23342APPLICANT TO FILL ININFORMATIONWITHIN RED LINES —USE BALL POINT PEN ONLY
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BuildingP o en Identification -
BulldlnB� �sV V L-1 PUD / L_N S -
PERMIT NO.
23.342 ,
sore: hone:
wrote i.. L_ a 9'"79F
-
. CITY OF CUPERTIN0.BUILDING DIVISION,
APPLICATION'/ PERMIT
BUILDING-ELMTMCAI PLUMBING -MECHANICAL
c°n anor.Name:, Lic.N.:
'CATEGORY
CONSROLM
Architect/Engineer. - Lk. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:
PERMITIS5UANC
❑ ❑
LICENSED CONTRACTOR'S DECLARATION
IherebyBion that l am hcensel under provisions °fCh.pte, 9(.a,
lcn3o(theBuslneasandProleaslonaCode,and my
time.ingwith /.full forcea and
Lcense le In full farce and dfect.
License Clam LIC#
Date - Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used u public records.
Licensed Profeaeloral
OWNER -BUILDER DECLARATION
License Anyckyhe
Iwiagme(0rm Sectimmezempt(ro ossa d Professions
montingreasequirsta per 31$Business and Pmprove, Code:Anydtyor
mantywhichrequiresaie a e,alsom4ct,alter,Improve,demolish,orrepelr
anyasignerepriorroltahat Eve is, alansed poslotot to ontforisions of to
t.
fie a actor. statement that h5 is (Chapter 9 (coed pursuant to the Pon 7000) of the
sion3ofth'dLIcerueLndPoxfohoe (commenting with xemptthe00)om and
theivi-
basis for
the basis for the alleged exemption. Any violation o(.ItWy c out1.5 by any
the elle and exemptions Any violationthat f Sump[th 11.5 by y
a permit subjeabthe applkanito a civil pewlty snot more than
five hundred
five 1, is pr).
property, or he employees with wages their dole
I, as owner will othe d for
compensation, wiltdo...d r fa .IhesC de:TMCocture h; not nt doended or lmmeUw
sale (Sec. apply to alnow and PMeeerty Code: The Contractors L ves moor Law
does noo.auch torn owner ofpmpertyi..wn who emporlmpmovidedreoryand
whoovements are nothimselfsed ooughed owns. If,hoeapa,theb ilding orhat such
improvements within
improvement swidwlthln oneyearofcompldlorytheowner-bullderwill have
earofredlortion If, howeveg deer ill have
not provingthat M did embulld crlmprove for purpose ofsae.).
Sa owner of the property, am exclusively contracting with licensed
adars to constmct the project (See. 70K Business and Professions Code:
ontractor. License Law does not apply to an owner a property who
?Hd.'rImpr°vee thereon, and who contracts for such pwiectr with a
c75t actor(e)Bcenud pursuant to the Contractor. License Law.
LJ I am exempt under Sec. B & P C for this reason
APPLIANCES -ME re.
JOB DESCRI'770N
� � �
'
PANELS
UP TO 2DO ANTS'
201-1000 AMPS
OVER 1000 AMPS -
SQ. FT. FLOOR AREA
$/SQ. FT.
SIGNS ELECTRICAL
SPECIALCIRCUIT/MISC
TEMP. METER ORPOLE INST.
_
POWER DEVICES -
SWIMMING POOL ELECTRIC
OUTLETSSWITCFIESEXTURES
VALUA}LON
/L'�lG`/�
� Qa.
NEW RESIDENTIAL ELECTR SQ.FL,
STORIES
TYPE CONSTRUCTION
,
7 L.
QTY, PLUMBING. PERMIT FEE
OCC. GROIN
RES UNITS
PERMIT ISSUANCE
ALTER -DRAIN & VEM-WATER (EA)
FLOOD ZONE
APN
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
_
- OUTSIDE FEES
DRAINS}TDORROOF,AREA,COND.
SANITARY- Y_ N_
RECEIPT p
Owner Date
WOR ANCO P SATION DECLARATION
I he by affirm that I have a certificate of consent ro .elf -Insure, ora
ce sofWorker�'Compenaatlon lruurancearamrtifled copy themof(Sec.
3800, Lab C.) ,
Polity p
- pLyT(B(pg PPR •/.RAP
SC[;001: TAX Y_ N_
RECENT X
GAS EA. SYSTEM -I INC.4OUTLETS
PARK FEE Y N
RECEIPT p
CAS F.A. SYSTEM -OVER -
Com
BUILDING DIVISION FEES
er
[] Certified copy is lumthy filed the cid.
�CerlBied copy bflled with the city inspection division. -
CERTIFICATE OF IXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thlsaection need not be completed lithe permit b for one hundred deltare
($100) rtifyt.) -
Icenot employhat any person in any wast cern Permit c bored.
I shall not employ any person in any manner ao u to become subject to the
W°rkeri Compensation Laws of CalBornla. Date
Applicant -
NOTICE TO APPLICANT: B, after making this Certificate of Exemption, you
should become subject to the Workers' Compensation pmvbloruofthe Labor
Code, you most forthwith comply with such provisions°rthb permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirmthxt there is a construction lending agency for the perforin
ance of the work for which this permit b issued (Sec. 3097, Civ. C.)
Under's Name
Lamice.Addreaa -
I certifythatl havereadthbapplia tionand statethattheabove information
Iscormet.I agree to comply with all cityand countyordlnances and state laws
relating to building construction, and hereby authorize representatives of this
cit" enter upon the above-mentioned property for inspection purposes.
(We) agree 1° save, Indemnify an d keep harmless the City of Cu portion
against liabilities,judgments, cons and•expensea which may In any way amus
a lost said City co eexeotthe- antingdthlspermlt.
Ig alv of p nt/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE-
Willthe applicant orfuture building occupant store or handle hazardous
materlal ae defined by the Cupertino Municipal Code, Chapter 9.12, and the
Health and Safety Code Settlor, 25532(a)7 i
❑ Ye. In No
Will the applicant orEature building occupant use equipment or devices
which emit hazardous air contaMoants as defined by the Bay Area Air
Qua lity Management District?
Yas nn No
have read the hazardous materials requirements under Chapter6.95 of
the Califomla Health & Safety Code, Sections 25505, 25573 and 25539. I -.
understa nd that if the building does not currently have a tenant, that it is my
responsibility to not ify the occupant of the requirements which most be met
prior to Issuance of a Certificate of Occupancy. 1. 1_
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECKFEE
'
PAID
Date Recel t#
CREASE TRAP
gE-IyEILSAM.I.ARY-STORMFA 200F1.
'
WATER HEATER W/VENT/ELECTR -
ENERGYFEE Y N '
PAID '
Date Rescel t#
WATER SYSTEM/TREATING
NEW RESIDENTIAL FILMS. SQ.FT.
TOTAL:
BUILDING E
,
SEISMIC,FEE
NOTAL:
ELECTRIC FEE b
PLUMBING FEE
-
QTY. MECHANICAL PERMIT' NEE
MECHANICAL FEE
PERMIT ISSUANCE
,
FEES PAID:
Date 'Recei t#
P
ALTER OR ADDTO MECH,
AIR HANDLING UNIT (E010,000 CFM)
SUBTOTAL'
AIR HANDLING UNIT (OVER 10,000CFM)
CONSTRUCTION TAX
EXHAUSTHODD(W/DUCT)
CONSTRUCTION TAX PAID:
Date Rfcel
TOT'
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER 100,000 BTRA
VENTILATION FAN (SINGLE REED)
ISSUANCE DATE
� A r
g�l�
PER ��'I[j�SB
- ,r�5{{t'/1 1r% 2
Vit 1 0' (yVr Cq!lIVU
ISSUED BS
BOILER -COMP DEEP OR 100,000 BTU)
BOILER -COMP (OVER 103,000 BTU)
NEW RESIDENTIAL MECH. SQ.FT.
..
Owner °r authorized agent Date,
TOTAL:
OFFICE COPY
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