23614APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
S �'
— L
CadreRor'3 Name: LIC. No:
CATEGORY
CONTROL*
nK
B=lNGELECTRICAT r'LUMBING-MFGHAMCAL
Ar:hltttt/Englnesm Llc Na.
O
'' - }, a s . s.., . y.:-.. -,_ . „:;, ., _..,. . :x
ELECTRIC PERMIT.^. k ` ,.s FEE
; BUILDING PERMIT INFOf ", Av
-
Addrese, / z
PERNUTISSUANCE
❑ El El
LICENSED CONTRACTORS DECLARATION
Ihertby aflbmthatiam licensed under provWon,olt7apter9 (03030303
APPLIANCES -RESIDENTIAL
]OB VH IclIrT/ON
PANELS
Ingwith Se ..7000)of DiAsi.n3ofthe Businsssand Profs ..Cade,and
If max Is In full f and d(e x. _ `
Data /7r7[/Qyi ICHITE 7' y�-N—y"��y�/
ARCC..-'cl` C TIOI N `��7
Data Cho Lk N_�� /
Iundeaandmyphnsahallbeu daspubBcmwda
�,�
Q aL�
p 1�
OVER 1000 AMPS
.FT. FLOOR AREA
$/
ISIGNSELECTRICAL
Licensed Profmahmal
SPECIAL CIRCUITIM19C
OWNER -BUILDER DECLARATION
I herebyafBnmthat I am exempt from the Communes Lbenx Law for the
TEMP. METEROR POLE INST.
following reasan. &man 70315, Business; and Professions Code.. Any city or
county roabomgt, orrepsir
theaprovademnihh,
anyatromsrtprfrmte the he e, ats.sed pursuant to the fmsacons,of to
mmrequiresaima
file a signed salement that he h licensed pursuant to the provtsbns of the
POWER DEVICES
3WMMNG POOL ELECTRIC
OUTLEISSWITCM15FURURES
Contractor'sLicenx Law (Chapter9(comnencing with Section 7000) of DIA-
ebn3ofthe Businevsad Profexbm Code)crthaheismmptthemfmmand
the basis for the alleged exemption. My violation of Section 70335 by say
appBant fora permit subjects the applicant los, civil pensRy W me rromthan
VALUATHY
) p
/
five hundred dolWs(SSM.
❑ I, as owner of the property, or my employee with wages as their sale
compematim, will do the work and the structure Is not Intended or offered for
NEW RESIDENTIAL ELECTR SQFT.
RIES
TYPE CONSTRUCTION
sale (Sec. 7094, Business ami Profession, Code: Th. Contredora Liansa Law
does not apply to sa owner of property who builds m Improves thereor,and
who dom=6 work himseBerthrough hisown employees, provided that such
OCC. GROUP
RFS.IINTTS
improvements are not Intended or offered fm sale. It havever, the building m
TOTAL
Improvement bsold within amyearofcomple11m9 the owner-bullderwill have
t1a,?uIdea of pawing that ha did t build or Improve for purpose ofm1a).
u L as owner of the Property, am eacbai ely mntruHng with Ilmnxd
contaaon to mn,lmR the projeC (See 7014, Business and Pmf essons Code:
The C.Ideadors Gasses, Law don mac apply to sa owner of property, who
Wilds or Improves themon, and who mmads for such piopme with a
cQBQactorW limned pursuant to the Contactors Limn. Law.
Lj I am exempt under Sec B Is P C for this masan
FLOODZONE
APN
_ ..
INGPER-fit'V ''.'FEE�5
QTy-' ,.'.PLUMBMI
PEAU ISSUANCE
ALTER -DRAIN A VENT- WATER (EA)
SUMMARY;'';i..T'-:?.i
..-t'_ :��y.OUTSIDERFS
RACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA COND.
SANITARY RECEPTI
Owner De
at
WORKMAN COMPENSATION DECLARATION
I heby affirm that I have a mrtlllaa of cauent to self -Insure, m a
re
Iate.(Worcere Compen,Wonlmuranae mamrtBlecimpytham((Sea
3800, lab C.)
Policy N
FD(7TIRE4I'ERTRAP
SCHOOLTAX Y N
REGERrf I
GAS EA.53'Si'FM-1 INCA OUTLETS
PARK FEE Y N
as RECEPT
! BUILDING DIVISION FEES
CAS EA.
Co.any
W. CertBbd copy ts hereby famished.
Certified ropy, ts filed with the city InspeClon division.2,Zs
CREASE/IND
NCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASEjVj EalAID
SEWER -SANTTAFJ) Rqe EA 2,
COMPENSATION INSURANCE
(Thissea1,m mxd as be completed lithe pemdt tsfmom hundred dolla s
($100)mt..)
I artlfythat le the perforrsence of thewmk forwh1ch this permit b blued,
Date Recel t#
WATER HEATER W/VENT/EECM
ENERtYFEE Y_ N_
SYSTEM/'IRFATIN'G
I shall not employ any pecan in any manner as m to become subject to theWATEt
Workers' Compensation laws of California. Date
Applicant
PAID
Date Recei tq
NEW RESIDENTIAL PIMB. SQFT.
NOTICETO APPLICANT: I, after making this Certificate of Exemption, you
should became sab)eet to the Workers' Compereaian provbion, of the Labor
Code. you .9forthwith mmply with mit provlsbn, arthis percent shall be
TOTAL:
BUILDING FEErs
Vd
deamed rewked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
TOTAL
ELECTRIC FEE
I hereby afirenthat them is a constmatimr leading agency farthe perform-
arm of the work for which Ihts permit is blued (Sec 3097, Civ. C.)
Leads,'. Na
Lender. Add rea
PLUMBING FEE
r r':
QTY. ,-�?•,MECHANICAL' PERMIT,nt nL` FEES;
MECHANICAL FEE
IrertifylhnlhavereadthisappliatbnaM siatsthatthes,bos'e In(omutlsa
istnaect. I agree tocomplymb all dtyand muntynWbsences and rate laws
PERMIT ISSUANCE
FEES PAID:
ALTER OR ADDTO MECH.
misting to bWlding construction, and hereby authorize reprtxntaives.( this
city to enter upon the aboveenentlonad property for Wpectlon purpoxs.
(We)agree to save, Indemnify an d keep harrafm the City of Cu penin
against BabWtin, judgments, costa and expenses which nay In say way amus
Date Revel tic
AIR HANDLING UNIT CFO 10,000 CFM)
SUBTOTAL:
against mid City In con ens of the greening of this Permits
R HANDLING UNITrovERloo3ocF'd)
CONSTRUCTION TAX
SI ofApllant/Contactor
E)LHAUSTHOOD(w/Darn
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSU
Will the appBant or(u/urt building ampant store or handle hazardous
HEATING UMT(T0100,000 BTU)
Date Recel IN
material as de0nsd by the Cupertino Municipal Coda Chapter9.12 and the
Health and Safety Cade Section 25532(s)T
Yn �]No
devio:s
appBant mlamabuildingodefine sexthe
HEATING UNIT (OVER 100,000 BTU)
TOTAL;
VENTILATION PAN (SINGLE RISID)
ISSUANCE DATE
Bay ror
whicheche
which emithavrdow atrrict? res de0ned by the Bay Arca AU
Quality Management District?
C) Y. ❑No
l n.. read the hmaNws materials requirementsunder ChapterOS of
'.I CaWomhHealthkStfetyCod.,SWW.25505,25533.d2S534.1
" widerstandlhatiflhebu0dingdonno.or ttyhavea term, that it is my
r A
MAY -4 1992
BOILFRCOMPOFI'ORIOo,OW BTU)
BOILER-COW'(OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQFT.
respons3Bity to notify the occupant of the ayulrements which at be met
prior to issuance of a Certificate ofOmupaacy.
CITY Ur vllrcnl"4u
ISSUEDBY:_)__�}��.
Owner or authorized agent Data
TOTAL
OFFICE COPY