24221APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pro'ea Identification
PERMIT Nq,
Building Address:
a 1,
D u r
4 2 21
_
Wn a MG:
F O
CITY OF CUPERTINC'-BUILDING DIVISION
APPLICATION I PERMIT
BUILDINGELECTRICALPLUMBING-MECHANICAL
C.ntn •N%g: T LI=. e:
K•
CATEGORY CONTROL N
BUILDING PERMIT INFO
Archite En neer.. Lk o:
1
QTY ELECTRIC PERMIT FEE
/
AdhWl"q L
LICENSEDCON A R'SDECLARATI N
Lbumbyaffirm that l am licensed under provisions of Chapter9(comment,
ingwith Sectlon7000)of Dlvislon3 ttheguslneaeand ProlesalonsCode, and my
license Is in full rce and effect. r� )
Llce�ypC)av Lic N tY Y S
It — Contra
HL� ELELI PLUMB MI
❑ ❑ ® ❑
PFRM]TISSUANCE
APPLIANCFSRESIDENTAL
JOB DPSCRETION
6 H ,
V Mh {-iJ'
PANELS
'
701-1000 AMPS
ARCHITE ECLA ION
lundentandmyplarueball usethaspu recorcl..
OVER 1000 AMPS
SQ. FT. FLOOR AREA
S/e.Q. FT.
SIGNSELECTRICAL
Licensed Professional -
`
OWNER -BOLDER DECLARATION
I herebyaf . that I sen exempt fmm the Contractor's License law for the
SPECIALCIRCOT/ML9C
TEMP METER OR POLE INSC.r
following reason.(Section 7031.5, Business and Profmbns Code: Any city or
countywhich requires a permit neconstruct, alter, improve, dernolhh,orrepair
any structure prior to its Issuance, also requires the applicant for such permit to
file a signed statement that he is limmed pursuant to the provisions of the
Contractors License law (Chapter 9 (commencing with Section 7000) of Divi-
sten 3 ofthe Busmen and Protections Code) or that he h exempt therefrom and
the oasts for the alleged exemption. Any violation of Section 70313 by any
athe applicant to a civil penalty of net es than
applicant fora permit subjedm
Belk.(S500).
five F11, as pro with wages as thele sole
❑Las owner .( /he property, or my sudors
POWER DEVICES
'
SWIMMING A70L ELECTRIC
OI7ILE.ISSWI.I.CI IESF7X.I'URES
VALUATION
NEW RESIDENTIAL ELECTR --�'�'
STORIES
TYPECONSTRUCTION
compensation, do tsaworkdicade and s oroffered
Businewill
Code:Tbootintended
..Lfar
sale (Sec. 7004, Business and Pmfmlons Cnde:7M Con/ractole License law
don net apply to an owner of property who Wilds or improves thereon, and
who doessuchwork himselforthrargh hisownemployees, provided that such
OCC,CROUP
-
RES. UNITS
improvements are net Intended oroffered forsals. If, however, thebuilding or
Improvementbsold withinoneyearofcompletion,the owner-bullderwill have
t1�G,�,uden of pmving that he did not build or improve for purpose oteak.).
LJ L as owner of the property, am exclusively =trading with licensed
eantractom to construct the pmjed(See 7004, Business and Profemom Code:
TOTAL:
- _
Q{y, ,"t PLUMBING PERM IT "3�`•,'FEE
PERMIT ISSUANCE
FLOODZANE
APN
The Contactor. License Law them net apply to an owner of property who
builds or improves tphemen, and who contracts for such Erwiects with a
egIlt do,(.) licensed ...amt the Contract.e. License Law.
L� I am exempt under S c. B k P C for this reuen
ALTER -DRAIN k VENT- WATER (EA)
BACK PLOW PROTECT. DEVICE
(-FEE SUMMARY,
:+r'+ ' {
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y N
RECEIPT N
Owner Date
❑Iherc WORKM Ih f BA ION DECLARATION
by affirm that I haw o laturs to of consent to ssl6lnwre, ora
certilicateo(W.rken'Compensalloninsurance oracertl(led copythereof (Sec:
3800, Lab CJ
p)KTUrypS. PER 1' _I _ �_ r
TA Y,_ N—
��, N
GAS EA. SYSTEM -1 O4 OUTLETSfj
f...� j
-PA Y N
CoPcim an%
Y Ea(_�
Ce e c em urN.h d.
MCertifled copy ls filed with the city inspection aivislon.
- GAS EA. SYSTEM -OVER 4(EA) ..
DINGRECEDIV]
ILOING DIVISION FEES
GREASE/WD sIRLw
NCH KFEE
GREASE TRAP
. CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATIONINSURANCE
ITw
hlsctlon need not Le completedpletedI(the permit h fororm hundred dollars
(§100).rlyth
I ll net employat in an performance in ny m workneer (, as to b co eermit i Wiled,
employ any perws In any manner w u to become object to the
Ishall Workers
e'Compenution Laws Of II(omla. Date
PAID
Date RCCCI t#
�J V`
SEWER -SANITARY -STORM EA IOOFT
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N —
PAID
WATER SYSTEM/TREATING
Applic
Applicant /+I t
NOTICEco esubje APPLICANT: er Workers' pe Certnlnte.(ons oft eLyou
Labor
shouldbecome subjecttothe ply wit' Compensation or this Perrot
Code, you must forthwith comply with such provhbns or thio pertnt shall be
deemed revoked. -—BUILDING
CONSTRUCTION LENDING AGENCY
.I hereby affirm that them is a construction lending.,," teethe perlom,
ance of the work for which this permit is Issued (Sec. 3097, Clv. Q
Lender. Name
Lender's Address
I certify that I have M7i applioti...M state that theabove Nfornutlon
Date Recti t#
NEW RESIDENTIAL PLMB. SQ}T.
�' -,00
TOTALas>'
:
- �Ck,:)
TOTAL:
•E
SEISM IC FEE
ELECTRIC FEE
"
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
FEES PAID:
is correct. I agree to comply with all city and county ordinances and Mate laws
PERMITISSUANCE
relating to building comtruRlon, and hereby authorize representativm of this
city to enter upon the above-mentioned property for inspection purposes.
(We) agree to save, Ind emnly an d keep harmless the City of Cupertino
against liabilities, judgments, cots and expenses which may In any way accrue
against said City N consequence of the granting of this permit.
ALTERORADDTOMECH.'
AIR HANDLING UNIT (TO I0,0DO CIM)
Dale REeei f#
P
SUBTOTAL:
AIR HANDLING UNIT (OVER 1 O,000 CFM)
CONSTRUCTION TAX
Signature of Applicant/Contractor Date
EYFIAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
'
HEATING UMT(TO 100,000BTI)
Will theappucsm orfutum building occupant store or handle hazardous
mater laedefinedbytMCgpertino M.MdNICode,Chapter9.17,andthe
Healthand Safety Code Ion75537(a)i
❑ Yes
Date RCCeI l#
HEATING UNIT (OVER 100,000 BTI)
TOTAL:
VENTILATION FAN (SINGLE MID)
ISSUANCE DATE
PAID 1
P M
Willthe eppliwnt o tore building occupant use equipment or devices
whichemithazsrd.us r tamI.m.mdGOnedbythe Bay Area Alr
Quality Marugemen ist ct7
4 Yes
BOILER-COMPpHPOR100,000BTI)
BOILER-COMP(OVER 100,000 BTU)
have read the hazer ousmaterlals requirements under Chapter6.95 of
the California Health k (sty Code,Sediou75505,2M3and75534.I
understand that lithe building does not currently have a tenant, that it is my
res Onsibtlity to notify the occupant of the requirements which must be mot
,OCT: 7 1992
e
NEWRE5IDENTIALMECH: SQ.FT
_
P or ss uincoofaCertlflcate f0 d ey.
L'
CITY Uf• l,u
ISSUED BY:
Owner rauthorbed t Date
�
TOTAL
v OFFICE COPY