23412APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification - -
Bnlldin Address: - f..s-�. �3z- .q 2 .. .-
PERMITNO.'
.. 23412.
e a�mne:�
N Irr(
one
U, AN -
CITY OFCUPERTINO-BUILDING DIVISION
APPLICATION if PERMIT
A
'� _�) Z
!O e
contractor'. Name: ,ue Nn:
CATEGORY
CONTROL X
BUILDINC-FT.FtndcALPLUMBING-MECHANICA6
rrhltect/Engineer. LIc. No:
Q7Y, ,ELECTRIC PERMIT �� ,',FEE
BUILDING PERMIT INFO
•
Acidness
PERM TI55UANCE �.OD
❑ ❑ ❑
LIC ENSEDCONTR
under rDECLARATION
Ihth SbW.(irm70 'hat 9)of Di lkensed 3ofthe usinemandPmfeovisions of aonr9de,and c-
Inensei Section forceanddiean3o(the Bustnessand Pro(easloneCode, and my
Licers b in full force and effect.
License Class Lk.N
DateContractorr—`
APPLIANCESRESIDENRTAL
JOB DFSCRE'RON r�
) P—
�-4
s
PANELS
ARCHITECTS DECLARATION
I understand my plans shall be used as public records.
Ot-1000 AMPS at
OVERIMAMn
SQ. FT. EAI
S/SQ, FT.
SIGNS ELECTRICAL
Licensed Professional
OWNEReBUILDER DECLARATION
Iherebyal0rm tOWNEexempt TER the LARNFOorsLicense Law for the
\ �js„ ''Vy'.
(} 1 R
SPECIAL CIRCUIT/MISC /
TD`RP'MEIFR ORIOLE INST.
following reason. 5ect1on 70315, Business and Professions Code: Any city or•'�.✓
countywhichrequimsaperMttowmtmMalter,impmve,demolbh,ormpair
Vd Y �
anystme mpriortolrsbmance,al mquimtheappikantforsuchpermitto
file a signed statement that he Is licensed pursuant to the provisions of the
POWER DEVICES 'DAT
G•
SWARMING POOL ELECTRIC
Contractor's License Law (Chapter9(commencing with Section 7000) of Divi.
sloa3 of the Business and Professions Code) orthat he Is exempt therefromand
VALUATION
the bash for the alleged exemption. Any violation of Sectlon 7031.5 by any
ppllcent(orapermltsubledotheappOcanttoadAlpemltyo(ndm mthan
OUTLETSSWITCHFSFIXfURES
NEWRESIDFNIIALELECIR SQ.FT.
live undyed dollars %500).
NLII, as owner of the property, or my employees with wages as their sole
STORIES
TYPE CONSTRUCTION
c nsaHon,wllldolhework andthestructure onot intended or offered for
sale (Sec 7044, Smite .. ad Po fessime Code: The C.N.dofs Llceme Raw
TOTAL: Z.
.,
does not apply to an owner of property who Wilds or improves theme, and
doeaeuch workhimself orthrwgh hlsownemployees, provided lhatsuch
Improvements are not Intended oroffered for sale. If, however, the building or
improvement usoldwithinoneyearofcomplatlorythe Owner-bullderwlll have
.00C, CROUP
RFS. UNITSwho
t4cjZurden o(proving that he did not build or 4nprove for purpose of sale.).
LJ I, as owner of the property, am exclusively contracting with Iianxd
contmetere to construct the project (Sec. 9014, Business and professions Code:
QTY: PERMIT' FEE
.,',irj,[JMBING
PERMIT ISSUANCE -
FLOOD ZANE
,
APN '
The Contractor• Llcenss Law don not apply to an owner of property who
build• or improves thaeory and who contracts For such pRojecta with a
cialf-darts ran xi pursuant to th Contractors Lioness,Law.
LII a erupt ee. B A P C for this reason
ALM -DRAIN kVENT- WATER (EA)
- -
BAIX FLOW PROTECT. DEVICE
FEE SUMMARY '
DRAINS. FLOOR( ROOF, AREA, COND.
SANITARY RECEIPT N
Own 1' Date
YO COI PENSATI N E�ION nau
❑I hereby Irm That I hi e a mrtiflcate of consent to self re, or
certl0oteof ken'Cmniumation Insurance or a certified copy therom(Sec.
3B W, lab C.)
FE(TlJRES PER TRAP
SCHOOLTAX Y N
RGC19I'f N
GAS LA. SYSTEM -1 WC.40U1LET5
PARK FEE Y N _
Policy X
RECEEPT #
GASEA. SYSTEM-0VER d (EA)
Com any
BUILDING DIVISION FEES
❑pCcrtifled copy 6 herebytd.
❑Ccrtifled copy V filed withh the the city Impassion division.
CREASE/WDUSIRL WASTE INTERCE'TOR
PLANCHECK FEE
GREASE7RAP
CERTIFICATE OF IXEMI`T[ON FROM WORKERS'
COMPENSATION INSURANCE
(Chis section need not M completed lithe permit V (Drone hundred dollars
($100)orless)
Iceor less)that In the performanceperformanceof the work for which this permit is Issued,
I shall not employ any person In any manner so as to become subject to the
Workers'Corepereation lawsof California. Data
PAID
Date Recei t#
SEWER.SANITARY-STORM EA. 200F[.
WATER HEATER W/VENT/ELECTB
ENERGY FEE Y N
PAID
WA77R SYSTEM/TREATING
-
ApplicaNOTICE
NOTICE TO APPLICANT: a after making this Ction pro of Exemption,aLabor
Code,shoulyou Women subject mthe Workers' Compensationprovisions
Code, you mlte[ (orthwlth amply with such prov(siona or this permit shall be
orthiorormit of s Lab he
deemed revoked.
Date Recei t#
NEW RESIDENTIAL PLMB._SQFT.
TOTAL:
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby afflrmthat there is a construction lending agency forth perform-
ante of the work for which this permit V Issued (See. 3097, CIv. C.)
TOTAL:
ELECTRIC FEE
,$-O
Leader's Name'
bander'. Addresa -
I mrtilythatl have read thisappBotionand statethal Iheabove Information
bcoreact.I agraeto complywith all cityand county ordinances and Main laws
, t,"' ..
QTY. ' MECHANICAL PERMITe:%tt; .;; . FEE ',
PERMITLSSUANCE
PLUMBING FEE
MECHANICAL FEE
FEES PAID:
mlatinglobuildingmmtmdi.,andherebyauthotl reprnUtivno(tMa
city to enter upon the abovementioaed property for Impaction purposes.
(W gree t nae, LWemnl an d keep harmless the City of Cupertino
ALAR OR ADD TO MECH.
Date Recei t#
P
aga t set nts, sand expense whkhentylnanywayacme
a •a C' Barye of she granting a(thl It.
IV//`Aq
AIR HANDLING UNIT (TO 10,M0 CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
Igram (App icant/C ractor DA.
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSU E
HEATING UNIT(TO 100,000BTII)
Willtheapplimnt or future building occupant store or handle hazardous
material ac defined by the Cupertino Municipal Cade, Chapter 9.17, and the
Health and Safety Code Stolon 25537(a)4
❑ Yes MN.
Date RCCeI t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
SI
VENHLATION FAN (SINGLE RESID)
ISSUANCE DATE
Will the applicant or future building occupant use equ 1prnent or devices
which emit havzniom air contaminants as dellned by the Bay Area Air
BOILER -COMP OHP OR 100,000 BTU
ooa llty Management District?
_
YYas No
have read the bazar ou•materials requirements under Chapter 6.95 of
p A-0
BOILER-COMP(OVER 100,000 BTU)
theCalifornia Health A Safety Code, Sections 75505,25533 and 25534. I '
'
NEW RESIDENTIAL MECH. SQ.FT.
understand that if the building does not conently have a tenant, that it is my
responsibility to notify the occupant of the requirements which must be met
prior to Issuance of a Certificate of Occupancy.
MAR 1 1992
((�� 'yu` (� ft lItr1�
ISSUEOBV
Owner or authorlred agent Dale
TOTAL:
OFFICE COPY