23142APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pro ed Identification
Buading Addrea:
PERMIT NO.
2 314 2
/0900 CL �GHOVl F LAS E-
nera came: one;
60 o✓r' 971
CJTY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
con a re Name: Uc. to
bvf1 CO qJC-1-3=!jBUH.DINGELECTMCALPLUMBING-MMliAMCAL
CATEGORY CO Wad`
l
BUILDING PERMIT INFO
ArchBeet/Engt. Lk. No:
. N o r1
QTY ELECTRIC PERMIT FEE
Address
1:1I
❑ ❑
PERhITISSUANCE
ICENSED CicOYNTRA
LICENSED RODECLARATION
RATION
hereby sa!C
IngwitootIon700XEofDlon3aftheBuelvessandProfehainnsCodeandmy
,
aseChm
sei31n'ul d Ill /ctor S
APPLIANCES-RESIDENTIAL
JOB DESCRIPTION
a '
LF C(sd^�
PANELS
ttermse C~Q
201-IODOAMPS
ARCHITECTS DECLAGTION
I understand my plata shag be used AS public records.
OVERIOOOAMPS
SQ. FT. FLOOR AREA
$/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
SPECLALCIICIIT/MLSC
OWNER -BUILDER DECLARATION
I herebyaffinn that lam i xeerpt fromthe Contractor'.License law for the
TEMP. MffM ORPOLE INST.
following mature. (Section 70315, Business and Professions Code: Any city or
county which requires permit to construct, alter, Improve, demolish, or repair
any structure prior to lis Issuance, also requires the applicant for such permit to
file a signed statement that he b licensed pursuant to the provisions of the
POWER DEVICES
SWIMMING POOL ELECTRIC
OII7LETSSWOTCIiESFIXTURFS
Con/nciore License Law (Chapter9(commencing with Section 7000)of Divi-
'on 3ofthe Buslnemand ProfessionsCode)orthat heb exerept therefromand
the basis for the alleged exemption. My violation of Section 70315 by any
appgantforapem tsubjcdatheapphcanttoadvllpewltydnmm mt"n
VALUAiI
}s.
V s
five hundred dollars (5500).
I, as owner of the property, or my employees with wages a their sole
NEWRESIDENTIALELFCTR SQ,Ff.
STORIES TYPE CONSTRUCTION
compensation, will do the work and the structure is not Intended or offered for
sale (Scc. 7064 Business and Professions Code: The Contactors Wave Law
does not apply to an owner of property who build&car Improves thereon, and
who doessuch work Mmeelorlhrough his own employees, provided that Such
OCC. GROUP RFS.lR 7T5
Improvements are not Intended oroffered forsale. If, howevegthebuilding or
TOTAL:
Improvement issold withlnaneyearofcompleWRtheowme bullderwW have
tIktQatrden of proving that he did not bund or improve for purpose of ale.).
LI L as owner of the property, am exdu.ively comradi . with I--
contnctoreto constvct[he projeR(Sec 7066, Business and Professions Code:
QTY. PLUMBING PERMIT FEE
FLOOD ZONE APN
PERMIT ISSUANCE
The Contnciorh License Lw does not apply to As owner of property who
Wild. or Improves thereon, and who contncta for such pAaject, with a
9,3,,acrorh) licensed pursuant to the Contractor's License Law.
LJ I am, exempt under See. B & P C for this reason
ALTER -DRAIN & VENT - WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
DRAINS. FLOOR, ROOF, ARG, COND.
SANITARY Y N
RECEIPT Y
Owner Date
WORKMANCOMPENSATIONDECLARATION
[:]I hereby a/(irm that I have a certificate of consent to self -Insure, ora
certificate of Warkers'Compensation Insurance or a certified copy thereof(Sm.
3800, Lab C.)
FIX.NRES PER .172nP
SCHOOL TAX Y_ N_
RECEIPT Y
GAS G.SYSTEM-1 INCA OUTLETS
PARK FEE Y N
RECEIPT Y
Polley M
Com
GAS F.A.SYSTEM-OVER 6 (EA)
BUILDING DIVISION VISION FEES
GREASE/INDUSTRL WASTE INTERC R
PLANCHECK FEE
/ (1
Gsya�•
PAIDq
Ified copy b hereby furnished.
Certified copy Is Ned with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WOR KERS'
GREASETRAP
COMPENSATION INSURANCE
(TMs section need net be completed 9 the permit isfor one hundred dollars
(5 Monet.)
I certify that in the performance of the work for which this permit b heated,
SEWER-SANITARY-b1URM EA 200FT
.
Date Rewi [ii
WATER HEATER W/VENT/ELFGTR
ENERGYFEE Y_ N_
I shall no.`-^ jy any person In any manner an AS to become subject to the
Workers'Compensatlon Laws of California. Data
PAID
WATl7i SYSTEM/TRG7ING
NEWRESIDENTIALPLMB. SQ}T.
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the Workers' Compensation provisions of the Labor
Date Recei t#
TOTA '
)__
MLDINC FEE Y
Code, you must forthwith amply with such provisions orthh permlt shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
lherebyaffirm that there Is a construction lending agency for the perform
ance of the work for which this permit is blued (sec 3097, Civ, Q
Lender. NamePLUMBING
Address
I cedifythatl have read thbapplicatlonand datethattheabove Information
Ismrred. 7 agree to complywlth all dtyand county ordinances and date law.
relating to building construction, and hereby authorlu representatives of thio
city to enter upon the abovcmentloned property for Inspection purposes.
(We) Agree to cove, Indemnify an d keep harmless the City of Cupedirw
against liabilities, pdgments, cosband..penses which may in anywayacaue
OTAL:
An d
ELECTRICFEE '
FEELenear.
[)TY. MECHANI ALP MIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
��J
FEES U / Pb�F7
Dye Receipt#
ALTER OR ADDTO MECH.
AIR HANDLING IJM7 R010,lYp CFM)
SUBTOTAL: s
agaivt a ty in cons a of the granting of this permit
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
EXHAUST HOOD(W/DUC'D
CONSTRUCTION TAX PAID:
Date RCCCI t#
gv oA 4
ppitunt/CUntrador Date
HAZARDOUS MATERIALS DISCLOSURE
WIIl the applicant or futum, building occupant .tumor handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1 2, and the
I lealth and Safety Code Section 25532W7
�IYes No
vill the applicant m—F Wre build log oavpart use equipment or devices
HEATING UNIT (TO IM,= BTU)
HEATING UNIT (OVER 100,000 BTI])
TOTAL:
VENTILATION FAN (SINGLE RESID)
- ISSUANCE DATE
which emit hazardous air contaminants as definsd by the Bay Area Ab
Quality Management District?
ii (L' D
PAID
BOILMOOMP OHP OR I DO,000 BTU)
Yre ❑No
have readtheb. us materialsmqulmmnhunder Chapter6.95of
Y
BOILER-COMP(OVER IW,WO BTU)
the Callfomia Health & Safety Code, Sediuv 75505, 75533 and 25537. 1
understand that if the building dues net currently have a tenant, that it b my
i['D A
FED 4 1992
NEW RESIDENTIAL MECH. SQFf
responsibility to notify the occupant of the requirements which must be met
prior to Issuance of a Cedifiateof Occupanty.
CITY OF
CITY UPLr1jury
ISSUED BY:_
Owner or authorized agent Data
TOTAL:
OFFICE COPY