23649APPLICANT TO FILL IN INFORMATION WITHIN'RED LINES — USE BALL POINT PEN ONLY
'
Building Project Identification
Building Address: -
C U C: , I4Jo so
PEILVIT NO.
236.49
wnero ams. , one:
} Tri A L 73 9 - OT 13
CITY OF CUPERTINO-BUILDING DIVISION
_APPLICATION / PERMIT
BNLDINGELECTRICALnUMBING-MEC LAICAL
A
- ^ �' A
c°"o-ageraName: �s / Lic."°:
I Tr C7l'E CJ-Cs/�LO lO tIO leuI
�1�3YU�L�DINGPEI
NTROL#
Amhlted/Engineer. LIc. Nre
Q?'': `•- ' .EGBCTRIC PER141IT,j,'gITINFO
PERMITISSUANCE'
❑ ❑
Address:
• LICENSED CONTRACTOR'S DECLARATION
Iheh Sectio irmthat lam,i.3 ftheBuinemand PmfeWonsunder provisions r9(mmm,c-
tnensei inffiaon3oftheguslnessand Pm(eesionsCode, and my
license is in full force and effect
force and
APPLIANCESRESIDENTTAL
PANELS
JOB DFSCRB'TION
92
D
`r
License Class - Lte, # -
'�/� I
Date Contractor
IM TO 200 AMPq
101-1000AMPS
• ARCHITECT'S DECLARATION
I understand my plaw.) Mil be used as public records.
OVER 1000 AMPS -
Licensed Prfessional -
OWNER -BUILDER DECLARATIONI hereby affirm that l am exempt from the CostraaSoreLImmuawforthe
reason.(Section 7031.5, Business and Professions Code: Any city orTEMP.MECER
countywhich requimsa permdtocoratmd, alter,impmve, demolish, °rrepair anystmc mpeortoltsimance,al mquimstheapplicantforsuchperMttoppyyER
file a signed statement that he Is licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9(commencing with Section 7000) of Diol-
slon3ofthe Buslnessand Professlo,C°de)orthatheisexempttherefromand
the basis for the alleged exemption. Any violation of Section 7021.5 by any
applicant for a permit subjects the applicant to a civil penalty elect more 'ban
five hundred dollars (S500).
M 1, as owner of the property, or my employees with wages as their sole
compensation, will do the work and the structure is net intended or offered for
'SIGNS ELECTRICAL
777:
SPECIALCIRCUIT/MLSCfollowing
OR POLE INST.
DEVICES
SWEr1MING IDOL ELECTRIC
- VALUATION
-
OUTLETS-SWTTCHFSFD(TURPS
NEW RESIDENTIAL ELECTR SQ'FT.
STORIES
TYPE CONS RUCTION
sale (Sec. 70K Business and Professions Code: The Contractors Lioness Law
'
does not apply in an owner of property who builds or Improv, thereo4 and
who doessuchworkhlmsslf orlhrough hisownempleyess, provided thatsuch
Improvements are not Intended oroffered forsale. 1(hmvever,thebuildingor
Improvement laaold wlthlnoneyearofcomplRion,the owner-bullderwill have-
t rd an of proving that he did not build or Improve for purpose ofsale)
,nu as owner of the property, am exclusively contracting with Iimmad
contractors to construct the project (Sec. 7064, Business and Professions Code:
The Contactors License law does not apply to an owner of property who
buor improves thereon, and who contracts such ptojeets with a
Cc,t LttjjaetorW licensed pursuant to the Cortmeor'sLicense Law.
Lm exempt under Sec. B 6 P C for this reason
.. - TOTAL:
"PI:LiMBING PERMIT t -' FEE•
OCC. GROUP
R]ESUNUS
PERMIT ISSUANCE ►�•
ALTER-DRAIN k VEM-WATER EIA)ilds
pLOOD ZONE
APN
BACK FLOW PROTECT. DEVICEOwner
t.,FEE.$UMMARY
DRAINS FLOOR ROOF, AREA, COND.
FIXTURES PER TRAP
TARY Y N_Oats RECmx!' #
'0I
WORKMAN COMPENSATION DECLARATION
hereby affirm that 1 have a m tificate of consent to self -Insure, or a
of Workers'Compensation Wurance or a codified copy thereof(Sec.
3800,Lab CJ
Pellryp •
OOL TAX Y _ Ncertificate
RECEIPTN
tSA
GAS EA.SYSTEM-I INC.40UTLEIS
K FEE YN
RECEIPT #Com
ny
copyle hereby famished.
MCerllfed copy is filed with the city Inspection division.
GAS EA. SYSTCM- OVER 4 (EA)
CREASE/INDUSTIL WASTE INTERCEPTOR
BUILOINCDIVISION FEES�CeRi(Ied
NCHECIGFEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION
COMPENSATION INSURANCE
SURApermit E(Drone hundred dollars
(ThlseeRion need nor be
PAID
Date Recei t#
SEWER -SANITARY -STORM EA. 200FT.
($10(fimless.)
I certifythat in the performance of thework forwhlch this permit is Weed,
I shall not employ any person In any manner an , to become subject to the
Workers' Compensation Laws of California. Date
Applicant -
NOTICEco APPLICANT: If, after making this of Exemption, you
WATER HEATERW/VENT/ELECTR
ENERGY FEE Y N
PAID '
Date Recel t#
WATTR SYSTEM/TREAHNG
NEW RESIDENTIAL PLMB.SQ.FT.
ationfpm
Code,shoulbecomat fort R m the Workers Comperovisi n s uthis permit s Labor
Code, you must forthwith comply with such provisions orlhh permit shall be
deemed revoked.
TOTAL:
BUILDING F`E
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the perform_
ance of the work for which this permit ie Issued (Sec. 3097, Civ. C.)
��
-
SEISMIC FEE
ELECTRIC FEE
Lender's Name
Lender's Address
I ecrilfythatl have read this application and elate that the above Information
i i,; . �t-..
QTY, �''IvIECHANICAL PfiRMIT '.,F$E.a
PLUMBING FEE
MECHANICAL FEE
-PAID:
Iscorred.Iagree to complywithall Rtyand county ordinances and slate laws
relating to building construction, and hereby authorize representatives of this
citytoenterupontheabove-mentioned property for Inspection purposes.
-.(We) agree to save, Indemnify an d keep harmless the City of Cupertino
against liabilities, judgments, restsand expenses which may In anywayaccrus
against said City in consequence of the antleg of this pe It.
JqlFxHAUS'fHOOD(W/DUCT)'
PERMITISSUANCE
-
ALTERORADDTOMECH.
AIR HANDLING UNIT (TO 10,000 CFM)
FEE '
Date Receipt#
SUBTOTAL:
AIRHANDLING UNIT (OVER 10,000CFM)
CONSTRUCTION TAX
Igmtureof ppbnnt/Contractor Date
• HAZARDOUS MAfRJALS DISCLOSURE
Will theapplicant orfuWm building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.11, and the
Health and Safety Code Section 25532(.)7
nYes No
CONSTRUCTION TAX PAID:
Date Recel
HEATING UNIT (IT) 100,000 BTU)'
HEATING UNIT (OVER 100,000 BTU)
TOT
Will the applicant or future building occupant use equipment or devices
which emit hazardous air contaminants as defined by the Bay Arca Air
Quality Management District?
4haveYeaad the n Ne
5533under
niaHeah &Safer Code, anChapter 25534G95of
the Call(ornia Health&Safety Code, Seciiom 25505, 75533 and 25534.]
VENTILATION FAN (SINGLE RESiD)
r>G),)ANCE�ATE ,
I § ii 1
MAY 12 1992
BOILFILCOMP IMP OR 100,000 BTU)
ROLER-COMp(OVER 100,000BTU)
NEW RESIDENTIAL MECTL SQFT,
understand that lithe building does not currently have a tenant, that it is my
mIluorolssuance of ifythe ocu a tomhe req
r,or to issuance
of a theoccupantof of the requirements which most be metpri
a7s7L
_
CITY Ut- LUhtr1)IIY�
ISSUEDBY: .'
Oweeror aulusleedagent Date -
TOTAL:
OFFICE COPY