22992APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification -
?a3i
- PEItMITNO.
22992
ne . ams: ,a /2� '!
(— /..7S-00771
CITY OF CUPERTINO•BUILDING DIVISION:
APPLICATION 1 PERMIT
BUILDINGFI.ECTRICALPLUMBINGMECHANICAL
..APPLIC -.
2'
tractor's Name:c.N�y9
(�
CATEGORY CONTROL M
Archil /Engineer. . No:
' ai
ELECTRIC PERMIT' FEE
.'.,BUILDINCPERMI'PINFO_
Address:
:❑ ❑ ❑ ,
PERMIT ISSUANCE
LICENSED CONTRACF SDECLARATION
Thereby a(lirm that lam Bcensedu erprevidonsofChapter9(commen
Ingwlth SeMon7f100)o(gvlslon3 oft Bunessand Pro(ealonsCode, and my��
license is in full form and effect.
AITUANCFSRESIDEMTAL
JOB DESC ON
PANELS
License Class Lk#
l
Date Contactor
UP TO 20D AM
201.1 O00 AMPS
ARCHITECTS DECLARATION
I understand my plans shall he used a public records.
OVER 1000 AMPS
SQ. FT. FLOOR AREA
S/SQ. FT.
SIGNS ELECTRICAL _
Licensed Professional
OWNER -BUILDER DECLARATION
License Law forthe
[wing raffiron son.rsatlam31.5, Bexampt fromthed Professions
following kaon. inaction rnatt , Bunions and Professions Code: Any rep it
countywhich rcquircaa perMttoconslroct, alter, Improve, demaibh,orrepalr
r1
/1 P U T E� w
V f C .ass({
SPECIAL CIRCUIT/MISC
TEMP METER OR POLE INST. C70f1
anystnmsre ptortola Lswance,alw requlratheapp0ont for such perNt to
Ole a signed statement that he Is licensed pursuant to the provisions of the
Contractor's Licence, law (Chapter 9(mmmencing with Section 7000)of Divi-
sion3ofthe Buslnemand Pmts.bmCWd )orihathelsex mpttherefmmand
the bash for the alleged exemption. Any violation o(Se tion 7(2115 by any
applicant for a permit subjects, the applicant to a civil penalty of not rmoretben
five hundred doliesm ($500).
, ❑ 1, as owner of the properly, or my employees with wages as their sok
POWER DEVICES
1
/ �!
\7
SWV4MJNG POOL ELECTRIC 1.
OUTLEISSWITCHESFIXRIRES - -
VALUATIO
NEW RESIDENTIAL ELECTR SQj1r'
STORIES
TYPE CONSTRUCTION
compeneaHorywBldothe work and thestructure is not Intended or offered for
,
sale (Sec. 7044, Buslness end Professions Code: The Contractors License Law
does not apply to an owner of property who Wilde or improvro thereon, and
whodansuchwarkhinuelforthwgh blsownempteyeea, provided thatsuch
OCC. GROUT'
REA UNTfS
impro'"nents are not Intended creamed for sale. IL however thebulldleg or
bnprovernent esoldwlthin oneyearofcompletion,theowner-WBderwlll have
TOTAL:
thi,tIurden of proving that he did not bund or improve for purpose of sale.).
LI L as owner of the property, am exclusively contracting with licensed
contractors to ronstrut the project (Sec. 7044, Business and Professions Code:
The Contactors Limnse law dons onet apply to an owner of property who
builds or Improves thereon, and who contracts for such pkajects with a
ooyTador(s) licensed pursuant to the Contractor's License Law.
LJ I am exempt under Sec B k P C for this reason
QTY, PLUMBING PERMIT FEE
PERMIT ISSUANCE /"�
ALTER -DRAIN & VENT -WATER (FA)
FI-OODZONE
APN
BACY FLOW PROTECT. DEVICE -
-
FEESUMMARY
-
Owner Me
DRAINS FLOOR ROOF, AREA, COND.
FIXTURES. PER TRAP IO, Ie
SANITARY Y N
RECEIPT.#
WORKMAN COMPENSATION DECLARATION
Qi hereby affirm that I have o I rt. a. of consent m �py tnwa, ora
13800(lateo(Worken'Competwtlanlnsuanaora certified mpythemaf (Sec.
3800, Lb CJ
#
SCHOOLTAX Y_ N_
RECEIPT #
GAS EA.SYSTEM-I INCA OLTMETS
PARK FEE Y N
RECEIPT #
CAS EA. SYSTF.VIAVER 4 (EA)
CoPolm
-
BUILDING DIVISION FEES
Certified ropy b herebyfamished.the cid.
�CY
ertNed copy le (14d with the city Inspection division,
GREASE/INDUSTRLWASTEINTERCEPTOR
PLANCHECK FEE
iGREASETRAP
CERTIFICATE OF D(EMPTION FROM WORKERS'
COMPENSATION INSURANCE
URA
Qhbsedionneed not be completed N/ he URAbforonshundred dollen
M OD)calese.)WATER
I38dlfy that In the performance.( the work fmwMch this permit is issued,
I shall not employ any person In any manner so as to become subject to the
Workers' Compensation Lowe of California Date
Applicant
NOTICE TO APPLICANT: It, after making this Certificate of Exemption, you
should become subject to the WorkersCompensation provisions of the Labor
Cade, you at forthwith comply with such provide. or this pemdt shall be
m
deeed revoked.
PAID
DatC Remi [#
SEWER -SANITARY -STORM EA. 200FT,
HEATER W/VENT/ELFCTR -
ENERGY FEE Y N —
PAID
Date RL'CCI� t#
WATER SYSTEM/TREATING --
NEWRESIDENTIAL PLMB. SQ.FT.
TOTAL:
NG FEE
CONSTRUCTION LENDING AGENCY
I herebya(Brm that there h a construction lending agency for the perform-
ance of the work for which this permit b Issued (Sec. 3097, Civ. C.)
IOTA: �'�
E
Lancers Name
Lenders Address
EE
'
,�.►�
14,17. "MECHANICAL PERMIT.' '•'.: FEE` `'AL
I certify that I have read this epplatbn and stale shat the above Inforrratiw
FEE
EFEESPAID.
Is corned.[ agree to comply with all city and county ordinances and nate laws
PERMIT ISSUANCE
relatln t0 natrodion, and hereby authorze representatives of thiscity rupon theabove-mentioned property for Wpetion purposes.
tosave, Ide t4, and p harmless the City of Cupertino
41bies,p ,co son nseewhlch mayIn anywayaccne
ltyl ue of gr ting ofthls permit.AIR
ALTER OR ADD IO MECH,
AIR HANDLING UMT(TO 10,000 CFM)SUBTOTAL•
Recei t#
HANDLING UNIT(OVER t0,00oCFM)
ION TAX
ppl ret/Contractor Date
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,OW BM
-
Wllltheappliant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Heallh and Safety Code Seciion 25332(.)?
❑ Yes MN.
Date RCCeI t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE 11ESID)
ISSUANCE DATE
PAID ' ry
i M V
Will the applicant or forms building occupant use equipment or devices
which emit luzardoes all contaminants as defined by the Bay Area Air
a llty Management District?
BOILER-COMPOHPOR 100,000 BTU)
Yes No
BOILER -COMP (OVER 100,000 BTU)
d
ve read the haze ous ma tedabrequirementsunder Chapter 6.95 of
the California Health A SafetyCod, Sections 25505,2513 and 25534. 1
understand that if the building does oat currently have a tenant. that It is my
responsibility to ntify the occupant of the requirements which at be met
prior to Issuance of a Certificate of Occupancy.
i] '
DEC 30 199'
'
Cl I Y1\�U�}fGUI'tr I IIVL&a)
NEW RESIDENTIAL MECH.. SQ.FI'.
ISSUED BY:'
Owner or authorized agent Data
TOTAL:
OFFICE COPY