19923APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
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Buildinpi Project Identification
PERMIT NO.
Bandgng Add.e:
;2.o�s2s�r, C2
19 9 2 3
racy, cameO: Phone:
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CITY OF CUPERTINO-BUILDING DIVISION
Contra&or, anr: NLic. No:
APPLICATION / PERMIT
;;P / LL M %S/ t a2U
BUfLDINGELECTRICALPLUMBING-MECHAMCAL
CATEGORY
CONTROL
Architect/Engineer. Llc. Na:
BUILDING PERMIT INFO
QrY ELECTRIC PERMIT FEE
❑ ❑ ❑
Address PERMUISSUANCE
LICENSED ED CONTRACTOR'S DECLARATION
I hereection mt0).famlkmsed under pnessaonsaf Csal...9(mmmmc
APPLIANCESRESIDENTIAL
JOB DESCRIPTION
InenseiSenion (the Buslnessand IarofesslonsCAde, and my
banes is in mu corm acts effect.
force and
rnNEls
License Clan LIO N
Date Contactor
ARCHITECTS DECLARATION
201-1000AMPS
SQ. FT. FLOOR AREA
S/SQ.FT.
I understand my plans shall W used as public memrds. OVERI000AMPS
Licensed Professiaal
ISIGNS ELECTRICAL
OWNER -BUILDER DECLARATION
SPECGL CIRCUI7/MLSC
I hereby affirm that I am exempt from the Contractors License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or
TEMP, M ETER OR POLE INST
county which requires permit to mmtruct, alter, Improve, demolish, or repair
ystrueturepriortoIt.Wuance,alsorequirestheappliantforsuchpemdtto
POWER DEVICES
file a signed statement that he b licensed pursuant to the pmvblons of the
/Y
Contractor's License Law (Chapter 9 (commencing with Section 7000)of Divi-
SWIMMING POOL ELECTRIC
`JI VALUATION
sion 3 ofthe Business and Professions Code) or that he b exempt therefromand
the basis for the alleged exemption. Any violation of Section 7031.5 by any
OUTLETSSWITCHESHXTUR
applicant fora permit subjects the applicant to a civil penalty of not more than
five hundred dollars CS500).
O1, as owner of the property, or my employees with wages as their sole
NEW RE4DENTIAL ELICTR
STOW 6
TYPECON'STRUCTION
compensation. will do the work, and the structure is not Intended or offered for
sale (Sec. 7054, Buxton. and Professlme, Cade: The Contractors Liceme Law
does not apply to an owner of property who builds or improves thereo,and
OCC. CROUP
RFS. UNITS
whodoessuchworkhimself orthrough hisownemployees, provided that such
Improvements are not intended oroffered for sale. IL however thebullding or
TOTAL:
improvement la sold within oneyearofcompl&ioq. the owner-builderwill have
tIg.1a rdenofproving that he did not build or improve for purpose ofsale.).
QTY, PLUMBING PERMIT FEE
FLOOD ZONE
APN
I I L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7064, Business and Professions Cade:
PERMIT ISSUANCE aY
♦„ yC�
The Contractor? Llmnw law does not apply to an owner of property who
ALTER -DRAIN &VENT- WATER (EA)
FEE SUMMARY
Wilds or Improves thereon, and who metra&. fee such projects with a
MMlicensed pursuant to the Contractor's License Law.
BACK FLOW PROTECT. DEVICE
LJ I am exempt under Sec B & P C for this reason
SANITARY RFOFII'1'N
e'1
Owner Date DRAINS 5060, ROOF, AREA, GOND. .r
4Vil,s/
WOR"AN COMPENSATION DECLARATION
OI hereby affirm that I have a artiRate of consent to self -insure, or a
FIX'TURFS PER TRAP
UN
SCHOOLTAX Y— N_
RECEIPT N
cenlBcate of Worker?Compematbnlmurance ora certlfiod copythemof(Sec.
GAS EA. SYSTEM -1 INCA OUTLETS
PARK FEE Y N
38W,Lab CJ
Policy N
—
RECEIPT N
Co any
GAS FA. SYSTEM -OVER d (FA)
BUILDING DIVISION FEES
ffCertiried copy N hereby furnished.
GREASE/1NDUSCRL WASTE INTERCEPTOR
PLANCIiECK PEE
�Cerlified copy b filed with the city Inspection division.
CERTIFICATE OF UEMPTION FROM WORKERS'
aart,sAs
GREASETRAP W
PAID
COMPENSATION INSURANCE
SEWER-SANITARY-SIDRM EA. 200FT.
Date Recei t#
(Thlsseelon need not becompided B the permit isforoK hundred dollars
ENERGY FEE Y N —
($100)mIces.)
WATER HEATER W/VENT/
I certifythat int ,,rformance oftheu k fo,whlch this permit is Lasued,
T shall not cmplo person in any r nn r so as to become sub' to the
WA.fEtSYS.I.Em TREATING
Workers'C=O.t ionlaw. of Gh �IaJDate
PAID
nppucunt._�
NEW RESIDENTIAL PLMB. SQ.FT.
Date Recei t#
NOTICE YO P ,aXe ting tNa Cer to o(Exemptlon, you
should become eubjer,"o the Wmkeri Comperes on proWions dl he Labor
TOTAL:
131JILDING FEEdcomed
Cod, you muatforthwith comply with such powb)om mthis permit shall be
revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
ELECTRIC FEE
I hembyafRrmthat there is a construction landing agency for the perform TOTAL,
ance of the work for which this permit is Issued (Sec. 3097, Civ.CJ
s�
P
PLUMBING FEE
t
Lauder. Name
Lender's Add..
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
(certify that l have madthis applicatlonand sratethat theabove Information
FEES PAID:
fsammet. l agreeto comply with all city and countyordinances and state laws
PERMIT ISSUANCE
relating tob.1khr g mmmactiory and hereby authorise representatives of the,
city to enter upon the above-mentioned property for Inspection purposes.
ALTERORADDTOMECH.
Date Receipt#
rue
( agree to save, indemnify an d keep harmless the the City of Cupertino
SUBTOTAL:
t Ilabllities, pdgmenb, consand expenses which may In anyway accrue
against
AIR HANDLING UNIT CFO 10,000 CFM(
CONSTRUCTION TAX
.ga Wt said City in consequence of the granting of this permit
AIR HANDLING UNIT (OVER 10,000CI•l. i)
CONSTRUCTION TAX PAID:
'
Slgroture of Applicant/Contactor Date EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE
Will the appli.ot or future building occupant store or hand le haradous
HEATING UNIT (TO ID0,(00 BTU)
Date Rece1 t#
material as defined by the Cupertino Municipal Code, Chapter 933 and the
IWith and Safety Cod,, Section 75532(.)?
HEATING UNIT (OVER 100,000 BTU)`
. TOTAL:
OYes M Na
Will the applicant or future building occupant use equipment or devices
VFN ITLATION FAN (SINGLE RESID)VyJ.
�E DATE
which emit h.zudm eair contaminants., defined by the Bay Arca Air
BOILER-COMPQHP OR 100,000 BTU)
r
Quality Management District?
-'.t\ vs/
/1 /
�1'IN's'l ° u 199U
Yes ❑❑ No
I have read the harardoa, materials Tremens under Chapter 6.95 of
BOILER-COMP(OVER100,000 BTU)
r1
ylnn
rP14
the C.Bfomla earth&Surety Code, ®75505, 25533 and 25936. 1
undcrstandI if the building d of rmutly have a tenant, that it 6 my
NEW RESIDENTIAL MECH. SQ.FT,
rose m it on&ifytheocmp tof erequimmentswItchmustWmet
'To
to nceofaCertifiat panty.
AOy
N cy/�
�s�% ��� �'fN�„�'
nen uthori agent Date
ISSUED BYM 1 x�`e�^ —`-
TOTAL:
OFFICE COPY