23867APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE HALL PnINT PFN ANI V
• Bulleln Pro act lJentlflol°n--------- — -
Building Address:
/0S CIO CAsr-/A/,c ✓23867
----—'--' PERMIT NO.
nereName:
'' 11 J one:
RIL'1E H/ (i /. —'1(S(,
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING-ELECTRICA4PLUMBINC-MECHAMCAL
�C "I
Contra '.Name Lic.
a O(
Archilect/Engineer, Lk. No:
CATEGORY
CONTROL If
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:
PERhITI55UANCE
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that lam licensed under prwbdore of Ch.pt.,9(mmmen
Ing with Sd on7000)of DiWsion3ofthe BupnesaandpcofesalonsC.ede,andm
limn.. b In foil force and I #
Date Contractor
APPLIANCESRESIDENITAL
PANELS
JOB DESCRIPDON
f2I `96
ARCHITECTS DECLARATION
' I understand my plam.hI be used as public records.
201 -IOW AMPS
OVER I(AM AMPS
SQ, FT. FLOOR]AREA
, O Tcounty
ER
S/SQ. FT.Licensed
Pmfes(orul
-BUILDER DECLARATION
hereby aNrm that I am exempt fromthe Contractor's Liman Law for thefollowing reason.(Section 7BIS, Business and ProfesalonsCode:Anycityor
which requires a permit to construct, alter, Improve, derrI or repair
strucure prior to Its tmanc"Iso requires the applicant formch permit to
file asignedstatement that he Is licensed Pursuant to the pawbiore of the Contractor's License law (Cha)ner 9 (commencingwith Section 7000) of Divi.SWIMMING
helsemmptthemfmmand
the bald for the alleged exemption. Any violation of Section 7B91S by any
applicant fora permit subjectstheapplicant too civil penalty d not mo rethan
five Jrundred dollars ($500),
u I, a. owner of the property, or my employees with wages as their sole
compensation, will do the work and the structure Is not Intended or offered for
vie (Sec. 7014, Business end Pmfe suns Code: The Contractors License Law
does not apply to an owner of property who builds or Improves thereon, and
wimpho doc such work himself orthrough Msown employees, provided that such
roven
rret, are not Intended or offered for sale. If, however, the build Ing or
improvement is sold within oneyearofcampletion, the amer-bullderwlll have
tlB,lIurd an of proving that he did not build or Improve for purpose of sake).
LJ I, as owner of the property, am exclusively contracting with (Im nd
contractors to consumer the project (Sec 7094, Business and Profeelors Code:
The Contractors License Law does net apply to an owner of property who
Weds ar Impravea thereon, and who mance for such ptuject, with a
x0.1.) Rmreed pursuant to the Commaeors Llmme Law.
I am exempt under Sec. B & P C for this mason
SIGNSELFf_'TRICAL /'OWNER
SPECIAL CIRCUIT/MISCI
\
TEW.METFRORPOLEINST.Vany
IOWFR DEICES
I170L I.GCTRICsion3oflheBuenessandProfealuvCMe)arthat
OULETBSWTTCHESFIXTURES .
ON
NEW RESIDENTIAL ELECTR SQ'hT•
STORIES
TYPE CONSTRUCTION
'
TOTAL:
OCC. GROUT'
R}S. UNCIB
QTY PLUMBING PERMIT FEE
PERMIT ISSUANCE `s
ALTER -DRAIN& VENT-WATER(EA)
bT-OOD ZONE
APN
BACK FLAW PROTECT. DEVICE
FEE SUMMARY
Owner Date
DRAINS FLOOR ROOF, AREA, GOND.
FD(1URES PER TRAP /
GAS PA. EM -1 INCAOUTLETS
SANITARY Y_ N_
RECEIPT at
WORKMAN COMPENSATION DECLARATION
❑1 hereby affirm that I have a certificate of cmeeat to self-Imure, or a
rens(Imte o(Worken'CompereaRon lreursna ar a certified copy lhemo!(Bac,
M00,Lab C.)
Policy p
SCHOOL TAX V N
RECEIT
PARK FEE Y_ N_
RECEI'l' N
Com any
❑C:AI❑Certlled ropy is hereby furnished.
led mpy Is feed with the city inspectors division.
CAS EA.SYSIEM-0VER4(FA)'
CREASE/INDUSTRL WASTE INTERCEPTOR
BUILDING DI VISION FEES
PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thissectum need na becompleted etheperm, b(amuhundred dollars
(Siro) or tem.) un
I renete poy he any ersonI e of any ar nner so whichas too ca permit Is Issued,
I .hall not employ any person In any manner m as to become mbkct to the
W plicae Compeneatbn Laws of California. Date
Applicant
GREASE TRAP
PAID
Date Recoi t#
SEWER -SANITARY -STORM EA. 200FT.
WATER HEATER W/VENT/ELEGTR
ENERGY FEE Y _ N _
PAID
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. SQ,Ff.
NOTICE TO APPLICAM:I, alar making lMa Certllcate of FaemlRbn, you
=shmld berome subjecttothe Workers' Compensation pro &sons of the Labor
.1, you cess forthwith comply with such provisions orthIs permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that them Is a construction lending agency for the perform-
ance of the work for which this permit Is Issued (Sec, 3097, Civ. C.)
Lenders Name
Lenders Addmsa
Iccret l aatlhocomplywithalidtynand statethatthe above information
Is rormct.]agreeto comply with ell cityend county ordinancesand pate laws
relzting to building coretmetion, and hereby authorlu representatives of this
city to enter a Pon the abavcmenttoned property far Inspection purpmea.
(We) agree to save, indemnify an d keep harmless the City of Cuperloo
against liabilities, Judgments, roes and expenses which may In any way accrue
age lmt said City In consequent the granting of this permit.
Date Remi til
TOTAL:
,
EE
FEE
r
QTY. MECHANICAL PERMIT FEE
PERMITLSSUANCE
ALTERORADDTOMECH.
AIR HANDU NG UNIT DO 10,000 CPM)
FEE
��
CAL FEE
FEES PAID:
Date RedeiFtk
SUBTOTAL'
AIRHANDLING UNIT (OVER 10,MDCFM)
CONSTRUCTION TAX
Sgnam'r ,-Aprpplumau Comnctor Date
HAZARDOUS ATERIALS DISCLOSURE
Will the applicant of future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 91Z and the
Health and Safety Cade SeNloon IS53ZI)9
Yn
DMAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,000 RTU)
Date Re,:eiptjkxs
HEATING UNH(OVER 100,000 BTU)
- TOTA
Will the applicant or tore busldingoccupantuseequiprOmtordevims
which emit hazardous air contaminant, as deflaed by the Bay Area Air
Quality Management District?
❑ Vee scrag No
lhalfamla Chet&Safer Code,teriSe tioulremenbunder Chapkr.1 of
the Callfodt Health &Safety Code, Sections25505,25533have
a to ad, t hat it
mpoatandthat if notihe fy
roor to I lily to natifCc If" pant of he requirements which must 6e met
the ing doesoccupant not .require encs tenant, that it met
prior to lv reo( Cel careof panty,`
VENTILATION FAN(SINGLE RESID)
1$$UANC.E DATE
Y_ iy B
W
f11 .s
�� ,V 1 1
/
oil
V r `r
`Vrfl
BOILER -CAMP OHP OR 100,000 BTU)rea
BOILER-COMP(OVFR IW,000 BTU)
NEW RESIDENTIAL MECH. SQ.FT
_
V
BY:_ ""!J►!/1(�
nor authorizdagent p,DateJ�/
TOTAL: ISSUED
OFFICE COPY