23680APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification
Building Address:
C;215-V9,C(%
PERMITNO.
/� /"g /"a /"� 0
G 3 �h18
sere. oftone:
r,L
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDINGELECTRICAL PLUMBINGMECHANICAL
A A A
Co act r'eNa Licc..�No:
'—+ `.ems 7/ �
CATEGORY
CONTROL #
ArcMtect/ gineer. Lk. No:
QTY ELECTRICPERMrr FEE
BUILDING PERMIT INFO
Address:
PERMITISSUANCE
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby
i -.with Seetion force andeffeon3o(the Buslnevand ProfeaslonsCode,and my
oction7")ofamlken3ofthcunder provisions dPmfmionsr c,andm
license bins form and
APPLIANCESRFSTDEMIAL
JOB DESCRIPfiON
/
PANELS
License Class LION
.#
Date Contractor
701-1000AMP5
ARCHITECTS DECLARATION
I understand my plamshall be used as pubecrecords.
OVER 1000 AMPS
SQ. FT. FLOOR AREA $/SQ. FT.
SIGNS ELECTRIC
SPECIALCIICI71
TEAtp,METEi(OR LE
Licensed Prefesskal
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason. 7031.5, Business and Professions Code: Any city or
county which requires a permit toronstruct, alter, improve, derrollsh,or repair
anystmumptlortoite ante,alsomqubestheapplinniforsuchperMtm
file a signed statement that he is licensed pursuant to the provisions of the
Contractor's License Law (Cha pter9(commencing with Section 7000) of Divi-
skm3ofthe Busi-esaand Professions Code)orthatheL cwmptthemfmmand
the basis for the alleged exemption. Any violation of Section 70715 by any
fora permit subjectathe applicant to a civil penalty of not more than
five 1, as owner
nerofthedollars pr.
❑Lasownerof theproperty,orhe employees nwithwage as their sole
POWER DEVICES DAT
VALUATION
SWI.Th9NC POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTIAL ELECTR SQ.ET.
SI'ORIFS
TYPE CONSTRUCTION
tion, will do the and theamcture not intended or offered for
role
sale(Sec. Business.work
(Sc. Profession Code: The
an h License Law
ppy to owner of or improves
apply loan owner ofp pertyrough who
does who does intelf or his owne.
nemorimpmovidedthRand at such
whodoemortsa
OCC.GROUP
Rf ,TS
net dedorwgh
If,hoes,providedhe ilding or
improvem ent iarenotintended earo co for sale. If, however, iklerwdl have
improverrcnth-Id within oneycaro(complaioMthe owner-builderwlll have
TOTAL:
tl eypurdao of proving that he did not bund or improve for purpose of sok.).
Ll L as owner of the property, am exclusively contracting with licensedPERMIT
contraciore to construct the project (Sec. 7044, Business ami Professions Code:
QTY. PLUMBING PERMIT FEE
ISSUANCEA�
V ri
p(gO z NE
AAPNr
The Con ohm's License law does not apply to an owner of property who
builds or improves thereon, and who contracts for such p(ojects with a
,5tp.aorta) licensed pursuant to the Contractor's License Law.
LJ I am exempt under Sec. B k P C for this reason
ALTER -DRAIN & VFM-WATER (FA)
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
OUTSIDE FEES
DRAINS A, COND. FLOOR, ROOF, ARE
�.�S PER TRAP
SANITARY Y N
RECEIPT N
Owner Date
IIaaAA WORKMAN COMPENSATION DECLARATION
11 hereby affirm that 1 have a mrtl0cate of consent to self -insure, ora
m iirole of Workers ComperwHonlnsurance oramrti(kd ropythemof (Sec.
SCIBOOL TAX Y N_
RECEIPT' N
GAS EA. SYSTEM -1 INC.t OITILETS
PARK FEE Y_ N
RECEI'r N
3800. Lab
1'ollmy p_`y_,z
GAS EA. SYSTEM -OVER 4 (EA)
Co�Cul Q, GGL
BUILDING DIVISION FEES
Certmed copy is here miffied.
Certified copy is filed with the city inspection division.
'C
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
GRFASE7RAP
CERTIFICATE OF EXEMPTION MOM WORKERS'
COMPENSATION INSURANCE
(TMs section need na be complded if ted permit h for one hundred dollar
(5100)oify that
I llnot that ti the Nor n in an (heworkmanner so as to b corn emnlHa iso ed,the
I shall not employ any person f any manner ro az to become subject to the
Workers' Compensation lawn of California. Date
Applicant -
NOTICE ca APPLICANT: If,a after making this ationlpro is Exempt a Lyou
n s or this p of the Labor
should become subject to the Workers' such provisions
Code, you mus: forthwith comply with such provisions or this permit shall be
Marcos revoked.
PAID
Date Remi t#
SEWER -SANITARY -STORM EA "FT
WATER HEATER W/VEE`/ELECTR s(�
ENERGYPEE Y N —
PAID
Date RC i t#
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. SQFr.
TOTAL:
BUILDING "E
TOTAL:
CONSTRUCTION LENDING AGE'VCY
I hercbyaffirmthat there hamestruction kndi-gagency, forthe perform.
arm of the work for which this permit b issued (Ser. 3097, Civ. Q
SEISMIC FEE
ELECTRIC PEE
Lender'. Name
Lsndcr'a Address
I certilythatl have mad this applicationand Gate that theabove information
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
bmrmct. I agreete, comply with all city and county-rdinarms and state laws
relating to building construction, and hereby author ice representatives of this
PERMIT ISSUANCE
city to enter upon the abovcme-Boned property for inspection purposes.
(We) agree to save indemnify an d keep harmless the City of Cupertino
against liabillties,judgments, costsand expenses which may in anywayacaue
permit.10,000
against said City in --sequence of the granting of this peat.
ALTERORADDTOMECH.
AIR HANDLING UNIT (TO CFM)
Date ReCei t#
P
SUBTOTAL'
AIR HANDLING UNIT (OVER I Q000 CEM)
CONSTRUCTION TAX
Signature of Applicant/Contractor Date
EXHAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Will the applicant or future building occupant store or ha nd le hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12 and the
HealthandSafety CQde ion 75537(a)7
❑ Yea �K I No
Date RCCCI t#
-
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION PAN (SINGLE RE9D)
ISSUANCE DATE
P A'
Will the applicant ELairc rebuilding occupant by theequipmentArea devices
which emithazardouaalrcontaMwnbas defined by the Bay Area Air
Quality Maagcmron Dlstrla7
Y:a No
BOILER-COMP(3FiP00,
OR 1000 BTU)
9hadrequirements
mode, h5533
BOILEILCOME (OVER 100,000 BTL)
salthe aChapte46.95-(
et Se ons 25505,
the Gliandt Health k Safety Code, Sections have Land, that It
understandthat
notifyithe the. does not e currentlyhavewhichL that It bay
responsibility to notify the ocmpant of the requirernents which at be met
JUN 18 1992
NEW RESIDENTIAL MECH. SQ.FT.
ior(o lssuanmofa Ce neat o(Ocmpancy.
UII1 V�(f vUl CfiI IIVIi
nem or out oriud agent Datelip
ISSUED BY:a
TOTAL:
OFFICE COPY