19695 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES — USE BALL POINT PEN ONLY ,
Building Prom Identification 7 - PERMITN'O.
Bullding Addma: t , 1 9 6 9
oti3Josevl � Glut Lot Z
sacra r sane: A A
OSF—PR POLL"— aSSOC. 25S -2a8 CITY OF CUPERTINO-BUILDING DIVISION �T_ �3_/? O
c° °radar'.Name: ' /Lm.Na: APPLICATION I PERMIT e7 77
SIS(L SOZ9 5 S BUfLDING-ELECTRICALPLUMBENG-MECHANICAL CATEGORY C M
AmMmet/Engineer. -t-^ Lic.NO
ftAAJ GLI— C.^ O BUILDING PERMIT INFO
_y
- - 5- � w QTY ELECTRIC PERMIT PEE
PERMIT ISSUANCE . 00 lbll I�e(� IlX
LICENSED CONTRunder rDECLARATION llJOB Ll IO ILL.ILLPPP
Ihereby a((170that lamlicensed 1o.3of underpr°vislonao(Cha...0 e,and APPLIANCESRESIDENTTAL - JOB DFSCRfITION
Ingwlth5ed1on7000)of Dlvlelan3ofthegualnenand Pro(ns(oneCode,and my -
license Ia m tut�rce and dlM. - PANELS
Llmn.e Cho LION f7Z
Date 2.h.TC 201-1000 AMPS
ARCHTTEHITEt�'CLARATION
q�q�uu
9
0 ZO I understand my plaru shat 6e used u public records. OVER 1000 AMPS - SQ.IT.FLOOR AREA S/SQ.IT.
k Licensed Professional SIGNS ELECTRICAL I S
<<�Q a OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC T' lT,
Z F•iWd Ihercbyafllrm that lamexempt from the Contractor'.License law for the .
pp following reaeen.(Section 78115,Businaaa and I7rofembm Code:Any dty Sar _4 p o. G e nAc�=
uct,alter, ve, TEMP.METER OR POLE INST.
F� countyreqpemate,al3otocrouquirestheb pro.tf.rderrWh• .r ttr
any swdure pde.mente that
he Is aisensed pursuant t the fonuconal of t e ,
O file a ct.r. Ice.sat that he t licensed pursuant to the Ion 7000) of the POWER DEVICES { -
C-nnlradorS Llcerae law(Cha er 9( ndn with Section 7000)of Diel.R SWIMMING POOL ELECTRIC
1. the basis fo the alleged
and Pmfealon.Code clarat ion of exempt therefrom and L VALUATION
the bean for the alleged exempttors. Any clarion of Section eat re by any OUTLETS I / 6/
O five hundred fora perrtdbubject he applicant actvll penalty o(nat mare than s
live hundred dollars NEW RESID TR `� STORMS TYPE CONSTRUCTION
I,as owner o(Ihe pro cry Players w h n IM1elr sole
CCZ6 compensation,wilidothA rk, structure Is nt�or offered far a
$ ❑ Saic(Sec.7046,Buame.9 lora a:The al.ittrue
dose not apply to en ow a of.p perry w d m ca thereon,and OCC.GROUT' RES.UNIT'S
0.0. whodoessuchworkhi tor/hrwgh M1b ours eee,pmvided that such -
Improvement.aream nded oro e r Ie.IL ever,thebuildingor TOTAL: .Q
Imp r,anartiasoldwit moneyed, fc Idlon,flu mer-builderwillhave
t",deno(pmviegthat he did n t 11 or 4nprove for puryweof.40. QTY. PLUMBING PERMIT FEEFLOG TZANE APN
u L as owner of the property, m ex lusively contracting with licensed PERMIT ISSUANCE
contrad
on,to construct the project(See.7044,Business and Profedilons Code: '
The Contractor'.License law don nm apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilda or Improre
ves thereon, and who contracts for such p(o)eda with a
m,Blador(.)licensed pursuant to the Cmdrador'a Lianm Law. - FEE SUMMARY
IJ I am exempt under Sec. R &P C for this reason BACK FLOW PROTFAT.OEVICE
FITq
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y'.. N�
Owner Date RECEIPTNN
WOR"AN COMPENSATION DECLARATION pD(nygES PER TRAIT SCHOOL TAX Y N
.hereby a((Irm that I have a ientOcate of consent to self-insure,m a - RECEIPT M .
c•00 cotee(Workeri Compensation lrau rance or a mr,i(led copy thereof(See. GAS F.A.SYSTEM-1'ENCA OUTLETS PARK FEE Y -.N'
3800;Lab CJ '
policy N _ RECER7f i--
-
CTA.SYST W OVER 4(EA)om anv IZ-�'N40N BUILDING DIVISION FEES
crtlBed py Is filed withh the city
inspection dlvWon. GASe
1��JpCenlOed copy Is herebytGREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE O .g
S..ICmhty ,a/ a
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID Nx7/ Sy�S
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FTDate Recei til
(This ion need not W completed if the permit is for one hundred dollars . -
(St00) x,la orlam.) 1 WATER HEATER W/VENT/BLLCTR ENERGY FEE Y N
Ill am thatemploy
to the pckor o,in an the work(orwhl h this become
b usual, —
I shall oat employ any perwn in any manner at u to Wcome abkd to the WATER SYSTEM/TRPATINC 9
Worken'Compenaation Laws of CalBornla.Dale PAID 4 /& 5AIj.� /
Z.Z Applicant' NEW RESIDENTIAL PLMB. SQ.FT. Date Recei of
O NOTICE TO APPLICANT:If,after ma king t his Ceniflcale of Exemption,you
should become subject to the Workeri Comperoal ion provtalom of the Labor TOTAL:
~ N Code,you=at forthwith comply with such provisbta or this permit shall be ! J
> deemcdrevoked.. BUILDING •
EE
LU CONSTRUCTION LENDING AGENCY SEISMIC FEE �.
I hereby af(Irmthat there is a ceralructlon lending agency for the perform- ELECTRIC FEE
Z an.oftheworkfor which this permit is iseued(See 3097,Civ.C.) TOTAL` .Q
'u O Lender'.Name - - &� PLUMBING FEE
LLh- Ienaer'.Adarcaa - QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW . l mditythat l havereadtheappllcation and datclhat theaboveinformation ' .
tl Is correct.Iagree tocomply with all eltyand county ardleances and slate laws PERMTFISSUANCE �{.— FEES PAID: .
relating tobulldleg emstrudlon,and hereby authorize representatives of this
F Z city to enter upon the above-mentionedinspection property fee purposes. ALTER OR ADD IO MECH. Date RLYei t#
_ (We)agree to Save,Indemnity an d keep harrams the City of Cupertino
against liabilities,judgment.,mks and expenses which may In anywayaosus AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: Q.7
nst cold City
AIR HANDLING UNIT(OVER I0,00(3CIM) CONSTRUCTION TAX
SI ore of Applicant/Contractor Dae EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE'
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)
materialDate RCCCI t#
as defined by the Cupertino Municipal Cade,Chapter 9.11 and the -
Ihaithand Sa(dy Code Section25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL-1Zi a
❑Yea N No
Will the a ppliwnt or futu on building occupant use equl poset or devices VENTILATION FAN(SINGLE RESID) I$f�l �NCE'DATE
which emit havnlou.air contaminants as defined by the Bay Area Air �,
Quality Mawgement District?No ROLLER-COMP DHPGR 100,IXp BTU)
n❑ Yee �❑'7 No 'A
`Thavc readthehazardous male rialsrequiremenlsunderChapter6.95of BOILER-COMP(OWB100,000BTU) f AY �� �Qn`T
the Callfornla Health&Safety Code,Sections 25505,25533 and 25534. I 9
understand that 11 the building does not currently have a tenant.that It is my NEW RESIDENTIAL MECH. SQ.FT.
resposondlity to not lfy the occv p.at of the requmancels which at be mel
prior to Issuance of a Certificate of Occupancy. ..:V of^II^rrt/17
Ownrr or authorized agent I Data - ISSUEDBY� s .{.
TOTAL:
OFFICE COPY '