23832APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT ,PEN 'ONLY
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B.lIdi.S Pmjad Identification uliding Add
ifress ^
PERMIT NO.
ams: /, - one:
l/./-
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BIALDINC- d ECTRICAI M' BING-MECHAMCAL
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S �L
Contr ore Name: Lk. Na
CATEGORY
CONTROL X
Architect/Englneer� Lie No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
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Addrnsc
PERMITISSUANCE �.�
❑ ❑
. LICENSED CONTRACTOR'SDECLARATION
Ihamby.(firmthatI am licensed under provisions o(Chapter 9 (examemenc.
Ingwilh Semon 7000)of Divlelon 3 wfthe Buslnns and ProfeslwnsCade, and my
time. is in full toren and dfed.
License Clas Lk.X -
Date CHITEC'r
ARCHLTECTSDECIARATION
lundentand my plana shag be used as public rcealrlX
Licensed Profits. cal
OWNER -BUILDER DECLARATION
I herebyaffirmthat I am exempt from the Contractors License Law Loathe
following reason. (Section 70315, Business and ProfmWns Code: Any city or
county which requima perMtmereca ud, alter, improve, demolish,orrepalr
anystmcture priorwits ice..ace,alsorequlrntheappBcantfa such perrNtto
file a signed statement that he b licensed pursuant to the provisions of the
Contractor's License law(Chapter 9(commencing with Section 7000) of DIW-
BusinseandPMe lens COde)orthathetenmpttherefromand
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant for a permit subjeatstheapplicant to a civil penalty of net more than
un
Xfive dreddo11ara(S500).
as owner of the property, or my employers with wages as their sok
nation, wW d.the work, and theetructure t not intended or offered for
sto (Sec. 70K BusU,es and Preload.. Code: The Contractors License Law
dare not apply to an owner of property who Wilda or imprwro thereon, and
who dace such work himveltorthrough his own employees, provided that such
Improvement are not intended Oroffered for eak. If, however, the W llding or
Improvement Issold within oneyearofcwmpletion, the owner-bullderwlll have
tllpjZued an of proving that he did not build or Improve for purpose of sale.).
u 4 as owner of the property, am exclusively contracting with licensed
contractors 10 comlroa the project (See 7094, Business and Pe faslom Cade:
The Contractor. License Law don not apply to an owner of property whopLTFR-DRAIN
or Improves thereon, and who contracts for such pct
tpjes with a
151ctaW licensed pursuant to the Contractor. License Law.
amexempt under Sec.' B & P C for this rcawn
APPLIANCFS-RESIDENTIAL.
JOB DESCRIPTION
GQ{/4!
S �a n \ � L ,
PANELS
'
L UP TO 200AMES
00 AMPS
OVEROVER 1000 AMPS
SQ. FT. FLOOR AREA
5/SQ. Ff.
SIGNS ELECTRICAL
SI+EC1pLCB2CUIT/MLSC
TEMP. METER OR POLE INST.
['OWER DEVICES
SWIMMING POOL ELECTRICsion3O(the
VALUATION
OUTLETS -SWITCHES -FIXTURES'-
NEW RESIDENTIAL ELECTR SQ.PE -
5fORIES
TYPE CONSTRUCTION
r
QTy, PLUMBING PERMIT FEE-
pp(Mp1.1S5UANCE
&VENT -WATER BEN
OCC. GROUP
RFS. DNIT$
plpp zDNNE-
'
pPN -
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
Owner Data
DRAINS FLOOR ROOF, ARE A, COMO..
FIXTURES PER TRAP
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SANITARY',Y _ N
RECEIPT
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificate Of consent to xlf-Insure, or a
cenlfluteofWorkeri COmPemati-1—ranceaacedifiMmpythereof(5ec.
3800,Lb C.)
Poky X
SGtOOL TAX Y N
RECEProt
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GASA.
ESYSTFM-1 INC.401TTLETS
PARK FEE Y_ N_..
RECEIPT X
Cam ny
[lCerdfled copy b hereby dwith thehM.
❑Gentled copy b filed with the city inspection division.
CERTIFICATE OF F3(EMPTION FROM WORKERS'
COMPENSATIONINSURANCE6f
ITh.o l..) n need not W completed Ithe permit k(a one hundred dottier
(4100)orlos.I
c issued,
I cent that In any personhe in n the weemanner sa as t becomh this e rmit
I shall not employ any -Lawn In any manner n m w become subject to ted
Wslicant mpensetlon Laws O(GBfomk. Date
Applicant
NOTICE TO APPLICANT: If, after making tint Certificate o(Exemptlon, you
should becomesubjecttothe Workers' Componsatwn provtkns ofthe labor
Cade, You moat forthwith comply with such provtlons orthtperMtshallbe
deemed revoked.
CONSTRUCTION LENDING AGENCY
Ihereby affirm that there is a counnodion kodingagency for the perform-
and, of the work for which this permit is tved(Sec. 3097, Civ. C.)
Lender'. Na
Add.
I ceN(y thavet I haread thb appBuwn and s[m that the above Infomution
Isco ed. I agree to comply with all city and countyordinanmand state laws
mating to building comtroclion, and hereby authorize tepreaenlat wa of this
city to enter upon the alevcmentioned property for inspection purposes.
(W gree w cave, IndemNharmless the an d keep harmlethe City of Cu penlno
a8 1 billt Igments'SaIt.end nsn which ms Ina wayamme
In Bald n cone of ming o It
�—
aturx.1APpllcant retractor Date
HAZARDOUS ERIALS DISCLOSURE
Will the applicant or future WBdingoccupantstore or handle haaardous
material as defined by the Cupertino Municipal Code, Chapter 9.1$ and the
Health an i Safety Cade Sadion 25532(x)7
Y. � No
RIll the applicant or future building Occupant use equipment or devices
whichemithaardoue air Cwntaminantas delined byline Bay Area Atr
Quality Management District?
Iyer V.No
haveola the hares fetyCoedabmum,25505tunderChapter8.95of
the Callfomkatifth Health bSafety Cods Section25505,25533and25539.1
understand that if the building does not corrently have atenanL that lttmy
responsibility to net lfy the Occupant of the requirements which roust be mot
prior to issuance of a Cartlfiut ofOttupa nry.
GAS EA. S-Y''TFM-OVER4(FA)
CREASE/INDUSIRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
PLANCHECKFEE
PAID
Date RcC' t#
GRFI:'"E TRAP -
SEWER-SANITARYEA 200FI
WATER HEATER W/VENT/ELDCTR
ENERGY FEE Y N —
PAID
Date 'Recei t#
'
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. SOFT.
//e_BUILDINGFEE
TOTAL:
"
.
TO
SEISMIC FEB
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
ass.
PERMIT ISSUANCE
ALTER OR ADDTO MECH.
AIR HANDLING UNIT (TO 10,0DO CFM)SUBTOTAL:
MECHANICAL FEE
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FEES PAID:
Date ROCCi f#
AIR HANDLING UNIT (OVER IO,000CFM)
CONSTRUCTION TAX
EXHAuSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,ODO BTU)
_
DateReCei t
HEATING UNIT (OVER 100,000 BTU)
TOT MISINto
p�1 IALMI
SgttAwICE DATE.
p�
.JUN 15 1992.
CII Y Ur l;UNtnl 14V
ISSUEDBY�!f'
VENTILATION PAN(SINGLE RESID)
BOILER -CAMP OM' OR I00,000 BTU)
BOILER-COMP(OVER lOJ,00087U)
NEW RESIDENTIAL MECH. SQFf
Owner or authalzed agent Date
TOTAL:
OFFICE COPY