous
material as defined by the Cupertino Municipal Code, Chapter 9.1Z, and the
Ilcalthand Safely Code�+ Sedion25533(a)7
M,Yes. M No
Date ReCei [N
HEATING UNITID0
HE(OVFR ,000 BTU)
... . ,
TOTAL,"
VENTILATION FAN (SINGLE RESRD)
ISSUANCE DATE
PAID
!lAAYY
'
-
JAN IA1J n6l P .'O �99OQ�
Will the applicant or town, building occupant use equipment or devices
which emit haranlous air cmt.nus ams as defined by the Bay Area Air
Quality Management Dutrid7
4n Yea. ❑No
havereadthehazarclOusmaterialsrequirementsunderChapter6.95of
the CaBmrnia Health&Safety Code, Sections 25505,75533 and 35534.7
understand that if the building does not currently have a tenant, that it is my
re7porsib7Bty to notify the occupant of the requirements which must be met
BOILER -COMP OIE'OR IDLE" BTLI
BOILER-COMP(OVER100,000 BTU)
NEW RESIDENTIAL MECH. SQ.Fr
prwr to Issuance of a Ccalficate o(Occupancy.
T CuPe11rt�rta ,
Owner or authorized agent- - Dace
-
TOTAL:
ISSUEDBY:�yL,l%
OFFICE'COPY