20986 APPLICANT TO FILL IN INFORMATION.WITHIN RED LINES — USE BALL POINT PEN ONLY
Bui b o act Identl(latlon
• BuOding Addrevi - PERMIT NO.
77"7 41440 w11- Y e0/0"7-.Yo
20986
nen arae: ane:
I AL DA IE
J k-k•� CITY OF CUPERTINO0.BUILDING DIVISION
cwnbawr.Name: u=.Nw:
APPLICATION / PERMIT Z —cd
Archimt/Engineer: BU[LDING-ELECTRICALPLUMBLNGMECHANICAL CA RY CONTROL
Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address
PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby offlim Ilia,Isonlicensed under pnwidone of Chapler9(¢mmeno- APPLIANCESRESIDENfIAL
Ing with Sect1on7000)of Divislon3ofthe Businemand Profemlons Code,md my IOB DESCRBTTON
license is In full force and effect.LimePANELS
D.m Clam LIcN fr3���� �O �e�
Date Contractor 1(J
ARCHITECTS DECLARATION 701-IWOAMPS '
0 O f understand my p6m sMB M used m public records. OVER 1030 AMPS
C SQ.FT.FLOOR AREA 5/SQ.FT.
(/ Licensed Professional SIGNSELEC G
OWNER•BUILDER DECLARATION
rpm Ihereb affimn that l amexempt from the Contractors,License law for the SPECIALCIRC
K�7 9;: following reason.(Section 7031.5,Business and Pm(evbne Code:Any city or
1't9 oountywhkh rcqubeaapeaNt toromtrvct,allen improve,demol6h,orrepalr P.METER N
3� anystmctumprlortolts6wame,alsorequimsiheepphmntforsuchpermltto
file a signed statement that he Is licensed pursuant to the proWioro of the D
3 0 Contractor's License law(Chapter 9(mmmencing with Section 7000)of Dlvl-
i.,� elan 3 of the Business and Profemiom Code)orlhat he is exempt lherefromand N RI VALUATION
G theW ss,for the alleged exemption. Any Walabo' of Section 70315 by any
,pJ O I antfora permit subjetetheappl'cantle adsI pemltyofnot morethan O TCHFS-E
n flv�eundrM dollen IS,AO. ` V
�n I,as owner o(tM my employee
g NEW DENTIAL ELEC SfOEES TYRECONSTRUCTION
P
or to Lea with we ee ce the sole SQ.FT.
compematlon,wW Bothe wmkandthn"oem 6not Mended or of
for
q vie(Sec 7094,Business and Profemin Code;The Cont'actoYe L Law
$ Boca notapply to en owner ofproparywho builds orimprwea thereon,and
whodmssuchworkhimmlfarthrwgh Msown employee"provided tMtoaeh OCC GROUIs RFS,l/NI'IS
Improvement,arc not Intended oro(fared fe"'a" If,however,lhebulIr m TOTAL:
Impmvement 6aold withinoneyearokomplelbq tMownerbuBderwlllhave
I
1 men ofpmvingthat he did nolbulldor improve(m purpose is QTY. PLUMBING PERMIT FEE
LJ I,as owner of the Property,am exclusively cantmRing with Ilmved FLODD TAME APN
rontracton to romlmct the project(Sec,70th,Buelnem and Profemlom Code: PERMIT NUANCE
The Contrsctors LI¢rue law does not apply to an owner a property who
builds or Improve thereon,and who,contracts for such ptojeats with a ALTER-DRAIN&VENT.WATER(W
Ks)B¢nnd pursuant to the Contractee.License Law. FEE SUMMARY
LP I am exempt under Sec B&P C for this mason BACK FLOW PROTECT.DEVICE
Owner A pREA,ODND. SANITARY Y_ N
.J' l_ Dar. 97�7i715— DRAINS FLOOR ROOF,
OR fAN MP�ENSATION p�ECLARAII RECEIPTp
❑1 hMbyM.that 1 have•certificate of consent to se161nwre,m a FIKTURES PER TRAP SCI IDOL TAX Y N
certificate of Workers'Compensation Insurance or a cer1ified copy thereof(Sec. RECEPN
3800,Lab C.) GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y_ N
Policy N
s ComnroGAS EA,SYS EM.OVER 4(EA) REL®TN
'EfCeydh
' BUILDING DIVISION FEES
❑Certified copy Is filed with the city Inspection division. CREASEANDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF ERSIFTSON FROM WORKERS' - GREASETRAP PAID
COMPENSATION INSURANCE
(This sectlonneed not be completed if the permit 6 forces hundred dollars SEWER"SAND'ARY-SIORM EA,ZOOFF Date Recei the
(5100)or len.) _
IcertRythat t,the perforranceof thwweek(orwMch this pertNt6blued, WATER I-IFAT}]t W/VENT/ELECTR ENERGY FEE Y_ N_ --
I shake not employ anyme,Laws In any manner so m to become subject to the
Workers'Compenastion laws of Glifomia.Date WATER SYSTLM/TREATING PAID
O Z Applicant
Z NOTICE TO APPLICANT:R,after making this Certlflate of Exemptlory you NEW RFSIDPNTIAL PLMB.__yQ}T, Date - Recel f#
1- N should berome subject to the Workers'Compensation provisiom of the Labor
Code,you mutt fo=10h comply with such prov6lom or this permit shall be TOTAL:
W d¢med revoked. .
1
IL p CONSTRUCTION themaLENDING AGENCY SEISMIC FEE (1�
I hereby affirm that there 6 a comtroctlon lending agency for the peKomt
D Z ane of the work for which this permit 66sued Oise.3097,Civ.G.)
TOTAL: ELECTRIC FEE
LL O Lendms,Nam PLUMBING FEE
LL F Lender.ytho"" QTY. MECHANICAL PERMIT
O w ced ylhetl ......dth6epplkatbnendeatethaltheabove nformMion FEE MECHANICAL FEE
IS. bmmet.l agresto comply with all city and county ordinances and nate laws PERMIT ISSUANCE F. PAID:
} W relating to building romtrudion,and hereby authorize representatn,ea of this
f Z city to enter upon the abovo-mentbr�M Properly(rn Wpectlon purpose, ALMORADDTOMECH.
(WC)agree to save,Indemnify an d keep harmless the City of Cu Fenton Date Recel tp
against liabilities,judgments,amts and expenses which may N any myamue AIR HANDIJNG UNIT 10,ODO CFM)
aA Iasi City once th granting Ofthlspwrred. SUBTOTAL:
AIR HANDLING UNIT(OVER 10,(100CFM) CONSTRUCTION TAX
s rare Applicant/Contractor Date MHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appllcant orfutum building occupant store or handle harardous HEATING UNIT(TO 100,000 BTU)
oummsl as defined by the Cupedino Municipal Code,Chapter 9.l Z,and the Date Red to
11ealthand Safety Ccd ctlon25532(.)7 HEATING UNIT(OVER 100,000 BTU)
1_71Ym No TOTAL:
Will the applicant tum building occupant use equipment or devices VENTILATION FAN(SINGLE RESID)
which emit Mra rdous air Contaminant,as cleaned by the Bay Area AU ISSUANCE DATE
Quality Management DLatdt7 BOILER-COMP OHP OR 100,OW BTU) pp
(, 4 Yes ``��No pimg
have mad Healthe h
a Safety
tCode,6mquirement,5533 aChapter6.95 of BOILER-COMP(OVEt IOD,l100 BTU)
the California Health&Safety Code,SectlOm 75505,25533 and 75536.I
understand that if the building does not currently have a tenant,that it 6m NEW RESIDENTIAL MECH. SQ.FF. SEP 2 1990
responsibility to notify the Occupant of the requirements which most be met
prierto usaw. aCcdifi�ce.tepf0ceg3vey-
er autFadmd agent_C\\yvx�C�J•'"e^"-'—y//(e o La'rfv rat .LI A
:a E TOTAL: ISSUED BY; 'l
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