24071APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pro'ed Identification
Building Address:
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24071 4O
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CITY OF CUPERTINO-BUILDING DIVISION
- APPLICATION I PERMIT
BUJLDINC-ELECTRICA4]'LUMBING-MECI]AMCAL
A�^ �` ^
C tract.' Name: Lic. No:
k. r-�n-O Qc-_bl G 9105
CATEGORY
CONTROL X
Archit /Engineer. Lie No:
QTYELECTRICPERMIT FEE
BUILDING PERMIT INFO
Addreax
PERMITISSUANCE
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Cha peer 9(commenc-
ingwlthsection 7000).( Divblon 3ofthe Buslneuand ProfessionsCode, and my
Bance le In fult fora and effect.
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
�/�j
. Ice PE.
PANELS
License Claes Lica
\ fF/
Date Contractor
LIP TO 200AMPS
201-IODOAMPS
' ARCHITECTS DECLARATION
I understand my plana shall be used as public records.
_
OVER 1000 AMPS
SQ. FT. FLOOR AREA S/SQ. FT.
SIGNSELECTRICAL �
Licensed Professional
_ s
® a
OWNER -BUILDER DECLARATION
Iherebyaffirmthatlamexemplfmmthe Contmdor'sLlcenmhwforthe
following reason. (Section 7031S, Business and Professions Code: Any dty or
countywhichrequlmapert ttommtmd,Oter,impmve,demolbh,ormpair
SPFGIAL CIRCUIT/MISC
�'
'j� II,�
' 1, v [,-DU'1 L.�.
gII,Tp METER ORIOLE INST.
anysimdumpr rtolreluuame,alsomquirestheappllantfasuchpev tto
file a signed statement that he U licensed pursuant to the probions of the
Contractor'sLicense Law (Chapter 9 (commencing with Section 7000)of Divi.
sion 3 of the Business and ProfessionsCode) or that he is exempt therefrom and
the basis fora theed exemption.
the tams for the alleged exemption. Any violation of Sectinatty o nor da by any
subjects the applicant to a dull penalty of not more than
five hundred dollars (SM.
❑ I, as owner of the property, or my employees with wages as their sole
POWER DEVICES
'
TE
- VALUATION
/
J
SWNHMING POOL ELECTRIC a
OUTLETS -SWITCHES
NEW RESIDENTIAL ELECTR SQ.Ff.
STORIESCONSTkl1CT10N
compensation, will do the work and the structure is not intended or offered for
sale (Sec 7044. Business and Professlom Code: The Contractors License Law
does not apply to an owner of property who builds or Improves thereon, and
who dues such work himself orthrough his own employees, provided that such
OCC. GROUP
RES. UNITS
Improvements arenot intended oroffered forsale. If, howevre thebullding or
Improvement bsold withinoneyearofcompldla0.tMa er-buliderwUI have
TOTAL:
thif.titaMen of proving that he did not build or improve for purpose of ule.).
L j L as owner of the property, am eacl,oiNely contracting with licensed
contractors to mpetrud the project (Sec. 7044 Business .rid Professions Code:
QTY, PLUMBING PERMIT FEE
PpRMp(ISSUANCE 1
plppDTONE
MN
The Contractor's License Law don not apply to an owner of property who
Wilde or Improves thereon, and who mntrads for such projects with a
c(bactor(•) licensed pursuant to the Contndore Litems Law.
LI I am exempt under Sec B & P C for this reason
ALTER -DRAIN & VENT- WATER (EA)
BACK FLOW PROTECT.
FEE SUMMARY
I • FEES
DRAINS FLOOR ROOF, AREA, COND.
FIXTURES PER TRAIT
SANITARY Y NOUTS
---
RBC M-7 R
Owner Date
WORKMAN COMPENSATION DEC& RATION
C31 hereby affirm that I have a anl0cate of consent to •elf.insure,
SCHOOL TAX Y N_
or a
certifiate of Workers'Compensation insurance or a certified copy thereof (Sec.
3800, bC.)
RECEIT Y
GAS F.A. EM -1 INCAOUTLETS
PARK FEE Y N
Pali N
RRC M. ,T#
CAS EA, SYSTEM -OVER 4 (FA)
Co any
BUI LEE NG DIV] SION FE IN
edified copy U hereby filed
C ified copy b filed with the city Inspection division.
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WO R K ER S'
COMPENSATION INSURANCE
tion need nor bO complded I(the permit ls farone hundred dollam
R)
PAID
Date Recei t#
SEWER -SANITARY -STORM E.A.20%7
m 1.
($1 I0)orlyth m wornner so a to b co permit b Issued,
] ll not that In any personhe Iperformance any
I shall not employ any person in any manner m ae to become subject to the
W Compenutlon hove of Callfornla. Date
Applicant
aaermaking fhb Ction p sof Exemption, you
NOTICEco esubJe to s Labor
shouldbecome subteen. the pry with
Code, you must forthwith comply with such provisions or this permit shall be
such provisions
deemed rcvakm.
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y N —
pplp
Date Recei t#
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. SQPT.
TOTAL:
NG FEE
-
.R.SJ_I
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby afflrm that there is a construction lending agency forthe perforin
ance.f the work for which this permit Is Issued (Sec, 3097, Civ. C.)
O
ELECTRIC FEE
Lender'.Name -
Lender'sAddress
1 artifythatI have read thbappllationaM patethauhcabove Inforr int.
-
Q'rY. MECHANICAL PERMIT FEE
PLUMBING FEE
�
MECHANICAL FEE
..L
•J_
FEES PAID:
bcorrect.] agree to complywith all city and countyordinaons and pate laws
PERMIT ISSUANCE
relating to building construction, and hereby authorize representatives of thio
city to enter upon the above-mentioned property for Inspection purposes.
(We) agree to save, indemnify an d keep h Mese the City of Cupertino
againstliabilturs,judgmente A. adeap hmaylnanywayaccrue
agalrat said City ens .(the g bpermit.
_s
ALTERORADDTOMECH.
'
Dail'. Recei f#
AIR HANDLING UNIT (TO 10,000 CFM)
-
SUBTOTAL:
AIR HANDLING UNIT (OVER I O,OWCIM)
CONSTRUCTION TAX
Si alu Appllant/Contra Data
E'XHAUSTHOOD (W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100pW BTU)
-
Will theappllunt or future building occupantstme or handle hazardous
serial as defined by the Cupertino Municipal Code, Chapter 9.IZ and the
IWith sad Safety Cod, Section 25537(x)7
❑ Yea NO
Phuretruilding
Date Recei t#
HEATING UMT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
p� B
D
�,•�
U 5 1992
CIIx Ur
Will theappliant or occupant useequipment ordevices
which emit hazardous air mntamlnantsas defined bythe Bay Area Air
Quality Management DlsMld7
4 ❑
have read the hazadoY. ss o
a materials requirements underChapter6.95 of
the California Ilealth&Safety Code, Sections 75505,75533 and 25534. I
.understand that if the building does not currently have a tenant, that It 6 my
responsibility to notify the occupant of the o qulrement• which must be met
prior to Issuance of a Corifrsar of Oedipa my.
BOILER -COMP OEIs OR 100,000 BTU)
BOILER -COMP (OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ.IT
VUf ry
to un O
ISSUED BY: 'g
Ownerar aulhorlud agent Date
TOTAL:
OFFICE COPY