22183 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Protect Identification
Building Addraas:
_�os3 ��l.�L �;ti�� Ll � ~►Na
PERMITNO.
2218
wners NIEntes: one:
LE m EtaN
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING-ELECTRICALPLUMBING-MECHANICAL
J— L
Cnnd(Jy]dq irrm; Lie. N.:
CATEGORY
CONTROL
I"'�),3(01;>
Architect/Engineer. - Lie. Na
QTY ELECTRICPERMIT FEE
BUILD ING'PERMIT INFO
1 - `(+
Add' d S .J eepsr_a
❑ ❑ ❑
PFRMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
'I hereby afflrmthat l am licensed under provlelonsofChapter 9(commene-
i?gwlth Sedi.n7000)of Dlvlelan3ofthe Buslnesand ProfessionsCode,and my
It... I. in full form and effect.' ya�((JJ Q
LicenseClam Lle.N lOi� I
Date ContnCorUP
ARCHITECTS DECLARATION
I understand my plane shall be used M public records.
Licensed Professional -
OWNER -BUILDER DECLARATION
I hembysonafRrenthat I sexempt from the CDAmotor's Limnos Law for the
following mons. (Section 7031S, Business and Profession, Code: Any city or
e. untywhlchrequiresapemdttommt Malter,impmve,demlbh,orrepalr
anysumcWro prbrto ltsbsusnce, alsorequlresthe applimetfor ouch permit to
file a signed statement that he b licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9(mmmencing with Section 7000) of Divi-
don3 ofthe Bukrassand Pmfenlma Code) orthat he is exempt therefromand
the basis for the alleged exemption. Any violation of Section 70315 by any
applicant for a permit subjects the applicant to a civil peralty of net mamthan
five hundred dollars($SM. -
❑ I, A. owner of the property, or my employees with wages u their sole
compensation, will do the work and the structure he not intended or offered for
axle (Sec. 7061, Boston. and Placed.. Code: The C.Mmewes Llcerue Law
does not apply to an owner of property who builds or improves thereon,and
who doessuch work himelforthrough his own employees, provided that such
improvements are not intended oroffered for As. It however, thebulldleg or
Improvement Insold within oneyearofcomplsiorytKeowneabuRderwill have
tliq�urdcn of proving that he did nor build or Improve for purpose of ale.).
u L a. owner of the property, am exclusively =trading with licensed
contractors to mrahud the project (Sea 7011, Busas lneand Professions Code:
The Contractors License Law does not apply to an owner of property who
builds or Improve thereon, and who mntrsds for such ploje U with s
coyVador(s)licensed pursuant to the Contncine. License Law. w
lLJ11 am exempt under Sec. B k P C for this rean
APPLIANCES -RESIDENTIAL
PANELS
TO 200 AbTS
JOB DESCRIPITON,
201-1000 AMPS
OVER 1000 AMPS -
e.4. Ff. FLOOR AREA
S/SQ. FT.
"
SIGNSELECTRICAL
SPECIALCI6CIRT/MISC -
TEP METER ORPOLE INST.
POWER DEVICES I '
SWIMMING POOLELECTRIC
OUTLETSSWITCHESFlrTURES
ys��TVALUATION
NEW RESIDENTIAL ELECTR SQFT.
STORIES
'
TYPE CONSTRUCTION
TOTAL:
QTY, PLUMBING PERMIT FEE
OCC.GROUP
RES. UNITS
FLOODTDNE
APN
PERMIT ISSUANCE
ALTER -DRAIN kVFM • WATER (EA)
FEE SUMMARY
BACKPLOWI'ROTECT. DEVICE
DRAINS FLOOR ROOF, ARG, COND.
SANITARY Y N
RECEIPT N
Owner Date
WORKMAN COMPENSATION DECLARATION
I hereby affirm ve that I haa artifiate of consent to self-Insure,FIXIlRtFS
[:]IPER
or .
art,lAbC W.rkemi CampenuHan lmuurana ora arti(kd copytharco(Cic.
Lab CJ - '
Policy
policy N
TRAP
SQTOOL TAX Y_ N_
RECEIPT
GAS G. SYSTEM -1 INCAOUILET5
PARK FEE Y N_
RECEIPT N
" GAS EA. SYSTEM -OVER 1(G)
amy
BUILDING DIVISION FEES
"Mpertfied ropy b herebyth the city
Certified mpyb Wed with the blty Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' _
COMPENSATION INSURANCE
(fhb section need not .c*bebe m completed lithe permit lefts ossa hundred dollars
($100)or lea.)
I artlfy that In the performance afthewak forwhich this pemdt is blued,
I shall not employ any person In any manner so u to become subject to the
Workami Compensation Iaws.f Gltfamb. Data
ApplicaNOTICE
NOTICE TO APPLICANT: If, after making this Certificate
ate of Exemption, you
should become subject to the Workers''CampemaHon provisions of the Labor
Code, you =at forthwith comply with such provisions or this permit shall be
deemed rev.ked. -BUILDING
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lendlegagency for the perform,
Ince of tho work for which this permit Issued ued (Sec.3097, Civ. C.)
Le.der's Name -
Len omilytdreaa
Information
Inst. Iagrectochatl hove mad mplywapplat andcounnand ty ordinances
IsmrroRlaglcetocomplywithall ndhereyAuthoordinancnandwtelaws
relatingtobuilding econstruction, andhereby ori pectionUtiva ofthis
city(We) to agree to saw, indemnify ind propertyharm) ss thecC t purpose.
the City of Cu pecan.
(We) agree to ave, Indemnify and keep es which
,gains liabilities, In co etacstsand expense which may In any way accrue
agalnets Ily ince sequence .(tics granting oj„[hlepermlt.,
•- 'Z
GREASE/INDUSIRI. WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date Re i t#
GRFASETRAP
sFwnR-SANITARY-STORM EA. 200Ff.
WATET'HFATFRW/VENT/EF.CT'R -
ENERGY FEE Y N
PAID
Date Recel t#
WATER SYSIFAf/TREATING
RESIDENTIAL PLMB. SUFT.
TOTAL:
a
SEISMIC FEE
L
TOTAL:
ELECTRIC FEE
QTY. MECHANICAL PERMIT -FEE
PLUMBING FEE
MECHANICAL FEE
- -
PERMIT ISSUANCE
FEES PAID:
ALTER OR ADDTO MECH.
ALR ]iANDLINC UNIT UO 101000 CFM)
Date Recei o t#
SUBTOTAL:
AIR HANDLING UNIT (OVER I0,000GFM)
CONSTRUCTTON TAX
cure. AppR t/C.ntrsd.r .. .Date
HAZARDOUS MATERIALS DISCLOSURE '
L WIIl the a pplimet orfutum building occupant store or handle hazardous
ilterlal as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Health and Safety Code Section 25532(a)T -
❑ Yes No
Will the applicant or lure building occupant use equipment ordevias
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District?
q Ya No
a out nateriaedt.m 25505, underChapter6.95 6.95 of
havemad Health
the California Health A SafetyCode, Sedlom)5505, 75537 and 25534. I
understand that lfthebulldlngdoes not currently have sterent, that It b my
r¢pooslblllty to notify the occupant of the roquirements which must he and
prior to Lasuance of a Cedifleate of Oaapancy.
E7(HAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UMT(TO 100,000 BTU)
Date ReCBI
HEATING UNIT (OVER 100,000 BTI!)
TOTAL:
L
VENTILATION PAN (SINGLE RESID)
ISSUANCE DATE r -
C
�&T
`r2�qv x1 1991
ISSUED BY.
BOILER -COMP OHPOR 7(X1,0(10 BTU)
90ILFR-IbMP(OVER l00,OL0 BTL))
NEW RESIDENTIAL MECH. SQ.FT'
E
Owner or eulhmieed agmt Date
I TOTAL:
OFFICE COPY
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APF?Rpi4�TFI L� h'I •
ACCORDANCE WITH THE C 7
�'.'. PERTlND; C015Es AND,... TTY 06 L_ L� �� iAAI �i� __.. .
pA OflQINANCE,g
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This plans and
4 ke on the . specifications MUsit �
b ul make wti at all time I ,{{
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