23508APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Protect Identification - "' ����� RVVUU r
- [ding Address:
PERMIT N'23508
nt� LL La
cAro
nera ams: ane:
_ p:q ,Z.Cj(o _L�
OF. CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
ontrautme,Name:
CATEGORY CONTROLp
.BUILDING. ELECTRICAL-PLUMBINGMECHAMCAL
Architect/Engineer. Lk. No:
qT,i ;' E4,ECTRIGPERiyIIT ';-FEL
*`'•i""BUILDIN''Pt;RMITINFOC,
�L
Address: O A hu P I -
-❑ ❑ ❑
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATIO
[hereby affirenthat l amllcensed under provbmasof Chapter9(mmmmc-
ingwith Section 7000).!DiAi i..3ofthe Businessand Profe»onsCode, and my
license Is in full force and effect..
License Class Lic.p
APPLIANCFSRESIDENTIAL -
)OB DESCRE'I ION
'
1p
PANELS
Data Contractor'UP
TO 2QQ AMPS/
I
201-1000 AMPS
- ARCHITECTS DECLARATION
' I understand my plans shall be used ss public records
-
OVERIODOAMPS
)�R ARJ.k _
$/SQ. FT.
SIGNSELECTRICAL - •I is 'J {"„
Licensed Prmossh al
OWNER -BUILDER DECLARATION
I hereby af(irmthat 1 am exempt from the Contractorb Lkense Law forthe
T ER
SPECIALCItCUIT/MISC
'
ITIVUi, METER OR POLE INST.
DEVICES
followingrehrNutectape7 tto Buinessand Professions C.de:Anytlpair
muntywMch requlresa permittoalsore uirestheaprovgdemolish,ormitto
.iso sed pursuant tlirantfmsuionsch of permittoPOWER
any strodurepriorfonts chat he pursuant it the Provisions of Me
file a signed statement that he is (Chapter 9 (commencing
Contractor's License Lawwsionscommor that with rampSectioherafof Divi-
ivi-
sion
she basi3 ofs ed Profession. Any violation
for the alleged n of exempt therefrom and
theWsisfor thealleged exemption. Anyyt tola civ? .(Section net more
'applicant for a permit subjects to the applicant to a dull penalty of not more than
five hundred dollars he pr ,
I, as owner the property, or employees with wages thele mk
7/
V
SWNSMINGPOOLELECPRIC
OUTLETSSWITCHIES-FIXTURES-
VALUATION -
"
NEW RESIDENTIAL ELECTR SQ.Ff.
S'IY3RIF5
TYPE CONSTRUCTION
l he e intended or d for
rk,Pr t..
dale (Sec.
saleBusinessand
an
usd ass and fa Code: T
ora Cade: The Contractors ?came Law
C law
to ow rope
apply f property-whoves hemon
who doeseuchwork himsel(orthr.ugh his ownemployeea, provldedthatsuch
whododoes tapply torn.wnero(Property whonempor improovide that such
_
.,OCC. GROUP
RES. UNITS
Improvements are not Intended .roffered for sale. If, however, the building or
Improvement issold within one yearofcompletion, the owner-builderwlll have
'TOTAL:
..
`.'•PLUMBING
-
-
theebirrdenofprovingthathedidnotbuildorImprove for purpose of sale.),
F1 L as owner of the property, am exclusively contracting with licensed
contractors to mnatruct the project (Sec 7044, Business and Professions Code:
&Y.,'. `�
PERM IT FES;-,
FLOODZONE
pPN
-
PERMIT ISSUANCE
The Contractors License Law does not apply to an owner .f property who
builds or improves thereon, and who mMrada for such pTjects with a
u1nactor(s) licensed pursuant to the Contractor's License Law.
LJ I am exempt under Site. B & P C for this reawn
ALTER -DRAIN &VENT- ATTR
' '
BACK FLAW PROTECT. DEVICE
FEE SUMMARY.
FLOOR ROOF, AREA, COND.
FD(TURES PER TRAP, sa��
SANITARY Y * N '
RFCEIT p
OwnerDRAINS-
" Data -
WORXMANCOMPENSATIONDECLARATION
QI hereby affirm that I have a certificate of consent to self -insure, or a•
SCHOOL TAX Y_ N—
mrlfimteofWorkere C.mpemadmlw mnamamdifiedmpythereof(Sec.
3800, Lab C.)
Policy ..
RECEI.1' p
GAS EA. SYSTEM -1 INCA
PARK FEE Y_ N
RE-CEIx1'p
m any -. -
CAS EA, SYSTElr1-OVER
BUILDING DIVISION FEES
ditledcopybherat furnished.
Certified copy is filedth the d y'repection division.
CREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thlasection need not be completed ?(the permit is (Drone hundred dollars
($100)or leas.)
I camlythat In the performance of thework forwhich this permit is Issued,
I shall nM employ any person in any manner m as to become aubjed to the
Workers'Compeneatlon Laws .f Calitornla. Data
Applicant
NOTICE co APPLICANT; a after making this Certificate is ons oft Exemption, you
shoddbemmesubject
wit the Worketh.oheneat .rihl Nrft,Labor
Code, you must forthwith mmpiy with each provisbra or This permit shall be
deemed revoked.. -
PAID
Date Remi t#
SEWER-SANITARYEA 200FT
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y N —
PAID
Date Recei t#
WATER SYSTEM/TREATING '
NEW RESIDENTIAL PLMB._SQ.FT.
-
TOTAL:
BUILDING FER
CONSTRUCTION LENDING AGENCY
I herebyaffirmthat there is a cunelmction lending agency for the perform
ante of the work for which this permit is Issued (Sec. 3097, Civ. Q
T
FEE
C FEE
Lenders Name
?endo'. Address '
I certifythatl have read thisappBcatl.nand etatethat theaboveinformation
QTY +'MSSHANICAI:PERMIT �'"FEEi;iICAL
G FEE
FEE'
D:
iscortect. I agreetocomplywith alldtyand countynrdinanc¢sand statelawa
PERMIT ISSUANCE
relating to building construction, and hereby authorize representative. of this
city to enter upon the above-mentioned property for inspectlon purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino
against liabilities, fudgments,consand expenseswhich maymanywayamma
agaisat a id City In consequence of the gr' ming of tl�a permuit.
—l�
ALTIXORADDTOMECH.
AIR HANDLING UNIT (To 10,000 CFM)
.Race? t#
P
SUBTOTAL:
AIR HANDLING UMT(OVFR 10,000 CFM)
UCTIONTAX—ISignature.
pplimnt/Contractor - Date
IXHAUST HOOD(W/DUCT)
UCTION TAX PAID:
HAlEARDOUSMATER L )ISCLOSURE
Will the applicant or (uNre building oc ant etore.r handle hazardous
material as defined by the Cupertino MuNdpal Cade, Chapter 9.1 2, and the
Ilealth and Safety Code Section 25532(a)?
' Yes �] No
(To 'a
HEATING UMT(TO 100,000 BTU)ReC
HEATING UNIT (OVER 100,000 BTU)
T -
VENIILATION RESID)
I$$UA CE DATE
kY W Y e1
Y" P9 Y
APR 9 1992
y
CITY UY I/Ilr,Ct71111(D�
Will the applicant or futum building mmpantuse equipment ordevlces
which emit hazardous air contaminants.. defined by the Bay Area Air
Quality Management District?
4 Y'. d No
have read the haze ousmzterlaisrcqutrementa underChapter6.95 of -
the California Ilealth&Safety Code, Sed lona 25505,15533 and 2:534. 1
understand that if the building does not currently have a tenant, that it is my
responsibility to notify the occupant of the requircmenta which must be met
prior to Issuance of a Certificate of Ompa acy.
BOILER -COMP QHPOR 100,0(0 BTU)
BOILFR-COMP(OVER 100,000 BTU)
'
NEW RESIDENTIAL MECHi SQ.IT.
ISSUED BY:
Owner or authorized agent Data
TOTAL:
OFFICE COPY