23065APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Address:
PERMITNO.
23065
nems - one;
L (�
CITY OF CUPERTINO-BUILDING DIVISION '^
APPLICATION I PERMIT
BUILDINGELBCTRICALPLUMBING-MECHANICAL
A
I ^ , -
I , _' +4N
Contnctor'aNa � Lic.No:
CATEGORY
CONTROL ,.
Architect/Engineer. Lle No:
QTY ELECTRIC PERMIT ,, ; ';
BUILDING PERMIT INFO
Address:
,FEE
PERMIT ISSUANCE
❑ 1:1❑
LICENSED CONTRACTORS DECLARATION
�hamlsy that lam Bcemed under provhlonaof Chapter9 (rommenc-
It...1 Section force of Dl effect o(the Buelneseend Pro(eaelomCede, and my
license lain fact force and effect. [A ,.--.�Cy
License Claas Lic.I IO �I —)
APPIJANCESRESIDENIIAL
]OB DESCRIPTION
�, • ` �`
PANES
Date Cormactor
UP TO 2DO AMPS
201-1000 AMPS
ARCHITECPS DECLARATION
Iunderstand my plans shag be used as public records.
OVER 1 ODD AMPS
SQ. Fr. FLOOAARFA$/9Q. Fr.
SIGNS ELECTRICAL
Licensed Professional
I''Ihereby
SPECIAL CIRCUIT/MLSC
OWNER -BUILDER DECLARATION
affirmthat l am exempt from the Contractors License lafeehe
i
TEMP.METFRORI'OLE INSF.iJanystmhmpriuitei.p
POWER DEVICES T
county hichre uire a parroH$Buslnew arWPm(mbv Code:An d or
at ,also uct,alter,lmpbmnif such,er ttr
anyatmtlum palerenthwnnegaborced pursuant to the provisions of to
file a signed statement that he h licensed pursuant to the provhlons of the
C.mbsci ar'e License Law (Chapter 9(coming ndng with Section 7000) of Divi-
sion3 ofthe Business and Profero)oru Code) orthat he is exempttherefcamand
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant fora permit subjects the applicant to a civil penalty of not moren
✓� ��
]
,'2
SWIMMING ]TOOL ELECTRIC t
OUTLETSSWITCFIFSFIXTURFS
VALUATION
NEW RESIDENTIAL ELECTR SQ.FT.
five hundred dollars (SSM.
E] 1, as owner of the property, or my employees with wages as their sole
STORIES
TYPECONSTRUCTION
compensation, wdI do the work, and the rtrumom isnot Intended or offered for
sala (Seo 70K Busmen sad P,.f.lon Code: The Contractors Lt.. Law
-
doesnotapplytoanownerofpropertywhobuild. or improves thereon and
whodaessuchworkhlmself orthrough hlsownempleyen, provided thatwch
OCC. CRO(1P
RIS. UNITS
Improvements are not Intended oro(fered for sale. If, hcwevep thebuilding or
Improvement bsold Mthlnontyearo(compleio tMe erb Uderwill have
TOTAL:
tryLIxuben of proving that he did notbulldorimprovefopurposea0ale.).
11 L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (See 7094, Business and Professions Code:
Qjy,, .' PLUMBING PERMIT FEE'
PERMIT ISSUANCE
Fl. ODD ZONE
APN
The Contractors License law don net apply to an owner of property who
Wilds or Improves contracts thereon, and who contfor such pTjects with a
cgq00.�t((.&or(.) licensed pursuant to the Contractor's License Law.
'IJ I am exempt under Sec B & P C for this reas
reason
ALTER -DRAIN & VFM-WATER (FA)
'FEE SUMMARY
BACK
BACK FLOW PROTECTDEVICE-
.
rH
FLOOK ROOF, AREA, CONE. -
FIXTURES PER TRAP
SANITARY Y N
RECEIPT N
Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificate of consent to self
SCHOOL TAX Y_ N_
-Insure, or a
certificate of Workers'CompewaHon Iruurance ma ceM(kd copythereo!(Sec.
3800,Iab C.) -
RECEIPT N
GAS F.A. SYSTEM-] INCA OUTLETS
PARK FEE V N_
Policy It
RECEIPT N
GAS EA. SYSTEM -OVER d (FA)
C° nY
BUILDING DIVISION FEES
rtified copy is herebyth the cid.
Certified ropy h filed with the city inspection division.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thlssectlonmed notbecompleted lithe permit lsforom hundreddollars
($100)oify th
I cent that h the performance FermatInany m worneer so as to b camhis permit Is
1 shall not employ any Fermat In any manner so n to become nrbjetl to the
Worken'Campensation Laws of GBfarnh. Date
PAID'
DateRemi t#
SEIVER-SANITARY-STORM EA. MFT.
WATER HEATER W/VENT/ELDCTR
ENERGY FEE' Y N_
PAID
-
WATER SYSTEM/TRFATING
Applicant
APPLICANT. r0 PLICANr: I, eller making This Certificate of Exemptbn, you
should become subject to the Workers' Compenatlon pmvhiom of the Labor
Code, you must forthwith comply with such provhlom orthh permit shall be
deemed revoked,
Date Rem I t#
NEW RESIDENTIAL PLMB._SQ.Fr.
TOTAL:
ECE
�..
-BUILDING
SEISMIC FEE
L
CONSTRUCTION LENDING AGENCY
I hereby a(firmthat there Is a construction lending agency for the perform-
of the work for which this permit h blued (Sec. 3097, Civ. C.)
Tornl:
ELECTRIC FEE
Izndd. Name
L. rdera Addms.
I mrtlfythatl have read thhappBotlonand ratethatthe above Information
Qri•. '' MECHANICAL PERMIT' r
PLUMBING FEE
-
.'FEE
MECHANICAL FEE
FEES PAID:
hconvaL] agree to comply withaB dtyand county ordinances and state laws
PERMIT ISSUANCE
relating to building constmctlan, and hereby authorize representatives of this
city to enter upon the above�menficned property for Inspection purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cu Fortino
agalrut llablBtie., judgmenb, costsand expenses which may In any way...
aga lost Bald City in ronsqu rare oft .,ting of this permit.
�C I
ALTER OR ADDTOMECH.
AIR HANDLING UNIT (TO 10,000 CFM)
Date Receipt#
SUBTOTAL:
AIR HANDLING UNIT (OVER ]0,000CFM)
CONSTRUCTION TAX
Signamroo Applicamx.roactur Data
F7(HAUSTHOOD (W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Will the applicant car future building occupant store or ha ad le hazardous
material as dented by the Cupertino Municipal Code, Chapter 9.12, and the
Health and Safety Cadera�Sectica M32(4)7
F-1 Yr. u No
Date RCCCI t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
FAN (SINGLE RESID)
ISSUANCE DATE
Will the applicant orfutum building occupant use equipment or devices4BOILER-COMP
which emit Iuzardous air contamirunts as defined by the Bay Area Air
ONTILATION
HPOR 100,000 BTU)
Quality Management District?
4 Yes d ❑ No
have read the haw o.. materials requirements under Chapter 6.95 ofILER-COMP(OVER
PAID
100,000 BTU)
the Califomh Health & Safety Code, Sectiom 25505, 25S33 and 25534. 1
NEW RESIDENTIAL MECH. SQFT
understand that if the building does not currently have a tenant, that It is my
priornsh.uance o(ay theoc u ant of pa the
rriorto b os to of a Certificate ofOcfihe requirements which must be met
DEC 4.1991
-
r�
Owner or authorized agent Date
TOTAL:'
ISSUEDB
OFFICE COPY