23169APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Protect Identification
Building Address:)Oslo �> STIAW w.
PERMIT NO.
23169
Awns,.. :
one:
I-I'XI"V[.-- H// Q8;M2-19fy
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDINGELECTRICALPLUMBINGMECHAMCAL
Contra ora Name: t. No:
E sfyg
Architect Engl Llc. No:
CA77Z'ARY CONTROL N
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Addreu
PERMIiISSUANCE
U^
❑ 1:1N El
CONTRACTOR'S DECLARATION
I laeby aiftrm that l am licensed under provisions of Chapterg (comment,
70(0)ot DlvWlmm
on3ufthe Be aand Prefrealons Code, and my
license is In full fa d dfe t.
License Cla Lic.# S .� ss
Data Contndm � �
APPLIANCES.RESEJENTIAL
PANELS
JOB DESCRIPTION
nII
`P(A IA./- A-7
ARCHITECPS DECLARAT N
Tundentand my place shag be used n publicrecords.
201-1000 AMPS
'
OVER 1000 AMPS
SQ. FT. RAREA
LED { ni
P T E R
S/SQ. FT.
Licensed Professianl
OWNEReBUILDER DECLARATION
I herg r afttnthat i n 7 exempt from the d Pmeesoh License Any firths
aMProfrnbneCode: Mydtyir
(ountyw which iced Formal to
anymywhich requTressperMt e,contact, es th a p Lica derreWh,orrepair
any atsudureprior to tatement lhathe i,also
to the reputdhpecfNte
gin a signed statement That heir9icolicensed pursuant it the provisions of the
pursuant
Contradict License Law 'miessin. Code)
od mendng with Section 7000) Divi-
or that violation f esempt therc(rom and
the basis for the elle a dPro(enionC Any
the bast for a e roust sd eaemption.theap Any violation call Snothmrshy o na m,, y any
applicant for a of ars %SDI dstheappgcantto a dW I penslty of rad more thin
five hundred dollen he pro
nI, as ower of the Property, or my employer with wages as Ibelr Bole
compensation, will do the work, and the structure la—intended or d(emd for
sale (Sec 7014, Business and Profession Gds: The Contra Llcenx Law
don net apply to an owner of property who builds or Improve themon, and
who donsuch work himself orthrough hlsown employers, provided that such
Improvement arc not Intended or offered fee star. IL however, the building or
improvement is sold within one yearofcompletbn, the owner-budderwlll have
EA.titrden of proving that he did can build or improve for purpose of axle.).
LJ L as owner of the property, am ernlusively contracting with Iianeed
contractors to conmact the preJed(Sec 7064, Business and Profession Code:
The Contractors License IAw don rat apply to an owner of property who
Wilds or Improve thereon, and who contracts for such pt,ojecm with •
cgpjfactor(s) licensed pursuant to the Contractor's License Law.
LJ I am exempt under See. B & P C for this manor
SIGNS ELECTRICAL
SPEGLILCIRCUIT/ML9C
TEMP. METER OR POLEINSp.
POWER DEVICES
SWIMMING POOL ELECTRIC ATE
pifp
OU LETSSWDCHIESpIXTURE9
NEW RESIDENTIAL ELECTR —TREE
STORIES TYPE CONSTRUCTION
TOTAL:
QTy, PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER-DRAIN&VENT-WATER(EA)
OCC.GROUP RESUNUS
FLOOD ZONE ApN
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
=DE Frrs
Owner to
DRAINS. FLOOR ROOF, AREA, COND.
FD(TURES PER TRAP
CAS F.A. SYSTEM -I INCA OUTLETS
SANITARY Y— N
RECEIIT N
WORKMAN COMPENSATION DECLARATION
QI hereby affirm that I have a certificate of consent to self -Insure, or a
ttrtificate of Worken'Cwnpenatlonlnsuvnce oraartifled copythereaf (Sec.
3800, Lab C.) /}a �Q�a,7 q,� O I
Policy # lT
SCHOOL TAX Y N
RECEU T #
PARKFM Y_ N_
RFCEtI'.T N
Com a�.T—I—IC{—•1 F
edified copy is hercbyth the cityed.
CedRled copy la (fled with the city inspection division.
GAS EA. SYSTEM -OVER 4(EA)
CREASEANDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FRES
PLANCHECKFEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thtasediun need not becompleted lfthe Purnell lefolmahe.dred dollars
(S10Damlesa.)In work
I llAm permit is to
PAID .
Date Reeei t#
SEWEF SAMTARY-SIDRM EA. 300FT.
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N
iod,
so as to b co
employ
oy any Person in any manner
I shall not employ any person In any manner ro n to become eubiect to the
ApplicWorkeant e'Compensatlon loran of GB(arnla. Date
NOTICE
NOTTCETO APPLICANT: orlmakingter CedlflpmvB.m.fthe Lyou
s:I
hwid become subject to the Workers' Compenatlon provtlan o(the Labor
deemed remkel forthwith comply Withsuch provBkunumtht pemetshallbe
deemed revoked.
—
PAID
Date Recei t#
WATER SYSTEM/TREATING !9 V
NEW RESIDENTIAL PLMB.__SQ.FI'.
/" �� f.JAT��
TOTAL:
DIJILDING FEE
i�V ce E?�Z 7b OGi-
/(y 00
TOTAL (0
CONSTRUCTION LENDING AGENCY
T hereby a(Erm that there la a construction lending agency for the perform-
anmof the work for which this Penrod t issued (S,1 3097, CW.C.)
1<ndert Name
Lender'.Address
I adifyth-tl have read thiseppllotlanaod statethetheaboveinfor atiw
tcorred. l agree to comply with all cityand countyordtancesand Battle"
relating to building cora udion,end hereby authomm representatives of this
citytoenterupontheabove-mentioned property for Inspection purposes.
ins a ve, indemnify an d keep harmless the city of Cupertino
again I Ilillea, ju Bment,cost npenaeswhlchmaylnanyway cane
ago t4aId C1 consequence eglan ng.ftMapennlL
/J,�
�l
SEISMIC FEE
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
PERMITISSUANCE
MECHANICAL FEE '
FEE -PAID:
-
ALTO6ORADDTOMECH.
AIR HANDLING UNIT (170 IQODO CFM)
Date Reuel t#
SUBTOTAL:
-0
AIR HANDLING UNIT (OVER Io,ODOCFM)
CONSTRUCTION TAX
Sig App n ontrect to
RDOUS MATERIALS DISCLOS
Willthea rat or future buildingompantsloreorhan Ir Mr,,doua
material as de used by the Cupertino Munldpsl Code, Chapter9.IZ and the
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,0DO BTU)
Date Recei t#
I health and Safety Code Section 25532(x)7
❑ Yee No
HEATING UNIT (OVER 1D0,000 BTIJ)
TOTAL:
Will the applicant or wmbuildingoavpantuseequlpmentordevicca
which emit hazardous air metamtnnt ore deflnd by the Bay Area plc
CL�a�,IityManagement District?
VENTILATION FAN (SINGLE MIDI
ISSUANCE DATE.
Ir
BOMER-COMP OHPOR 100,000 BTI)
BOILER-COMP(OVER 100,000 BTU)
Ihavc read the hararQousmatcdab requirement under Chapter 6,95 of
the Gllfomia Health&Safety Code, Sections 25509,25533and 75534. I
understand that if gdom not amently have. tenant, that It La my
responsibili notlfythe pentofthe iremt entewhich muatberre
prior to ntt IficateotOttupan
JAN 07 1992
CI Y r'L UrcHI BvU
ISSUED BY.
NEW RESIDENTIAL MECH. SQ.FT
Owner or authortaed t
TOTAL:
OFFICE COPY