24216IIrrus.agary T Tv rILL Iry InrunmAl NJIV WI I FIIN HtU LINES —USE BALL POINT PEN ONLY
Holding Pm ed Identification
Ouilding Addmm:
PERMHN
24216
L/iPNF l g�U
CITY OF CUPERTINO"BUILDING DIVISION
APPLICATION / PERMIT
BUILDING xTRICAL LUMPING-MLCIAMCAL
APPLICA IIGN SUBMITTAL DATE.
10-1-91-1
"1 'L
_
CATEGORY CONTROLI
rehlted/Engineer. I1,, L�j Nm
%�Ff1L/lt1�FAlr
"r'i,':.EI.ECTRICPER
BUILDING PERMIT INFO
Addrcac D` )!/2;4a /M %D,t.1T �i.7335
LICENSEDCONTRA OR'SDECLAR TION
therebyaffIrm that l am licensed under provisions o(Chapter9(rommenc.
ingwllh$ecti°n 7000)of lNvlslon3 ofthn Businessand Professlona Code,end my
I"tun Cbm
license le In full remand effect y�J�
IJate mu��a.x"O
E =FEIN
PERMITISSUANCE
11
❑ � ❑
APPLIANCES -RESIDENTIAL
-
PANELS
}JJal'p ppAh9'S
`� Ud Rll' ON
1 1
NI -1000 AMPS
CHF=`a=4
ARCI{ITECP� EC= TION
�/
IundentandmyplamehallbeusedupA cmcmds.
OVER 1000 AMTS
SQ. Fr. 17,O0R AREA
S/SQ. Fr.
SIG NSELECTRICAL
I.Im..d professional
OWNER -BUILDER DECLARATION
I hereby of@m that I am exempt from the Cmdraaor's Llcenee Law for the
following reason.(SMlon 70015, Business and Professions Code: Any city or
county which requlrcaa permit toconstmct, alter, Improve, demolish,., repair
any atru dune prior to Its bwanae,ateo requbn theapplla nl for such permit to
file a signed statement that Eu le licensed pursuant to the provisions of the
Contractor's License Law (Chapter9(mmmencing with Section 7000)ol Dlvl-
alo03 of the Busies and Profemlom Code) °moat he b exempt thamfromand
the basis for the alleged exemption. Any violation of Section 7031.5 by any
appllcanl fora permit aub)ede the applicant to • dvll penaltyof not more than
live undreddoBau($5(10).
I,uowner,ofthe property, or my employees with wages as their sale
compensation, will do the work and Ihestruciurc b not Intended or offered for
'
SPECIAL CIRCUIT/MIBC
7RMp.METiiR ORIOLE INST.
POWERDLWCFS
SWIMMING POOL ELECTRIC
OUT'LE7SSWI7CI IESE%TURES
VALUATON
NEW RESIDPN77ALELEC7R e"Q'rr.
STORIES
—TYPE CONSI'RUCIPON
.1c&c.7044. 11.0nem and Pmfcmlone Code The Conluctors License Law
does not apply to an owner d property who builds or Improves thereon and
whodoessuch work himself orthr°ugh hlsown employees, provided that such
Improvements arc not Intended or offered (waste. I(, however, the building or
Improvement b sold within oneyea rofcomplelion the owner -builder will have
I tau Of en of provl ng that he d id not build or improve for pu rpomof sate.).
U L am owner of the properly, am exclusively contracting with licensed
rontradun to rontlrud the oroled (Sec. 761` Ouslnem and Professions Cade:
The C°nludori Llunx Law dose oat apply to an owner of property who
Improves,ilds orImproves,thereon, and who contracts for such ptoieda with a
contra dOHS)
exemt punuanttothe Cwlndor'a License Law.
I a'^ °'°r^W urldej $ec�1 � B h P C for Ihb reason
TOTAL:
Pt UMB ING PERMIT^
ppgMlT ISSUANCE
ALTER -DRAIN 4 VFM-WATER (EAT
'•;FEE
OCC GNONs
RIS. UNITS
F1,OpU7DNE
APN
BAIX FlAWPROT[CT.DEVICE
A NIT .Q1- FEESUMMARY.
OUTSIDE
FFVq
DRAINS FLOOR, ROOF, AREA, COND.
SANITARY Y— N_
RECEII'rI
--�, mal-/C//� Data
n
nal WORK MA I PENSATION DECLARATION
I hereby affirm That 1 have a certibute of consent to self -Insure, or a
certificate Of Workeni Compensation Insurance or a mottled copy t hemof (Bee
3801,IJ6 C.) {)
policyF ��, �1 /1 �I_� /
Coroany[�j�j�GI _! �
c•:fieeddcopyb ]M thi ed.T
CertlOed copybllled with the cityWpedlon divlslw.
FIXNRFS PER TRAP
SCI TOOL TA% Y N_
RECEIPT 4
GAB-EA.BYSTFM-1 INCAOUTLR
PARK1IM Y N
RECE117I
CAS I?A.SYSI'R.IAVER
I(Fi1)•
—
BUILDING DIVISION FEES
CRUSE/INDUSfRL WASTE INTERCEPTOR
PIANCI'IECK FEE
GREASE TRAP
CERTIFICATE OF E%FMITION FROM WORKERS'
COMPENSATION INSURANCE
(Thlssedionnced not be completed if the permit b lw one hundred dollars
PAID
Date Revel tN
Ir}
BETVER-SAMTARY-SIORM EA. 20017E
(fl I mAllem.)
laOut that in the Person Ian the work for awhich 1.beo permute issued,.the
I shall not employ any prawn in any manner n as to become subbed to the
Worken'Compen ti Kava of Gllfornla. Date
Applicant
NOlicant '1' A T:IL after makingthb Certlllute of Exemption,you
should Weome.o 1Mtothe W°rken'Compensallonprovblom°flhe Labor
Code,ynummtfort hwithromplywllhsuchprovlsloroor fhb permit shallhe
deemed revoked.
CONSTRUCTION LENDING AGENCY
lending agency for (he perform.
I of ebythe work for at which t barony Is tionIssued
ancder the work for which this permit tsbwed (Bee 3097, C1v.q
Innder's Name
1<nae.anaare.a -ry -
I cenifytha0 have read th ap B tionand slauthatthe above information
bcorrcd. i agree to comply with all dtyand muntywdlnanm and pate lawn
relating to building mnstructlon, and hereby authortae representatives of this
dty to enter upon the above-mentloned property for Inspection purposes.
(We) agree to save, Indemnify an d kap harmless the City of Cupertino
agalnet llabllilles,)adgments, copeand expenses which may In anywaysaroe
agalnet said City In consequence of the granting of this permit.
WATER I IUTIR W/VENT/ELECTR
ENERGYFEE Y N —
PAID
Date ReaeiptN
NATER SYSIGVf/1RFATING
/
g
NEW RESIDENTIAL ELMS. SQ}T.
"—
TOTAL:
IiSf II,Rf Nie_�'EF.
.c5E_SMIC FEC
ELECTRIC FEE
_
1 /✓71 ,/L,.
YLY
TOTAh:
/'Yr
QTv.
-' MECHANICAL PERMI'E. -, `'"'IEE'
PERMIT ISSUANCE
ALTER OR ADD TO MECE.
AIR I IANDLINC UNIT H010,000 CIM)
PLUMBING FEE
�•�
MECI'IANICAL FEE
FEES PAID:
Date ReceipE1
SUBTOTAL:
.%
AIR HANDLING UNII'(OVER 18030 CIM)
CONSTRUCFIONTAX
Signature of Appllant/Contradw Date
HAZARDOUS MATERIALS DISCLOSURE
IX11At7smooD(W/DucF)
CONSTRUCTION TAX PAID:
HEATING UNIT 00100,ODO BTU)
__
Will the applicant or future building occupant store or handle haeardom
nutertal as defined by the Cupertino Municipal Code, Chapter 9.17, and the
I kalth and SaldyC er Sr lion 2S532(a17
Yes o
Date Receiptii
HEATING UNIT (OVER Ig1,1100 BTU)
TOTAL:
Illthezppliunto tture Wlldingwcupantuseequlpmentordevlces
which emit hamrdous air contaminants as defined by the Bay Area Air
ality Management Tat I
Yes No
have read the hav smatedile requirements under Chapter 6.95 of
the California Health 6 Safety Code, Sediom 255nS, 7SS)3 and 25534. 1
understand that if the building does not currently have a tenant, that It la my
mpomlblllly to naifythe°ccupant o(the requlrememswhkh must be mel
PIoimuanceofaCerllpcateofOmpancy.
/CIS-y�Z yL
VFN'DLATION FAN (SINGLE RFSID)
ISSUANCE DATE
r'
r A' ��
7 •IOr)�
OCT I IJJ
rITY 'I'
ISSUED BY,
BOILERCOMPUITPOR 00.0MBIU)
I{ORERCOMP(OVQt 100,00D BTU)
NEW RrSIDENiIAI"MECH. SQ.rr
nerorauth and gent Date
TOTAL:
OFFICE COPY