23272APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Addoam:
PERMIT NO.
Egsr �- T
23272 327n
nam _ one:
A A
6ler U
CITY OF CUPERTINO-BUILDING DIVISION���
APPLICATION it PERMIT
.r'a ante: LMe.No:
xw.zG°^
mhltect/Engineer: — Lk. N.
BUILDING-ELECTRICAI?PLUMBiNG-MFGFIAMCAL
CATEGORY
CONTROL p
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Addreaa
I'FFRM177SSUANCE
❑ ❑ ❑
CONTRACTOR'S DECLARATION
LICENSEDthat
I a
I herebyaffirm70t0)of Di licnsedunder p,ovtdooaof Cskons e,andmc-
lfi,givithearse ISection 7000)of Dl effect 3o(the BuelnessandlarolcaslonsCode, and my
icense le ine��ccqQ effect. / r p
Linnse la _p!Lic.p CW .s�/
APPLIANCESRESIDENTIAL
JOB DFSCRF'I'ION
PANES
Dat Conbanor ���LIP
ARCHIT co"SDE TION
I understand my plans shall be used as public records.
TO 200 AMPS
x11"1000 AMPS
OVER I ODO AMPS
SQ. FT. FLOOR AREA
S/SQ. Fr.
SIGNS ELFCFRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affinothat I am exempt fromthe Contractor's License Law for the
SI'FLIAL CFRCIRT/MISC
TEMP. METER ORIOLE INST.
_
following reason, (Section 70LS, Business and Professions Code: Any city or
county which requires a permit to romhuct, alteq Improve, demolish, or repair
any simmer prior to its bwa race, also requires the a ppllcant for such permit to
file a signed statement that he b licensed pursuant to the provisions of the
Contractor's License Law (Chapter9(commencingwith Section 7000)of Divi-
of the Business and ProfessionsCods).,the he bexempt iherefromand
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant for a permit subjects the applicant to a civil penalty of n.t morethan
Ove hundred dollars (SM.
❑ I, as owner of the pmpe ty, of my employees with wages as their sole
rompenmtion, will Bothe work and the structure b not Intended or offered for
POWER DEVICES
gWP1MING POOL ELECTRICsi.n3
VALUATION
390
/
OU7LETSSWITCHESFlXNRES
NEW RESIDENTIAL ELECTR SQFT,
W . TY E CONSTRUC ON
sale (Sec 7044 Business and Professions Code: The Contractor's Licnse Law
docs not apply to an owner of property who builds or Improves thereon, and
who does such work himself or through his own employees, provided that such
OCC. GROUP RES. UNITS
Improvements are not Intended oroffened lorsale. IL hcwcvep thebuildmg or
Improvementbsoldwithinoneyearofcompidiorythev ner-bu0derwllhave
t Nen of proving that he did not build or Improve for purpose of sale.).
Lj L as owner of the property, am exclusively contracting with licensed
contractors to roec nstruct the project (S 7016, Business and Professions Code:
The Commences License Law don not apply to an owner of property who
builds or Improves theism, and who contracts for such IxWjecis with a
cgnS[anor(s) licensed pursuant to the Contractor'. License Law.
L -j I am exempt under Sec. B & P C for this reason
TOTAL:
QTY.L HI P,BR IT FEE
,
PERMIT ISSUANCE I' t ..• r
I ! I�
ALTER-DRAI & VENT- WATER ffA)
F[.00D7ANE APN
-
_
BACK . WIROT-CT. DE.,—VICE u
FEE SUMMARY
3
UUTSI [IF FEES
Owner Date
/� c
DRAINT.ODRlA CO 4
I
ptt.SpER 7RAI•
SANITARY Y N
I RECQ['1, p
WORKMAN COMPENSATION DECLARATION
emby affirm that I have a .er ifieale of consent to self -Insure ora
cenificateof Workers'Co Np tionlrourannora¢difled copythenroffSee.
3800, lab C.7 n
PolkyN
SCIi LTAX Y_ N_
RECEF'r X
GAS EA.SYSTFM-1 WC.60IfILE15
PARK FEE Y N
RECEF'TMVFR6(FA)
������07T03
Com anY ('tA /09/I
[PCenilled ropyb hereby (urnlshed.
�f'jrtl/rd ropy b flied with the city InspMion division.
GAS- EA.SYSTFM-0
CREASE/WDUSIRL WASTE INTERCEPTOR
B UILDING DI VISION FRES
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WOR KERS'
COMPENSATION INSURANCE
(Thisseci(onneed natio mpieted fthepermitbforonehundredd°Ilan
(5103)orlessJ
not that in the person nce
I tmanner.astork obeco perNtbhwed,
1 shale not employ any Peron In any manner at as to become subject to the
Workers Compensation Lars of California. Date
Applicant
NOTICETOAPI'LICANT:If, after making this CeNflatte of coupon, you
should become subject to the Workers Compersatlon provblom of the Labor
Code, you =at forthwith comply with such provisions orthls permit shall be
deemed revoked.
PAID
Date Recei t±i
SEINER-SANITARY"STORM M. 20 F
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N—
—
PAID
Date Remi til
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. SQFr,
TOTAL:
G' •E
CONSTRUCTION LENDING AGENCY
I hereby work for w there baronslmctlsn lending d(Sec. agency097,0 r. C.) perform
arm of the work (or which this permit u towed (Sec. 3097, Civ. C.)
IerWer'sName
Lender§Addrem
I certify Nat I have mad thisappllotion and orale that the above information
I, correct. l agree to comply with all city and county .Ninancesand state laws
relating to building commotion, and hereby authorize representative of thio
city to enter upon the above-mentioned property for inspection purposes.
(We) agree to save, Indemnify and keep harmless the City of Cupertino
against liabilities, judgments, costsand expenses which nay In anyway acme
against mid City In consequence of the granting of this permit.
TOTAL:
FEE
C FEE
'
QTY. MECHANICAL PERMIT FEE
G FEE
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,030CFM)SUBTOTAL:
MECHANICAL FEE
D:
Reeeipt#
!SE
AIR HANDLING UNIT (OVER 10,000 CFM)
UCTION TAX
Signatureof Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
IXHAUST HOOD(W/DUCT)
UCT ION TAX PAID:
HEATING UNIT(TO t 00,ODO BTU)
Will the applicant orfum re building oavpant store or handle havrdoua
material as defined by the Cu ppppppeeeeeenim° Municipal Code, Chapter 9.1 Z and the
IInithand Safny Cad 2553](a)t
Yes No
ReCCI t#
HFATINGUNIT(OVER 100,000BTU)
TOTAL.
Will the applicant or future building ocmpant use equipment or devices
whichemithmoird. fteenta rants as de/l red by the Ray Area Alr
Ouality Management Dlstd
Yes
VW17LATION FAN (SINGLE RESID)
ISSUANCE DATE
gj A 8 L+A
PSI D
BOILER-COMPOH[POR100,IXt0BTU)
have he haza ous ma tedalarequlrementsunder Chapter6.95of
the Gll is ealth &Safety Code, Seniors 25 ,24513 and 255M.I
undo a t if the bull Ing don otou tl havcatenant titkmy
repo i h o notify oro mentsw 'c st be rtet
prio to u &a IOn o pa
MAY 13 sea
1Q92
CI I Y' ur GUrE 1' Rvk
ISSUED BY:
BOILER-COMP(OVEt 103,000 BTU)
NEWRESIDENTIALMECH. SQ.FT.
r or authorized agent Date
TOTAL:
OFFICE COPY