23554APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Buildin Pro act Identification
PERMIT NO.
2 3 5 5 4
Building Addreea;
o�, I
wee c _ one:
CITY OF CUP TINO-BUILDING DIVISION
APPLICATION /PERMIT
A
_
°"" • °' a
PA4L
BUfLDINGELECTRICA4MWBINGMECHAMCAL
CATEGORY
CONTROL N
A h ct/ neer. No.
"QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:
mum" ml�h
❑ ❑ ❑
PERMITISSUANCE
LICENSE DCONTRl DECLARATION
Ihereby ection 70NafDivJg 3oftheBu3in 4slonsofChapter fmions9de,and c
underS
Ingwith Section 700D)of Dloff1d. ofNegusinessandProlesslonaCode, and my
limnseisin to effect.
Date Contractor —
APPLIANCES -RESIDENTIAL
�IQI
JOBDF—VWre.isl�'N
/`�j�'-�`r�
-
PANELS
201-1000 AMI"'
ARCHITECPS DECLARATION
•/Rl�iy`�
OVER 1000 AMPS
SQ. FT. FLOOR AREA $/SQ. FT.
I understand my plana shall be used as public records.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
1 herebyaffirm that I am exempt fronothe Contractor's Llmme law forthe
following reason(5ecUon 70315, Business and Professions Code: Any city or
coifmywhich.qubasapert tw..0 d,alter,impmve,de=Wh,ormpalr
D '
K
SPECIAL CIRCUTIM19C
TEMP. METER OR POLE INSE.
any structure prior to its issuance, also requires the applicant for such permit to
fib a signed statement that he is licensed pursuant to the provisions of the
POWER DEVICES%
/� �1
(� C/
SWIMMING POOL ELECTRIC E
OUTLETSSMICHESFIX"ES
Contractors License law(Chapter 9(commencing with Section 7000) of Mot.
sian3 of the Business and PrefessivesCode) orthat he t exempt therefromand
the bast for the alleged exemption. Any violation at Section 7031.5 by any
applicant fora permit subjects the applicant to a civil Ex,.Ely W not monethan
Unn
NEW RESIDENTIALELECTR SQ,Fr.
fivehundredI, a sreddollars ofthe M.
pro with wages as there sole
um L as owner the property, or
STORIES
TYPECONSIRUCTION
will he ouchre 13 for
and Iheatmdure b not Intended or..
mmpenaat044,
sale (Sec Business and
Business and Code: The Contactors Licame law
L
f penile ty
docs not apply to an owner of property who n lids or improves thereon, and
apply to
who himself htowne eq that ouch
OCC. GROUP
RFS. UNITS
amwork
nded orough
Improvements er, theprovided
Improvement arenMintendedoro(feoo for sale.ILhowever,
. If, ho
TOTAL:
Improvement tnld withinoayeam(completion,theowner-bu0derw111 have
deer iii have
tlrdao of proving that he did not Wfid or improve for purpose of sale.).
u own. of as ownof the property, am exclusively contracting with licensed
coto MMtMd the project (See. 70K Business a nd Professions Code:
QTY, PLUMBING PERMIT FEC
FLOOD ZONE
APN
PERMIT ISSUANCEntractors
The Contractor's License Law does not apply to an owner of property who
Wada or Improves thereon, and who contracts for such p(u)eda with a
��7W(actor(.) licensed pursuant to the Contractors Lt... Law.
LJ l am exempt under &e B & P C for this reason
ALTER -DRAIN& VENT-WATER(EA)
FEE SUMMARY
BACK FLAW PROTECT. DEVICE
OUTSIDEFEES
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y_ N—
. . RECEIPT 0
Date
WORKMANCOMPINSATIONDECLARATLON
QI hereby affirm that 1 have a cartificate of consent to seUdnmm, or a
mrtificateofWorken'Comperualion I.... ora nrtifledcopythereof(Sec.
3800, Lab C.)
Policy
FD(TTIRFS PER TRAP
5CHOOLTAX Y N
RECEIPT M
GAS EA.SYSTEM-1INCA OUTLETS
PARK FEE � Y N
RECEIPT M
p
Cam any
GAS EA. SYSTEM -OVER t (FA)
BUILDING DIVISION FEES
Bled copy t hereby furnished.
YmL/ertl(letl copy b (fled with the city inspection division .
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECKFEE
C
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
COMPENSATION INSURANCE
CFhla section need not be completed If the permit t (ororN hundred dollars
Date Recei [N
,�gy-gTORM EA. NOFT � —
RIOTER BEATER W/VENT/ELCCIR
ENERGY FEE Y_ N_
W00)orless,)
I.Kifythat In the per(ormana of the work forwMch this pevdt Is blued,
WATER SYSTEM/TREATING
I shall not employ any person In any manner an as to become subject to the
Wealmrd Compenaatlontaw.o(Califernt. Date
PAID
NEW RESIDENTIAL PLM1L SQ.FT.
Applicant
Date Remipt
NOTICE TO APPLICANT: If, after making thisCertificate of Exemption, you
should becomesubject to the Wmk rs'Compr.tlonp mixture ofthe Labor
TOTAL:
BUILDING
Code, you neat forthwith comply with such provisions ortht permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I hereby affirm that there t a construction lending agency for the perform -ELECTRIC
an m of the work for which this permit b issued (Sec. 3097, Cie. Q)
Lender'. Name
Lendeh Address
I artlfy that haveread this application and Natthatthe above Information
tmrrect. I agereto coreplywilh all clly.ed countyordtances and Nate laws
FEE
PLUMBING FEE
a'
QTY. MECHANICAL PERMIT FEE
MECHANICALFEE
PERMIT ISSUANCE
FEES PAID:
relating to building construction, and hereby authorize representatives of this
citytoenter upon the above,mentioned property for Inspection purposes.
(We) agree to ease, Indemnify an d kap harmless the City of Cu pertbm
agalodllab0lties,udgment, co aandexpense wMchmeyinanywayaccom
-
ALTERORADDTOMECH.
Date Recel til
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
ag.irldp y ns en the granule hPermit. t
AIR HANDLING UNIT (OVER I0,o00cFM)
CONSTRUCTION TAX
I�/'•a J''N�JJ
Slgwv�o�plicant/Contractor Data
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BT U)
Date Ret:ei tW
Will the applicant orfuture building occupant store or handle hazardous
material as defined by the Cupertino MuNdpal Code, Chapter 9.1 2, and the
Elea 11h and Safety Code �Se,ttab 25532(a)2
Yee - rlQo
Will the applicant o ewra building equipment or devices
which emit hamrdou. are meta runt.. defined by the Bay Area Air,
uali ecnt DTs rict
Qty Marugm
HEATING UNIT (OVER IM000 BTU
TOTAL:
�—
VENTILATION FAN (BINDLE RFSID)
ISSUANCE DATE
PAIDi
BOILER -COMP (3EI'OR 100,000 BTU
Y
nT rs o
have read the batlFacus materials requirement under Chapter6.95 of
the California Health & Safety Code, Stolons 25505, 25533 and 25534. I
understand that if the building docs not mrrently haveatenanl, that it is my
respoiuibWtytonolifytheoccup.rd ofthe equimment which must be met
prior l niq creme grtui t ofOavpa
loorr J
APR 22 1992
�\
/� 0\1-k
Gil i (�i' GUI't ii tarsi ,( 1 k
ISSUED BY: \`^//%
BOILER-COMP(OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQdT
Owner auutthhad-fzedLgent D�e
TOTAL:
OFFICE COPY