23873APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification
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APPLIUA RON SUHM11 IAL
ZULS�4 GBE�O
CITY OF CUPERTINO-BUILDINGDIVISION
APPLICATION / PERMIT
BIRLDINGELBCTMCAIPLUMBING-MECHAMCAL
Contractor's Name: KC%7s0 �%P< cjJ Lk. No:
S CCCQ L.(S/ C `/O %�sy
CATEGORY
CONTROL#
rcMtea/Engineer. Llc. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
.
Address -
LII f
�I JO`s
PERMIT ISSUANCE
LICENSED CONTRSDECnsof
Ihereby under ChON
ectiamaffirm that lamgcen3o(tis.erprovislonsof Chapkrode,an my
Busineuand ProfesdonsCode, and my
Incense is ecikn force and
Ilmnse Is in full form and effect.
APPLIANCFSRESIDENITAL
LOB DESCRI'IION
f� J
PANEI9
License Claw Lk.N
-
Date Contrector
nil -1000 AMPS
ARCHITECTS DECLARATION
I understand my plans shall be used as public records.
Licensed Professional -
OVER IOW AMPS
SQ. Fr. FLOOR AREAS/SQ.
LED IN
FT.
SIGNSELECTRICAL
SPECIAL CIRCUIT/MLSC i
-
OWNER -BUILDER DECLARATION
mptfrothe
/Ij R
jll
TEMP METER OR POLE INST.
owing raBtrmthaton 7031 Code:A ylm
-countywreasogira. es (Section t, Business and Proprove, Cade: Myrepaicity r
ossa d Professions
county which requires a permit N comBlmQ alter, Improve, demolish, or repel r
� ���
anystmcture prim to its Issuance, also requires the applicant for such permit to
file a signed statement that he is licensed pursuant to the provbloru of the
POWER DEVICES DATE
SWIMMING POOL ELECTRIC
OUTLETSSWITCHFSFIXfURES
Contractor's License Low (Chapter 9(commencing with Section 7000) of Divi-
slon3ofthe Businessand Profe.br Code)orthathelsexempttherefromend
the basis for the alleged exemption. Any violation of Section 7001.5 by any
applicantEarn permit subjects the applicant to a civil penaltyofnct morethan
,VALUATION
LAIC ---a ,r I O.ta'
,/,,
NEWRESIDENTIALELECTR
fiundred dollars (S500).
6SQ.FC.
I, as owner of the property, or my employees with wages as their sole
STORIES
TYPE CONSTRUCTION
compensation,will dothe work andthe structure Is not intended or offered for
vie (Sec. 7044, Business and Professions Code: The Contractors License Law
'
does not apply to an owner of property who builds or Improves thereon, and
who does such work hlmselforthrough his own employees, provided that such
OCC.GAOIR'
RES, UNITS
Improvements are not Intended oroffered for sale. If, however, thebulldingor
T
Impmwe ntissoldwlthinoneyearofcompletioMtheowner-bu0derwillhave
tilil,tlurden of proving that he dim notbulldorlmproveforpurpoecofule.).
LJ L as owner of the property, am exclusively contracting with licensed
contractors m
to rutruct the pmject (Sec. 7044, Businessand Professions Code:
QTY, PLUMBING PERMIT FEE
FLOODZDNE
APN
PERMIT ISSUANCE �.
The Contractor'. License Law does not apply to an owner of property who
builds or Improves theron, and who contracts far such pRo)ects with a
m,,66t{{actor(s)Ikensed pursuant to the Contractors License Law.
tJ I am exempt under See. B k P C for this reason
ALTER-DRAIN&VENT - WATER (FA)
FEE SUMMARY' "
RACK FLOW PROTECT DEVICE
OUTSIDE FEES
DRAINS R FLOOROOF, AREA, COND.
SANITARY Y_ N_
RECEI
Owner Date
WORKMAN COMPENSATION DECLARATION
[:]I hereby affirm that I have a mrtlfimte of consent to calf -Insure, ora
mnifimteofWorke Compemationlnsu.nmmamrtifledmpythereof(Sec.
3800, Gb C.) V / MS• r�
Poliq# s• J G
PER TRAP
FLCII)RES. s�
SCHOOL TAX Y
Epp� N N '
E N
GAS F.A. SYSTEM -1 INCA OUTLETS
PARK FEE V N_
RECEIFT #
GAS EA. SYSTEM-0VER4 MAE
Com any £ C l
BUILDING DIVISION FEES
mtlfied mpylshereby furnished,
Certified copy is filed with the city impaction division.
GREABE/INDUSIRL WASTE INTERCEPTOR
PLANCHECKFEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
' COMPENSATION INSURANCE
(This seRlon need not be completed lithe permit Is forests hundred doll..
Date Recei t#
SEWER -SANITARY -STORM EA. 200PT.
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N
(St W)or less.)
I mnifythat in the performance of thework forwhich this permit is issued,
WATER SYSTEM/TREATING
I shall not employ any person in any runner so as to become subject to the
Workers' Compensation Laws of California. Date
PAID
Applicant
NOTIC
NOTICE 70 APPLICANT: IL after making this Certificate o(Exemptlon, you
Daft Recei [#
NEW RESIDENTIAL PLMB. SQFI'.
,
TOTAL:
should become subject to the Workers Compensation provisions of the Labor
Cade, you =at forthwith comply with such provisions orthis permit shall be
deemed revoked.
BUILDING ms's
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I hereby affirm that there is a construction lending agency for the perform-
ance of the work for which this permit ls issued (Sec. 3097, Clv. C.)
Lender. Name
Lenders Address
Imrtlfythatl have..dthls apphmtbn and O.tethattheabove Infomution
Is correct. I agree to comply with all city and county ordinances and state laws
T �.�
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEEMECHANICAL
FEE -
PERMIT ISSUANCE
FEES PAID:
relating tobullding construction, and hereby authorize representatives of this
city to enter upon the above-mentioned property for Inspection purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cu pertlno
against bilines,judgments, coeroandexp... which may In any way acerae
Dale Receipt#
ALTERORADDTOMRCH.
NR HANDLING UNIT DO 10,000 CFM)
SUBTOTAL'
agalu d City In comequenm of the granting of this permit
'L err
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
sig to of Applicant/Contractor - Date
EXHAUST HOOD(W/DUCD
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant atom or handle hazardous-
material as defined by the Cupertino Municipal Code, Chapter 9.1 2, and the
Health and Safety Code Section 2553200)7
nn Yes No
�Vllitheepplimntm lure building occupant equipment ordeviccs
-
Date Recei [#
HEATING UNIT CFO 100,000 BTU)
_
HEATING UNIT (OVER 100,000 BTU)
TO
VENTILATION FAN (SINGLE REED) � .�
I UANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
lily Management District?
Yes ❑ No
shave
r D
BOELMCOMP OM'OR 100,000 BTU)
BOILER-COMP(OVER 100,000 BTU)
read the hazaMous materials requirements under Chapter 6.95 of
the California Health A Safety Code, Sections 25505, 25533 and 25534. I
'JUN
VI 1992
NEW RESIDENTIAL MECH. SQ.FI
undaaand that if the building does not currently have a tenant, that it is my
.responsibility to actify the occupant of the requirements which must be met
prior to issuance of a Certificate of Occupancy.
f+
V
C lti ail' VNttli
ISSUEDB ",
-
Owner or authorised agent Data
OFFICE COPY