19967APPLICANT TO FILL IN INFORMATION WITHIN RED LINES,— USE BALL POINT PEN ONLY \ �/
Building Pm oe identification
Building Addrms:
P`7T NO.
'•i31S00 DRi �F_ pfd UIItTS 2.1 21 - P� T
19 9 6 7
Mere:
Fxn,9-w-tCj67
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION IPERMIT
-
CantnRor'aNarro: lNo:
LL
ULl RUG ZiUBUILDIN
-ELECTRICALPLUMBINC-MECHAMCAL
.•
CA TSARY
CONTROLY
Archltet/Engircen IJc. N
Z G' 16
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address 6 l b S •
❑ ❑ ❑
PE2IATISSUANCE %
LICENSED CONTRACTOR'S DECLARATION
I hereby elkmtlut lam llcenaed urderprovLsi.nsdaapter9 (mrmrwe
Ingwlthgectbn700Mol Di"Mon3ofthe Budnesand ProfessionsCode,and ny
APPLIANC6Iff3DENTIAL
)OR DESCRIPTION
license 61n full form and elect. -
PANELS
Dat Clam LILY
Dale CJs.r
— UP TO 200ANIPS
VPLEX
1201-10DOANIPS
ARCHITECTS DECLARATION
IuMm Mmyplemst llbeuwdapubbcremrda
OVER10DOAMPS
OFT. IMREA
$/SQ. FT.
SIGNS ELECTRICAL
Licensed PNmbnal
OWNER -BUILDER DECLARATION
I hereby afBrmthat I am exempts lromthe Comratore Llcerue I�w for the
U
T E R
SPE(7ALCIRCUIT/MUSTCia
orentyngreaarn.f$ea1m 7031S,Bwln®aMPrdessbns Codr.Anycity.r
c.untywhlch requlw a pemtlt to mutrut, alter, Imrove lr
p, drmoW h, Orrtp
TE✓.P METERORPOLEINST.
/]!/
7
anystmt mprtmto RsissusnceaborequtmtheappBcamfwsuch permRto
file a signed statement that he h licensed pursuant to the provisions of the
POWER DEVICES UATe
SWAIMING RX)L ELECTRIC
Contractors License Law (Ch+ptar9(commencing with Section 70D0)of Divi-
abs 3 of the Business and Professions Code) orthat he isexempt therefromand
VALUATION
the Wee for the alleged eaemptien. My vldnlon of Setbn 70313 by any
appllantfor. perndt eubjrcta theapplkant to a civil penalty, snot more than
OLT LE7SSW=HF FDMJRIS
^� O G
L� I 37 ger
NEW RESIDENTIAL FT R7TR SQTT.
nvghundrednerof thepr1.
�f I, u owner of the property, or my employee with wages an there suis
STORIES
TYPE CONSTRUCTION
mmpcnsatiK B.Mos, anal rfeado"ndes Code: The
eit C.M odedi or offered d.e.Lict.Law
dale(Sec Buslnemantf Code:The rs IJceroe Law
property
dm out apply to an owner d property who W erns or Improve thertoR and
apply or trop
who does such work Mansell orthrwgh his own emplgee,provided that such
OCC.GROUP
RES UNITS
Improvementsarenotintended ... fferedlorsale. ILhcwever,the Wlldingcr
Improvement Issold whhln Orieyearofcompltbri,the ownerbu0derwW have
TOTAL,
IC. ��
tp&b,rden of proving the the dice not build or lmprow for p.rpea, ofdale.).
tu4 as owner of the property, am exrl wry contracting with licensed
ctms to mnstrut the pmjed (See 7011, Bwme ."Pr.(l m Code:
QTv. PLUMBING PERMIT 'FEE
FLOODTDNE
APNN
PERMIT ISSUANCE
The Contractor's License Law dm not apply to an owner of property who
re
s or imp. theon and who comms for such ptojectd with a
apijIactMs) licensed pursuant to the Contractors License Law.
LJ 1 am exempt under Sec k P C for thio reason
ALTER -DRAW 4 VENT -WATER am
FEE SUMMARY
BACK FLAW PROTECT. DEVICE
OUTSIDE F
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y N_
RECEPT 1
.mss
Owner
WORILVIANCOMPEJSATION h7
❑I hereby affirm that I have a ceNBute to self-bsure, a a
certificate of Workers' CmnpenuHm lrauran a a¢rtBkdcopy thneof(See
3800,isb C)
pp(.ITJgpS PER T]tAP
SCl'IOOL TAX Y N_
RECEI'TY '
GAS F.A. SYSTEM -1 INCOUTLETS
PARK FEE Y_ N
Policy
o icy a
RI]CEI'T Y
CAS EA. SYS171(-0VER (EA)
y
BUILDING DIVISION FEES
canines ropyehereby (ureshed.
Ceriieci copy b filed with the city inspection division.
CREASE/INWSIRL WAS INTERCEPTOR
PLANCHECK FEE .
GRFA.SETRAP
CERTIFICATE OF FXEYIPHON FROM WORKERS'
PAID
SEWER -SANITARY -STORM EA 210FT
COMPENSATION INSURANCE
(fhiaerectionneednotbacompletediftF per tk!bonehundraddoBan
Date Reece t#
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N
(SIm)aless.) •
I orleshn tithe peeornuna.f thewaklorwhlch WapemdtVblued,
WATER SYSIIM/TREATING
I shall not employ any person In any manner m as to beco. subject to the
W.rkeri Cmnpensatbn LawsdG Wmnia. Date
PAID
Applicant
NOTICE TO APPLICANT: If, after nuking this Certificate of Exemption, you
Date Recei t#
NEW RESIDENTIAL PUSm. SQF7.
TOTAL
should beoons, sub)eet tO the Wolcers' Compemukn provisions .the Labor
Code, you nun fathwbh comply with such provisions orthid pemdt shall be
deemed revokad.
L DING FEE
5EISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm Hut there b a mnstmti.n lcMing agency for the perfor,
ance of the work for which this permit is issued (Sec. 3097, CW, C.)
TOTAL
ELECTRIC FEE
PLUMBING FEE
IeMer+Name
]ender. Add,a,.
] mrtifythe l have read thsappllatbn and statethetthe above lnformrtlon
L+correct. I agree to comply with all city and county ordinances and state laww
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID.
relating to W Edlog mn+trution, and hereby authonae mpresentatives of this
city to enter up..the+bovarrentbnsdproperty for lvpecti.npurposes.
(We) agnc to save, bdenusly an d keep harnsess the City of Cu pen W
ALTEtORADDTOMFLH.
Date ReCOi t#
SUBTOTAL:
s
against liabWtb,Odgenees,costs and expense which may in anyway accrue
against sed City N consequence of the granting d this pcmdt.
_Pop d
fpVI'1 6"d
NR IIANDUNG UNIT (TO 10,ODD CFM)
AIR HANDLING UNIT (OVER IO,OnOCFM)
CONSTRUCTION TAX
slgnsn,rednppuanVee„er.atm— Dale
ExttnusT Hoop (W/DUCT)'
CONSTRUCTION TAX PAID:
HAZARDOUSMATERI BDISCLOSURE
HEATING UNIT (170 lm," BTU)
WOl the applicant or Nun, 1,u0ding occupant store or handle havrdous
material as dcOm'd by the Cupertin M.mtpal Code, Chapter 9.17, and the
Date Re i t#
HEATING UNIT (OVER tm,OW BM
TOTAL:
I ieehh+M Safcty Code Setkc.25334)t
n❑ Ye No
,lithe applare or tore Wilding oavp..t use Nolpment o.devise
VENTILATION FAN (SINGLE R ESLD)
_
IS C$IDATE
which emit hanrdous air mntamW ms as defined by the Bay Arca Air
J
BOIIRR-COMP PHP OR 100,00D BTU)
oust Bty Managemem Doom?
YesNo
ilhaverea[-]dthehuardousmateriabrequeenentsunder Chapter 6.95of
I Q
. A Q 1_90
BO LER-COMPOVE1m,IXOBU
the CaW.rela Iielth A Safely Code, Sctloro 25503, 25533+nd 735.14. I
NEW RESIDENTIAL MECH. SQI-7
understand that if the Wilding doe not currently have a tenant, that it is my
responsibility to notify the occupant of the requirements which mmet
be
,
4/
City, of N["rn ��!
prim to lmuane da Cenlllcate ofOavpanry.
.l
�•�� pace �},.�a � ,� �.W
Owner or authorized agent Date
t]TAL:
ISSUED BY:
OFFICE COPY