22470APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT -PEN ONLY-
Buildin Pro'ed Identification F'l u, l.Y ^
BURdiry{ Add.
M1
PFYTNO.
122470
wnen otos: one:-
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT.
L-
BUILDINC-ELECIRICAPLUMBING-MECFIAMCAL
A - _
�' �C•�
Contractoro Name: Lic. N.
CATEGOR
-
CoyROj MO /t
t b
Architect/Gglneer. Lk. No:
Qry ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:
�R1
PERMITISSUANCE
-LICENSED CONTRACTOR'S DECLARATION
]hereby aftirmthat l am licensed under provlslonsaf Chapter9(commem,
ugwlthScctlon700R)of Division3ofthe Businessand PratessionsCixe,and my
license is In full force and effect.
Li®nm Clam LIcN
Dale Contractor
--
ARCHITECRATION
I understand my plaru shall be used
useedd aas s ppuublic records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that l am exempt from the Contractor's License Law for the
'following rcuon.(Section 70313, Business and Professions Code: Any city or
rom
untywhich rcquirwa permit tocorutruct, alter, Improve, deoli.h,compair
any structure prior to its Issuance, also requires the applicant for such permit to
file a signed statement that he b Bmnsed pursuant to the provisions of the
Contractor's License Law (Chapter 9(commencing with Section 70D) of Divi-
sion3 ofthe Busloweand Profwalma Ce,10.,that heb exempt therefromand
the bash for the alleged exemption. Any violation of Section 7071.5 by any
appBcant for a permit subjects the applicant to a civil penalty of not marc than
five1, asrcwner of she W).
withtended r there sole
I, as owner o! the property, or m compensation, will dotlix, work, and the structure is offered for
Code: The Contractors Lim.hereon Law
toalnow ami of property
sale(Sec. apply
does whodotapplytoanowner ofthroug hisobuilds nemplrlmproves ovidedreoRand
whodoments amrkhimselfed orough hloowneor . If,ho eprovidedthatsuch
improvements sold wlntenone Warofco pldio.lbhoweveg deer ilI g orhave
Improvementhsold wlNinoneyearofdompldlaMtheownenbulWerw111 have
t enof proving that he did not build or improve for purpose ofwLe.).
I as or of the property, am em1twivaly contracting with licensed
ntnctoosto rorutiuct the project (Sec 70K Business and Profe s tom Cale:
e Contractor's License Law does not apply to an owner of property who
Eds or Improves there on, and who contracts for such pWjeds with a
,a4actor(.) 1lmnsed pursuant to the Contractor. Lim.. Law.
LI I am exempt under Sec. B k P C for this remora
APPLIANCESRESIDENTIAL'
JOB DESCRIPTION
PANELS
201-1000 AMPS
. OVER IOW AMPS -
SQ. TrE FLOOR AREA
'
- -
S/SQ. FT.
SIGNSELECTRICAL
SPECIALCIRCUIT/MISC
P.MEI'IROR POLE ]NST.
POWER DEVICES
POOL ELECTRIC
SWITCHES-FIXTURESes
VALUATION
-
NEW RFSIDFNTTALRIXuR SQ.Ff.
STORIES
TYPE CONSTRUCTION
<'
QTY, PLUMBING PERMIT 'FEE
OCC.GROUP
RES. UNITS
'
FLOOD ZONE
-
APN
pp IT ISSUANCE
-
ALTER -DRAIN k VENT - WATER (PA) '
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE FFr'a
DRAINS FLOOR ROOF, AREA, GOND.
SANITARY Y_ N_
RECEIPT#
Owner - Date
' WORKMAN COMPENSATION DECLARATION
C31 hereby affirm that I have a mrtlflate of consent to self -Insure, or a
mrtlflcate of Workers Compensation Insurance ora certified copy thereof (Ser.
3800, Lab CO
M
FIXTURES PER TRAP Pte'
SCHOOL TAX Y_ N_
RECFR'I' M
S FA
GA.SYSTEM-1 INC.4011TLET5
PARK FEE Y N
RECEIPTM
GAS RA. SYSTEM -OVER I(FA)
Cam a
Cook ny,
BUILDING DI VISION FEES
Certified ropy is hercbytehed.
Certified copy is filed with the dty.IrupMion division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(fhb section need not M completed It the permit h (Drone hundred dollars
(f]W)orly that
I llnot that emIn ploy anyhe arson I m of the neerweeso as to b co pesubjec booed,
I shall not employ any person in any manner so act to became subject to the s'Com
Lewy o(Call(arnla. Dale
Applicant
Applic
NO]lCETOAIsuLIGNT:e after making thio Certificate pro is Exemption, you
shaldbucmrcforth it the Worken'...h po isinprovhlomafthetabor
Code, you must forthwith comply with auch pmWbru orlhh permit shall6e
deemed revoked, �
CONSTRUCTION LENDING AGENCY
' I hereby affirm that there Is a coommuction lending agency for the perforn,
ance of the work for which this permit b issued (Sec 3097, Civ. C.)
Lender. Name
Lender'.Addrev
lconifythatlhavereadthbappBmtionand statethat theabave Information
isrorrect. Iagrestocomplywith all cityand rountyordlnances and state laws
relating to building construction, and hereby authorize represenlalives of Bit
city to enter upon the above-mentiomd property for lropMlon purpoxs.
(We) agree to save, indemnify an d keep hawidth the . i O( Cupedlno
against liabilities, judgments, may Inanyway accrue
queroofth a granting
ago' Ity in roneryuenm of the granting o/thls perml.
J�_q�
GRFASE/INDUSIRLWASfE INTERCEPTOR
PLANCHECK FEE
bQ
PAID 27 k �-Z Ll7U
Date Recei tp
GREASE TRAP.. -
SEWER-SANTrARY-SIURM EA 200F1.
WATER IIFATER W/VENT/ELECTR �a
D•NERGYFEE Y. N
PAID ✓ I �!
Date' Recel of
'
WATER SYSTEM/TREATING
TREATING
NEW RESIDENTIAL PLMB. :OFT,
.TOTAL:
BU •E.
,
_
SEISMIC FEE
-
ELECTRIC FEE 3
_
t
MECHANICAL PERMIT FEE
PERMITISSUANCE _
PLUMBING FEE 11 lb
MECHANICAL FEE
1,1114b "A
—
OR ADDTO MFOH. , v
Date Recei t41
AIRHANDLING UNI"1'(fO 10,000 CFM)
SUBTOTAL:
AIRHANDUNG UNIT (OVER IB,WBCF M)
CONSTRUCTION TAX
Igoatupphcant/Contractor - Date
HAZARDOUS MATERIALS DISCLOSURE
Will capplicant orf utumbulldingoccvpant st.eo,handleha rdous
material a. defined by the Cupertino Municipal Code, Chapter 9.12, and the
Heshhand Safety Cade Sectloo 25532(a)7
❑ Yes ,_I No
Will the applicant opium bcilding occupant use equipment or devices
which emit harardous air contaminants as defined by the Bay Area Air
Quality Management District?
'?Yea n❑ No
have read the harardim materials mcFairemantsunder Chapter 6.95 of
the California (Irate, h Safety Code, Sections 25505, 25533 and 75534: I
understand that if the building does not rorrcntiy have a tenant, that it is my
respwwlbllllyto notlfythe occupant of the mquirementswhlch must be nal
Priortoux%i.rmof a certificate of Occupancy.
XH
EAUST FLOOD (W%DICT)
CONSTRUCTION TAX PAID:
`.
HEATINGUMT(TOiW,WO BTU)
Date R
TdOOL71:
HEATING UNIT (OVER 100,000 BTI)
VENRILAI'ION FAN(SINGLE RFS] s',,,I$$UANCE
_
DATE
pp
p{ D
AUG 93
cHI11 U
ISSUED BY:
BOILER-COMPOHPORIW,"BTU)
BOILER -COMP (OVER 100,000 BTU)
NEW RrSID AL MECI1. SQ,
—
, '�a�,
_
- -L.
Owner or authorixed agent Date
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OFFICE COPY