23887APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
fluildinst Ponied Identification -
Building Address: o cW tku - W
PERMIT NO.
' 23887
Ownerst,arne: /� one:
VpLFG.-Lsfi
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
p -
c�ntpaor'sN LIallo
BUILDLNGELECTRICAL.PLUMBING-MECHAMCAL
CATEGORYCONTROL M
Architect/Ener. gineLk. No:
QTY ELECTRICPERMIT
BUILDING PERMIT INFO
Addreds:
5LUG —not'
/�I ❑ ❑ ❑
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
Ihereby Sedaffirm n7Othat lam licensed under provisionsof Cssions9(commrnc
^(the Budnsssand Pro(eutonaCode, and my
Inense
APPLIANCESRESIDENTA
JOB DESCRIPTION
is inull force ands tied.
.licenseieIns form andk,N
LiceD.to ass LICA
PANELS
Date Contractor
UPN A"
-
20
ARCHITECT'S DECLARATION
lundentandmyptamahaRbeuwdaapubhcreccards.
OVIER1 AM1, 1 1SQ.
_PgL
FT. AREA
S/SQ.FT.
9G E
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby of . that I am exempt from the Contractor's License Law for the
following reedan. (Section 7031.5, Businessand ProfessionsCode: Any cityor
caunlywhich requires a permittomrutmat, alter, Improve, dermll.h,orrepair
anystmu mpdortoltsiswame,akonquirestheappBantforauchperrNtto
file a signed statement that he is licensed pursuant to the provblons of the
Contractors License law (Chapter 9 (commencing with Section 7000) of DIv1-
slon3oftheSudoess and ProferbnsCode)orlhat he Is exempt there(romand
the basis for the alleged exemption. Any violation of Station 70315 by any
appaant fora permit mbjeds the applicant to a civil penalty ofnot more than
five hundred dollars ($.500).
❑I, as owner of the properly, or my employees with wages as their sok
CUIT/MLSC
TEMP. BIER OR POLE IN .
POWER DEVICES
SWIMMINPOfILWER,
O
VA LUy7pN
I] Cw 6
Ir J V{J
NEW D L ELECTR '
STORIES
TYPE CONSTRUCTION
compeneati., Uld.th. work and lhiatociure ie not Intended or offeredfor
sale fSec. 7064, Business and Pmf ddmd Code: The Contractors License Law
I
don, not apply to an owner of property who Wilds or Improves thereon, and
whodoeaeuthworkhimself.rthmagh Msown employees, providedthat such
OCC.GROLIP
RES UNITS ,
Improvements are nm Intended omffered fwmie, If, however, the building or
Improvement bsaldwithlnoneyearofcompletloktheowner-buRderwBl have
en of proving that he did not build or Improve for purpose of sale.).
as owner of the property, am exclusively contracting with 11—o—PERMIT
^tactors to construct the project (Sec. 7044, Business and Professloru Code:
TOTAL:
QTY, PINC PERMIT FEE
I NCE
'
FLOOD �p(�
ppN
CoMe cmr's License Law don not apply to as owner of property who
Wild. or Improved thereon, and who contra for such ptojedwith th a
�gB(Iactor(.)B... punuanttothe Contractors Limnae Law.
L,JI am exempt under Sec B & P C for this recon
ALTER- IN &VENT- WATER (EA)
IN PROTECT. DEVICE
BA XtT
FEE SUMMARY
ES
NS FLOOR ROOF, AREA, COPID.
SANITARY Y_ N_
RECEIPT 5
Owner Date
WORKMAN COMPENSATION DECLARATION ❑
I hereby offimt that I have • certificate of to
FIXTURES- PER TRAP
SCHOOL TAX Y N
commit sail-Imurs, or
certificate of Worken'Compereatlonlesurance or a mrtifled re
copyeheuf (Sec.
3800, Lab Cd
RECEIPT
CAS EA. TNG<OUILETS
PARK FEE Y_ N
Policy a—
N
C°n^ •^Y
GAS EA. SYSTEM -OVER s (EA)
DING DI
BUILDING DIVISION FEES
Med
Cerilfied copy is herebytumishity
❑Cedifled copy is filed with the city inspection divlslon.
CREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECKFEE
GREASETRAP
CERTIFICATE OF F3(EMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thbssctbnneed not becompleted Rtheperndl isforunshumdred dollars
(StI0)orfy that
] certify employ an person
I .hall not employ any peso^ In any manner ar u to become subject to the
any m nnerwork so as to b this cam permit is Issued, the
Workcre'Compensation Laws of Gll(omla. Date
PAID
Date ReceI tM
SEWER -SANITARY -STORM E.A. 200FT.
WATER HFATERW/VENT/ELECTR
ENERGY FEE Y N
PAID
WATER SYSIFM/,TREATING
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subpct to the Woden' Compensation provisions of the Labor
Date Revel tN
NEW RESIDENTIAL PLMB. SQFf.
TOTAL:
Code, you mot forthwith comply with such provisions or this permlt shall be
deemed revoked. ,
BUILG
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
Ihereby affirm that there is a constroRlo^ lending agency for the perform,
ance of the work for which this permit k tuned (Sec. 3097, Civ. C.)
TOTAL:
ELECTRIC FEE
-
QTY. MECHANICAL FEE
4
PLUMBING FEE
Landers Name
Lenders Addross
Imdifythatl love read lhisapplicatlonand statethatthe above Information
iscorrect. I agersto comply with all city and county ordinances and date laws
relating to building mnstmdlon, and hereby authorise reprsssntaelvm of this
MECHANICAL FEE
PERMITLSSLIANCE
FEES PAID:
city to enter upon the abovementlaned propoty/orlropectloopurposee.
(We) agree to save, Indemnity o% harmless the City of Cupertino
agaWtllabWtln,jr nU, ex se.whichmuylnanywq�
.gains Id C f the ting ofthls permit.
ALTER OR ADOTO MECH.
Date Recti tR'
AIR HANDLING UNIT (TO 10,(00 CFM)
SUBTOTAL:
AIR HANDWNG UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
5 nor P t d IA
EXHAUST HOOD(W/DICT)
CONSTRUCTION TAX PAID:
A RD MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Willppllant or homes building occupant tore or handle hazardous
defined by the Cupertino Municipal Code, Chapter 9.17, and the
Date Recel I#material
HEATING UNIT (OVER 100,00) BTU)
TOTA
af 711
HealtY d Safety Code Sloon 25532(a)?
VENTILATION PAN (SINGLE REBID)
ISSUANCE DATE
Will the applicant or❑❑future building occupant use equipment or devices
which emit lotuoh sae air comoomunts as de0ned by the Bay Area Air
BOILER-COMP(3W' OR 100,000 BTU)
�uality Management District?
L�Yes No
BOILER-COMP(OVER ID0,000 BTU)
I we read the h.Rus materials requirement, underChapter&95 of
P A 1 D
the California Health & Safety Code, Sections 25505, 75533 and 25536. 1
NEW RESIDENTIAL MECH. SQFT
understand that O the Wilding does not currently have atenanL that it is my
responsWRityce of aCeheocte of of the upancyuircmenta which must be met
prior ns Issuance notifytheocu^(taupe reqs
JUN 24 1992
4,y
ISSUER M 4V
Owner or authorized agent Data
TOTAL
OFFICE COPY