23732APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building If Idemifkatia^
8u11ding Address: -
caner. ame:
PERMIT NO.
23732
ne,
. �Mf}5%� �� -
CITY OF CUPERTINO- BUILDING DIVISION
APPLICATION / PERMIT
BUILDING -ELECTMCALPLUMBINGMECHANICAL
M
ha
ContraaoraName: No:
O .a%7� V 1
CATEGORY
CONTROL Y
Architect /Engineer. ', No:
"�A
-
I' t
QTYFEE,Addressr:
BUILDING PERMIT INFO
J /J Sr LS
I'QRhRTISSUANCE
—J
tICF.NSED CONTRACT mmenc-
Ing as Section7(100)of Dlvlaion3o(thneualnes -and PrefeaslonaC cle, sed my
licensela In/uB d'fa �/'
Llanse Clam � Lie N__�, / Y
Date CHITEtorA^'1Q I'%L
APPLIANCESRESIDENHAL
PANELS
JOB DESCRB'3'ION
'
ARCh.11beTSDECLARAT ON
]understand my plaru shall be used a public records.
701M -
I(30MPS
OVER 1 W0 AMPS
SQ. FT. FLOOR AREA
'
$ /SQ. Fr.
Licensed Pro(essiowl
SIGNS ELECTRICAL
OWNER - BUILDER DECLARATION
Iherebyrffirm that I am exempt fmmthe Contraclor.Limr.Lawfmthe
following reason. (Section 70315, Butlneesand Professions Code: Any city or
c^ untywhichrequimsapermltto comtroa ,alter,bnpmve,demolbh,ormpalr
anya tmctumptlortoltslssuance, alw mquimstheappllaniforsuchpermitro
(Ile a signed statement that he in Hearted pursuant to 1M pnw atom of the
Contractor's Licame,Lsw(CMpter9(wnmenMg with Section 700(B of Dfvi-
ofthe Business and PmlemiomCode)orthat he b exempt therefromand
W sb for the alleged exemption. Any siolatlon of Section 7631.5 by any
applicant for a permitsubjects theappllaant to a dvil penalty of na more t Wn
five hundred delta.($500•
�❑ I, as owner of the property, or em to ees with wet es as their sole
m satlon, wdI do the wor °ty P y R
sale (Sec. 7044.
apply Business and f property Code: The Contractors hereon Law
does who does apply torn owner ofthroug property who bulmporee, pre idedthat oRand
wMdoementsa not intended Nsowals.If however, ingor
lmprovement6sold ithe oed earofc pletio. thaw ev buiiderwillh,ve
improvement lssold wlthinoneyearof completion,tM owner- bullderwlll have
t o rden of proving that he did ram build or Improve for purpose ofaale.).
LJ L as owner of the. property, am exclusively contracting with Ilcenud
contractors to --tract the project (See. 7044, Business and Professions Code:
The Contract.[. License Law does not apply to an owner of property who
Wilda or tmprovas thereon, and who - contracts for such pLojecb with a
co actor( -) licensed Punuantrothe Coot enr''sLlanse Law.
L,J I am exempt under Sec. B A P C for this reason
-
"
SPECIAL CIRCNT /MLSC
pp
7r21P' EfF.R 0�1'eOL
I V ' s ;A
MWERDEVICES, ,I
I 'sion3
POOL H.
VALUATIOthe
H � N
-
STORIES
7YPECONSTRUC'HON'
-
OCC.GROIR'
.RIS. UNHS
QTY,
- TOTAL:
" "' " PLUId BING•PERMIT: I',
pp RI55UANCE
ALTER -DRAM & VENT- WATER(RA)
` FEE`',
H'ODU�
AI'N
BACK FLOW PROTECT. DEVICE
„I•`,`. t >'FEE,SUMMARY. 'r
FEES
Owner Date
WORKMAN COMPENSATION
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y N
RECERer#
Isl DECLARATION
Of hereby affirm that I have a certificate of coment to self - Insure, or a
certificate of Worken'Compans.i.e Insurance ora certified copythereof (Sec.
3800,LabC) ;../
Policy # �'JYI? 6�✓ Gtr
MTURES PER TRAP
GAS PA. SYSTEM.1 INCAOUTLEM
�—�
SCHOOL TAX Y N
RECEIPT #
PAKK FTF. Y N
RECENT x
Cam ray IL
❑❑CertlBad copy b filed the
Certified copy b (Bed w th 1M city inspection division
GAS EA.SYSTFM- OVER4(EA)
CREASE /INDUSTRL WASTE INTERCEPTOR
BUILDING D I VISI ON FE
'PLANCHECK FEE
ES
GREASETRAP' -
'CERTIFICATE OFD(EMPFION FROM WORKERS'
COMPENSATION INSURANCE
(Thlsseelonneed na becompleted lfthe permit isforons hundreddollam
(§100)ar1m.)
PAID
Date Receipt
SEWER - SANITARY -STORM EA. 200Pr.
WATER HEATERW /VENT /ELECTR -
ENERGY FEE Y N_
'
PAID
I certilythat influx performanceofihe work forwhlch thlspermitfa issued,
I shall net employ any person In any manner n as to been. subject to the
Workers C^mpensatlor Lawa of Calffornla. Date
Applicant
WATER SYSTEM /TREATING
N`EWRESIDENTIALPLMB. SQ,FT.
- -
'
NOTICETO N'PLICANT:ILaftermakingthb Certifioteof Exemption, you
should becomesubJect to the Worksm'Compematlon provisloruofthe Labor
Code, you must forthwith comply withumh provisions orthla permit.haltbe
deemed revoked.
CONSTRUCTION LENDING AGENCY
I herebyaf rmthat there is a construction kedingagency forthe perform-
anne of the work for which this permit Is issued (Sec. 3097, Civ. C.)
Larder.Name
Mnaers Address
Icedlfy/hmlhave resithbapplicatlo nand9mthattheaboveinformatian
isommet. Iagreeto comply with a8 city and comAymetinancaand state laws
retail ng to building construction, and hereby author ize representatives of this city to enter upon the above- mentioed property for Wpection pu rposes."
(We) agree to save, Indemnify an d keep har less the City of Cupertiw
agalmthabillties;jodH7 9rsa meawhkhmaylnanywayaecrue
�a enting Mthpermit^
Date ReCel t#
TOTAL:
DIN • •
'
-
-
T
EE
FEE
QTY.
MECHANICAL PERMIT`,,
PERMIT ISSUANCE
-
o' FEE
`
FEE
CALFEE.
:
ALTER OR ADD TO MECH."
AIR HANDLING[NIT(TO 10,ODO CFM)
R6 eipt#
!CONSTRUCT!IONTAX,'
SU$TOTAL:
AIR HANDLING UNIT (OVER 30OWCFM)
EXEUUST HOOD (w /DUC'D
CTION TAX.
TION TAX PAID:
ignature of ApplHA 7A Rntractor Dam
HAZARDOUS MATERIALS UISCIASURE
HEATING UNI.T(TO 100,000 BTU)
Will the appilant orfuture building occupant store or W nd In hazardous
material as defl red by the Cupertino Municipal Code, Chapter 9.12, and the
He❑alt hand Safety Code, Sectloon 2553iG)7
Will the applicant or❑ future building occupant use equipment ordevices
which emit haaardous alr conta mutual... defined by the Bay Area Air
Qu IIIy Mavgement DisMcit
4 Yea No
haveread t n u i S r mn sune r 95 of
1M CalBona H.Ith& Safet y Co,Secti..2550.5, 25533and2S5M. I
rmponszndtFatntifytheo =paearoterq.1,Mveateiah ematle met
ream issuarmcf cerli ocecof ofihercqulremente which musfbemet
prior to issuance a a Certificate of Ompanry.
Recei
HEATING UNgT (OVER 100,00) BTU)
TOT
VENTILATION PAN (SINGLE RESID) ,
ISSUANCE DATE
P M ' D
�flY26
P'1I {{JJ 1[I(]r's
1992
BOILFR- COMP(3EPOR100,000BTU)
BOILER- COMP(OVR 100,OD0 BTU)
NEWRESIDENTIAL MECIi.. 'SQ.f7.
City c
eY:
O zewner or aulhor'd agent Date
TOTAL:
ISSUIiD
OFFICE COPY