23650APPLICANT TO FILL IN INFORMATION WITHIN -RED LINES.-' USEBALL POINT PEN ONLY. '
- Building Project Identification
Building Address:
10-70 u k-
PERMIT NO,
23650
hone:
ra L -L, WSY
-- -
CITY OF CUPERTINOLBUILDING DIVISION
APPLICATION/PERMIT
Bl fLDING-ELECTMCAI4PLUMBINGMECHL NICAL
p -
c o-aRor a ° SLI=No-
CATEGORY
CONTROL
rc IteR/Engineer. Lie. No:
3 .,i itt,'
LTi".,,; ELEG'TRYai PERMIT t .. ,; FEE .'
",t.;. `t,a B,UILDIN6PERI1'IIT INFO '•
•. , .� •
AddressPERMITISSUANCE"
,
..
�.
El ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirmthat l am licensed under provisions of Chapter9(commene-
ofthe Buelnseand Pro(es3onaCode, and my
Ectionh i.fon7000)Of it effect
license le in fur force and effect.
Licen 5,.,=LIc:I S
APPLIANCES-RESIDENTIALIrgwIt
JOB DESCRIz['[ON
n/t1�A
•� t
-
PANELS -
Lx -r
Date^Contranor - Vim
ARCHITECT$ �CLARATION Ildrea
I understand my plans shall be used as public records.
'
�» R EAI $/SQ.Ff.
X11-1000 AMPS
OVERIOOOAMPS -' ' II'
SIGNS ELECTRICAL i
Licensed Professional
/ � B
�{ 1
P T
SPECIALCItCUIT/MLSC
OWNER -BUILDER DECLARATION'
I herebyaffirmthat Iam exempt from the Contractor's License Law for the
following reason, (Section 7031.5, Business and Profesions Code: Any city or
county which require. a permit to construct, alter, improve, d enn W h, or repair
any structure prior ocfts Issuance, also requires the applicant forsuch permit to
file a signed statement that he U licensed pursuant to the powisiow of the
Contractors License Law (Chapter 9(commencing with Section 7000) of Divi-
Mon 3 of the Business.nd Profs sloes Code) orthat he V exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant for apermit subjectstheapplicant toacivil penalty ofnot morethan
five F11, asrowner xrshepr.
I, a9 owner property, or my employees with wages there sole
00 V
G"
TEMP. METER OR POLE INST. i DATE
�- -
]OWER DEVICES
SWIMMING POOL ELECTRIC
OUTLE'iSSWITCHESFUQ'URES -
VALUATION
- '
NEW RESIDENTIAL ELECTR SQ.FT,
g[ IMS
TYPE CONSTRUCTION
compensation, will ofhe seethe structure Isnot Intended or
r
-
Business and
sle (Sec. 7014, Business and Pro(eslos Code: The Contractors Llceme Law
mminofferedL w
'
TOTAL:
I
QTY,PLLjIViBINC'r'PERMI'!„y
, ,`.FEE;
POWHISSUANCE
ALTER -DRAIN & VENT WATER (EM
does not apply to an owner of property who Wilds or Improves thereory and-
who does suchwork himself or through his own employees, provided that such
Improvements am not intended oroffered forsale. If, hmvever,thebullding or
Improvement issold withinoneyearofcomple lomthe owner-builderwill have
tlyG�rdeu Of proving that he did net build or Improve for purpose ofsale.).
u L as owner Of the property, am exclusively contracting with licensed
contractors to contract the project (Sec.7044, Bueines and Professions Code:
The Contractor's License Law does not apply to as owner of property who
or Improve thereon, and who contracts for such ptojects with a
on tt(aa (a) Rrensed pursuant to the Contractor's Llcens Law.
L,J I am exempt under Sec. B k P C for this recon
C.GROUP
RIS.UNTFS
}755D7ANE
APN
BACK FTAWPROTECT. DEVICE
•FEE;$IJMMARY.'.'
-
DRAINS FLOOR ROOF, AREA, COND.
FIXTURES PER TRAP
SANITARY Y_ N
RECEIPT N
Owner Date
WORKMAN COMPENSATIONDECLent to N
❑i hereby affirm that I have o certificate of consent d Or a
cele ofWorkeni Compesatlon Insurance oracertifkd ropythereof(See
SCHOOL TAX ,Y— N
RECEIPT' M .
GAS EA. SYSTEM-11NC.4 OUTLErS
PARK FEE Y N
RECEIPT B -
3800aftipythemof
3800, Lab Cd p� -
Pollry N
an 1T ATc L7 N !]
ro
GAEA. SYSTEM -OVER
S 4 (EA)
BUILDING DI VISION FRES
Certified ropy R hereby famished.
❑ Certlled copy U filed withh the
e citlty inspection division. '
GREASE./INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASETRAP
CERTIFICATE OF EBEMPIAON FROM WORKERS'
COMPENSATION INSURANCE
((his section need not be completed tithe permit R (Drone hundred dollars
($100)orlesl
Issued,
I of not that In the parson in an the manner ad as t b comehis subject
I shall not employ any person In any manner at s 10 become subject to theWorke
Applicant s' Compenstion laws of Califomla. Date
Applicant
NOTICE TO APPLICANT: If, aftermaking this Exemption, you
sation provisions
Workers' Comp meati n s orchis p rmitof s Labbe
Code,shoulyou
Code, you mus; forthwith comply with each provisions orchis permit shall be
fort d to with comply
deemed revoked.
PAID
Date Recel t#
,
SEWER -SANITARY -STORM EA. 200FT.
WAT W%VENT/ELFJCTR
ENERGY FEE Y N —
PAID
Date ReC l t#
WATER SYS EATING -
NEW RESIDENTIAL: PLMB. SQ.FT.
TOTAL:
BUILDING
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there R a construction lending agency for the perform-
ance Of the work for which this permit Is issued (Sec. 3097, Civ. C.)
O
ELECTRIC FEE
Lender's Nam¢
Censer's Addreea
QTy. ” MECHANICAC'PfiRi11IT :'','FEE �'j.
PLUMBING FEE
r'^ '
lintian state
I cent.
hatlafire have readywith
MECHANICAL FEE
FEES PAID: t
I a d county ordinances d Mateation aws
Mate laws
Ectingtaagreeto complywith andherebauthorize
PERMITISSUANCE
repncesand
relatingtobupon t rosove-mn,andherebyrtyori represenpurposof this
property for impaction purposes,
city to EWc)aeree to ave;he Indemnify an
(We) agree to eve; Indemnify an d keep harmless the City of Cupertino
against liabilities,Indgments, manzand expense which may inanywayaccme
a/g�a i'n�st s/aid(�i-ty in ronsary ccepf the granting Of this permit.
�Z
ALTER ORADDTO MECH.
—
AIR HA IDLING UMT,'TO 10,000 CFM)
Date ReCelpt#
SUBTOTAL:
AtR ITA NDLING UMT(OVER 1g000CFM)
CONSTRUCTION TAX
�f —fins—tore--oli{%pplf//Cont actor Date
E%HAUST HOOD (W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT ITO 10,000 BN)
Will the applicant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1Z and the
Health and Safety Cody Rion 25532(.)4
F1Yes �s[J NO
Date ReCel f#
HEATING UNIT (OVER 100,000 BTU)
-
TOT
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE ,.
Will the applicant orluture Wilding occupant use equipment or devices
which emit hazardous air contaminants as defined by the Bay Area Air
BOILER -COMP DEE' OR 100,000 BTU)
Quality Management IaMR4
QW.O
4 av of
have read thehaai.Safa
PAID
BOILER-COMP(OVER 100,000 BTU)
the California Healthe Safety Code, S 5533under
Code, Sed Ions 25505, andChapter 2S534.I
25534. 1
NEW RESIDENTIAL MECH. SQ.Ff.
building t airs ently ve afernC
understand that if ntifyteoccupant of the requirmnts tenant, that It Is mybe
responsibility Inilitytpbf a ytheicate% Coupancyulremenb which most be met
prior to issuanc fa Certificated Ocxvpanry.
FI x77
MAY12 1992
- •'
..
(`1„yF'il
Csffier u orized age - ate
TOTAL:
ISSI)h'1$I�1r:
OFFICE COPY