23178APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pru'ed Identification
%Jding Address: - -"
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- PERMIT NO.
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CITY OF CUPERTINO-BUILDINGDIVISION
APPLICATION / PERMIT
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` `�i��BUILDING-ELECTRICMGPLUMBINGMDClAMCAL
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CATEGORY CONTROLIgimer'.,
: ;t BUILDING PERMIT INFO,',
BUILDING t. .
^ Lie. No:
" it 1"
QTY ELECTRIC PERMITi '. t,i FEE,
Address: �O /K
T�/i } �j{_ ❑
L_L] Imo• L
PERMITISSUANCE
CENR EDCONTR under rDECLARATION
Thereby affirm that lam licensed under provisions of Chapter9 (commene
ingwith Sectlon7000)of Dlvislon3o(ihe Busimtand Pro(eselomCode, and my
Learlicemse le In full force and effect.
License Class LIc1
Date Contractor
ARCHITECPS DECLARATION
I understand my plain Mull be used as public records.
Licensedd Profetioml
OWNER -BUILDER DECLARATION
I herebyafflrm that l am exempt from the Contractors License Law for the
following reton.(Section 7MIS, Bualnet and Promotions Code: Any city or
countywhich renot pereattomestruct, alter, improve, derradish,cumpalr
anystroc m, prior to its issuance, also requirmthe applicant for such permit to
file a signed stateem that M is licensed pursuant to the provisions of the
Contractors License Law (Chapter 9(comrrentlng with Section 7000)of Divi-
Mon 3 ofthe Business and Profession Code).,that he is exempt therefrom arad
the basis for the alleged exemption. Any violation of Section 7Wl.S by any
applicant for a permit subjects the applicant to a Avll penalty of tat more than
five 1, a. ..a, deltaof the property,
I,as ownerll theproperty,.rhe employees with wages r their sole
compensation, B.Mic, the work,and ihes Code:rotto e is The
et Contractors icame d for
Law
.In (Sec. apply rope ty Code: The Contractors L1ceme Law
to show and f propertyorlmprowes ovidedrcogand
apply for himser.fproagh his own
who ddoes oes oemployers, er,the uilding or that such
whodcessuch work himtidedm.ugh hisown.If,however,
improvement In sold
intended In
Improvemenlusold within oneyearo(complellon, lheowner-builderwill have
earofredfar pletio, If, owns-buBdorwill have
tlrL¢tme. of proving that he did out wild or improve for purpose of is.).
LJ L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec 7074, Business and Professlom Code:
The Contractor's License Law does not apply to an owner of property who
Wilda .r improves thereon, and who contracts, for such pp)ect, with a
co,fLtt[[ad.r(a) licensed pursuant to the Contractor's Llcent Law.
LJ 1 am exempt under Sec. - B k P C for this reason
r
-
APPEANCFSRESIDENTIAL �
JOB DPSCIRIPHON
O
-
'tom✓ �/'•L ,4i,gL
PANELS
201-1000 AMPS
OVER 1000 AMPS
SQ. Fr. FLOOR AREA
A ® . pw�ipi �I
^ 11 11
YVYTE
/ l/ 4
/�/ 9 e
S/90. Fr,
'
SIGNS ELECTRICAL ass
SPECIAL CIRCUIT/MISC
TEMP, ME TER OR POLE INST. aaO'•a+
POWER DEVICESm
SWIMMING POOL ELECTRIC
OUTLE'ISSWIICI ICSH%TURFS
VALUATION
O
NEW RESIDENTIAL ELECTR SQ.FT.
STORIES
,
TYPE CONSTRUCT ION
77 vJ
TOT L:If
..
QTY. "' PLUMBING PERMIT:
OCC.GROUP -
RES. UNITS
.•FE'E,
ac
PERMITISSUANCE
ALTER -DRAIN & VENT - WATER (EA)
FLOOD WNE
APN
' 1 "set t,� "TEE SUMMARY"r"'
t �' "
t"''i ., '
BACK FLOW PROTECT. DEVICE
E
DRAINS FLOOR NTISANITARYROOF, AREA, CO
PER TRAP ��
SANITARY Y N
RECEIPT 1
Owner Date
WORKMAN COMPENSATION DECLARATION
C31hemby affirm that 1 have a certBlc to of consent to self -Insure, or
mnifimteofWorkers'Comper honlmumamoramnifb mpythereof(See.
3800, lab C.)
Policy p
SCHOOLTAX RECEIPTNM "
GAS EA. SYSTEM -1 INCA OUTLETS
PARK FEE Y N
RECEIPT 1
GAS EA. SYSTEM -OVER 4 (EA)
y
BUILDING D I VIS ION FEES
2Com
Certlfled copy is hereby furnished.
Canertified copy is filed wllh the city Inspection diviafan:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATIONINSURANCESEWER-SANITARY-STORM
e <
(fhlaelon need not pert
be completed lithe permit b morons hundred dollars
($100)or lead
I certifythat in the performance of the work for which this permit is issued,
I shall not employ any person 1n any ,runner so as to become subject to the
Workers' Compensation Laws of Caiffo..is. Date
Applicant
NOTICE TO APPLICANT: If, after making 1hls Certlfirate .(Exemption, you
should become subject to the Workers' Compensation pme"t of the Labor
Code,you mustforthwith comply withsuch provisions orthis permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction land Ing agency for the perform
arca of the work for which this permit is Word &c. 3097, Civ. C.)
Under's NamePLUMBING
Lender's Address -
I cnutifythat l have read thisappleatlon.M state that theaW lnformtlon
iscormot.I agree to comply with all city and county or,=. -n -nand statelaws
relating to building curstroctfon, and hereby authorize representatives .f thla
citytoenterupontheabove-mentioned property for trupectfoe purpots.
Ne) agree sunt Inderrmi( n d keep barMen the City of Cupertino
against Bablltin' dgrrcnts, sand espenta which rmyln anyway acauc
against s dC' inns ryu eo the granting .(this permit.
, 1
GREASEA NDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date- Remi t#
GREASE1RAP
EA 200FT
WATER HEATER W/VENT/ELrcrR
ENERGYFEE Y N
PAID
Date Remi t#
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. SQ.Irf.
TOTAL:
BUILDING FEE
r�
SEISMIC FEE
TO
ELECTRIC FEE
QTY. "MECHANICAL PERMIT ' FEE
FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
-
ALTEROR'ADDTOMECH.
Date Receipt#
-
AIR HANDLING UNIT (T010,000 CFM) -
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,000CFM)
CONSTRUCTION TAX
Signature of Appll t ontmcmr Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.IZ and the
iinllh and Safety Code Section 25532(a)7
❑ Yea MN.
Will the applicant or future building occupant.. equipment or devices
which emit bazardous air contaminants as defined by the Bay Area Air
Quality Management District]
4 Yo No
have read the baza ous mlsateriarequirements under Chapter 6.95 of
the Calif.mf. Health & Safely Code, B Mi.m 25505, 25533 and 25534. I
understand that if the building does not currently 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 ofOttupancy.
EXHAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 1Wp00 BTU)
Date RCCCI t#
-
HEATING UNIT (OVER 100,000 BTU)
- TOTA
`mss
4J
VENTILATION FAN 6INGLE REBID)
ISSUANCE DATE
p' D ,
M
1RP1 ,, 3 1992
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ISSUED BY:V1/La ilii
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BOILER -COMP OM' OR 100,000 BTU)
HOMER -COMP (OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ.Fr.
•,VT�aVVp
Owner or authorized agent - Data
Az:
OFFICE COPY