23848APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification -
building Address:
PERMITNO.
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77 ,C1 ,�-
1 G3j8(4 j8
Ph one:
U,�'TE/L
CITYOFCUPERTIN4DUILDING DIVISION'
APPLICATION / PERMIT
e"s" Q77Z
Cost 'd a Name: Le. No:
A" E 1a
Archt /Engineer. Lie. No:
BUILDING-ELFJCMUCA PLUMBING-MECHAMCAL
CATFOORY
CONTROL N
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
AddreuL/
1 PERMIT ISSUANCE . � a
❑ 3 1:1 ❑
1--�]
LICENSED CONTRACTOROR'SD RATION
I herebyfirm arolitersedunder provisions Pro Chapter9(mmmmc
Inense I Bectkn force of d citeon3o(the Bustnessand Pro(essionaCode, and
isms force end
AI'I'LIANCESRESIDENTIAL
JOB DESCBPITON
���
PANELS
Liven .If
Datenee Chm Cmd
Date Contractor
S,
201-IOOOAMPS
ARCHITECT'S DECLARATION
]understand mypkrushallbeused as publierecmds.
OVER1000AMPS
SQ. FT. FLOOR AREA
S/SQ.Fr.
SIGNSELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby afRrrnthat I am exempt from the Contractors License Law for the
following reeson. (Section 7031.5, Business and Professions Code: Any city or
countywhich requires a permit to mrolruct, alter, improve, demolish, oreepalr
5['ECIAL CIRCUIT/MISE
TEMP. METER OR POLE INST.
anystmettre prions its heuance,ahorequlresthe appllcant(or such permit to
file a signed statement that he is licensed pursuant to the provisions of the
Contractor's License too, (Chapter9(commencing with Seaton 7000) of Dist.
alon3 ofthe Businemmd Profession Cede)orthat he is exerepitherefromand
POWER DEVICES
SWIMMING POOL ELECTRIC
- - VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any
e the applicant los civil penalty of not ore than
apphcant fora permit wbjMm
five hundred dollars (&500).
n1, as owner of the property, or my employees with wages as their wk
OUTLETSSWITCHFSFIXTfIRES
NEW RESIDENTIAL ELFOTR eSQFf.
STORIES
TYPECONSIRUCTION
compensation, will d o the work and the structure is not Intended or offered for
.to (Sec 70K Business and Professions Code: The Common?. License Law
_
TOT 6
does not apply to an owner of property who Wilds or Improves themes, and
who does such work him eUor through his own employees, provided that such
Improvements are not intended oroffered for sale. If, however, thebuilding or
improvarmnt iswld withinoneyearafcompletio,lheowner-builderwHi have
OCG GROUT'
RFS. UNITS _
lhe*rden of proving that he did not Wild or Improve for purpose ofsale.).
L as owner of the property, am exclusively contrasting with licensed
contra, to construct the project(Sec. 70K Sunless and Professions Code:
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
FLOOD ZONE
APN
The Contractor's License law don not apply to an owner of property who
builds or Impmmves thereon, and who contracts for such ptojeats with a
cgplfactor(s) Bernard pursuantto the Contnctoes License Law,
L� I am exempt under Sec B & P C for this rew
an
ALTER -DRAIN. & VENT - WATER (RA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y N
RECEPT N
Owner Date
WORKMAN COMPENSATION DECLARATION -
of consent to opytneure, ora
❑1 hereby affirm that I have o Insurance
3800, Lab of Worken'Compensatlon Insurance oracertifled copythereo((Sec.
3800, Lab CJ
FIXTURES PER TRAP
SCHOOLTAX Y_ N
RECEIPT N
_ FIA.SYSTII.Mi
t
PARK FEE Y_ N_ -
Po1kyN
RFOFR'I'N
CAS EA. SY57'EMAVERd(F/s) ,�.
0
Com any
BUILDING DIVISION FEES
�Certlfied copy is hereby furnished.
Certified copy is filed with the city inspection division.
E/INDUSIRL WAS
PLANCFIECK FEE
G
CERTIFICATE OF EXEMPTION FROM WORKERS•
PAID '
COMPENSATION INSURANCE
(Thlssectian need not bacompletrA if the permit hforone hundred dollen
($100)orkss.)
I comlythat in the performnmo(the work forwhich this perrdt is in ued,
I shall not employ any person In any manner an as to become subject to the
Workers' Compensation laws of California, Date
-gAN17gRY-S[ORM FA _ a
Date RCcei [# '
WATER HEATER W/VENT/ELECT,
ENERGY FEE Y N
'
PAID
WATER SYS[FM/TREATING
ApplNOTICE
NdHCE ences, APPLICANT: a after making thissationlpro of ons oftExempa Labor
Lab
shouldoucroa
Workers•Compensationprovhisnermit
Date Recel t#
NEW RMIDENTIAL PLMB. SQJ-7
-
TOTAL:
forth ithto
co
Code, you must forthwith comply with such provisions or this permit shall be
s be
dcemM revoked.
BG FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affim that there is a crnstrudlon lendingagenay, forthe perform-
ance of the work for which this permit Is homed (Sec. 3097, Civ.C.)
Lender's Name
lender
TOTAL:
ELECTRIC FEE !:K1 WWI
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
PERMIT ISSUANCE
Lender's Address
I certilythatl have read thisapplkationand statethat theabovelnforeration
iscomert. I agreeto complywilh all cityand county ordinances and state laws
MECHANICAL FEE
FEES PAID:
relating to building construction, and hereby aUthmiae repersomatives of this
city to enter upon the abov nxentioned Property for inspection purposes,
(We) agree to save, indemnify an d keep harmless the City of Cupertino
'
Date ReCeIPt#
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
against babNtks,judgments, cats and expenses which may in any way accrue
against said City in conasquence d am ingd Is pemdt.
-l7,FZ
AIR HANDLING UNIT (OVER t0,000CIM)
CONSTRUCTION TAX
Signsture of Applicant/Contactor Data
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HA2 BOGUS MATERIALS DISCLOS URE
HEATING UNIT (TO 100,000 BTU)
Will the a ppUnnt or tutu re building occupant store or ha rad ie harardous
mterlaI as defined by the Cupertino MuolI Code, Chapter 9.1 2, and the
-Dale Revel t#
HEATING UNIT(OVER 100,000 BTU)
TO A
Health and Safety Cade Sedion25532(a)T
❑ Yes No
VENTILATION VAN(SINGLE REBID)
[$SUAjDATE
Willthe xpplianl or tore building occupant use equlpmnt or devices
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District?
QYra n No
have read the hav sus mteriahrequiremntsunder Chapter 6.95af
the California Health & Safety Code, Sections 25505, 75533 and 255X. I
G'
_
�i�.
JUN 17 1992
BOILER -COMP OHP OR 100,000 BTU)
BOILER-COMP(OVQt 100,000 BTU)
NEW RES[ DENTIAL MECH. SQ.FT.
understand that if the building don nor currently have a tenant, that it is my
responsibility to notify the occupant of the requirements which at be rot
prior to issuance of a Certificate ofOxxupa noy.
CIIY VV%f urCN
1k;
ISSUED BY:
Ownerorauthmiredagent Date
TOTAL:
OFFICE COPY