23470E
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Buildln I'mied IdemmoUon I
Building Add.:
P192MIT NO.
0
5 i7l� sn� o G l' 2 9 So 5�
23470
' hone
CITY OF CUPERTINO-BUILDING DIVISION�j
APPLICATION (PERMIT
BURDINGELBCMCA4PLIIMBINGMECHAMCAL
APPLICATID77M797T7 A
:on&,atnr ame: uc.Nn://
�5e E
CATEGORY CONTROL
AaNltect/Enginser. Llc. No:
``''"-"l'''- -Y�'`""-"
Q .r +�''o, ELECTRIC PERMIT � �� FEE
BUILDING PERMIT INFO
Adernc
( PERMIT ISSUANCE
Yom' YJ�
LICENSED CONTRunder provisions
I herebyatf&mthat of amlfcaasefthe Bupeaftannsof Cha pter9(mmmmc
Ingwith 5ect1on7000)of Dlvision3ofthe Businmand ProfeasionsCade,and my
limruc la s d dfe. `
LicenseCk.R
Date3— ComAche, S rexed7o'
ARCHITECT'S DECLARATION
I understand my plans shall be used An public records.
APPLANCESRESIDENTIAL
JOB DI'SCft1I'IION
Vw``_Vf� R e Axsl
PANELScr
20I -IOW AMPS
OVEIIIWOAMPS
FT. jLQQI�4RFA
\YI
5/SQ. Ff.
Licensed Pro(eadonal
OWNER•BUILDER DECLARATION
I hertby+(Brm slut I am exempt lromthe Caatrarrori License law (a the
following mason. (Section 7015, Business and Pmfmlons Code: Any city or
muntywhkhrequlreaapermkrommh Miner,lmprove,demollah,ormpair
9GN5 ELFGTRICAL
_
�' �� R
=
!1 y•/
SPECULCIRCUIT/MISC
TEMP. M= OR POLE INST.
anystr =mpr toima ame,aboaequl theappU=tfmw&pemdtto
file a signed statement that he b licensed pursuant to the pnevbions of the
POWER DEVICES
AFI
SWENAENGPOOLELECTRLC
OUILETSSWITCI{FSFIXTURFS, Z
ContractorsL Ares, Law(Cha pter9(commencing with Section 7=) of Divi-
alon3ofthe Budrmand ProfmWmCMe)orthathebmmpttherefromaM
the basis for the alleged eaemptlen. My violation of Section 78315 by any
ntfora persubjectsthe applicant to a civil penalty not othan
Applicant mR d mre
VALUATION D A
' 0 /' s (�
00,
five hundred doism( An.
as owner of the property, or my employwith wages As the& sole
❑L es
mmperwtlon, will do the work and the structure is not Intended or offered for
NEWRESIDE,1IALELECIR SQFf.
FS
TYPE CONSiRUCT1ON
sale (Sec 7066, Business and Professions Code: The Contractors License law
TOTAL: f /
does not apply to an owner of property who builds or improves thereon, and
es
whodosurhworkre himselforthwgh hisownempluyees, provided thatsuch
Improvements anot Intended oroffemd forsale. IL however, thebuilding or
OCC.GROUIa
R15. UNITS
Improve issWdwithlnomyearo(cmple mtheowner-budderwiB"ve
t"rdenofprovingthathedid notbulldorlmproveforpurposeo(sale.).
LJ L As owner of the property, am exclusively contracting with licensed
mneractas to mnswct the project (See 701{, BusNm and ProfessionsCode:
,.
&Y-Mit,;_,iPLUINBINGPERMIT•�_:'-�, �, FEE""
FI.DODZON
APN
PERMIT ISSUANCE o(�
The Commeures Licenp law dm not apply to An owner of property who
Wilds or Improves thereon, and who contracts for such p(o)ects with A
cgnt(actor(s) liansad purmant ro the Contractors Liam Law.
LJ I am ezempt under See B & P C for this reasonES
ALTEILDRAIN& VENT- WATER(EM
_ - 'FEE.SUMMARY
BACK IIDWI'ROTFL7. DEVICE
OUTSIDE TE
DRAINFOR ROOF, AREA, COND.
DRAINS.
SANITARY Y N
RECEIPT
Owner Data
WORKMANCOMPENSATIONDECIARATION/
❑I hereby aR&m that I have A arti0ute of consent to self -i mase, a a
certificate ofWorkeW Compeaoatlan lruurana or a art8&d copy thereof (See.
3300, Lb C)
` FIXTURES. PER TRAP DV
SCHOOL TAX Y N
RECEIn 0
GAS EA. SYSTEM -1 INGI OUTLETS
PARK FEE Y N
RECEIPTa
Polley R
C. ray
C
GAS FA. SYSIFM.OVER! (FA)
BUILDING DIVISION FEES
rcertified copy &hereby furnished.
❑ CerlNed copy is filed with the city Inspection division.
GREASE/WDUSIRL WASTE INI'QtCEPTOR
PLANCHECK FEE
GREASE TRAP
' CERTIFICATE OF EXEMPTION FROM WOR KERS
PAID
SEWEILSANRARYSTOR2,1 E.A.20OFT
COMPENSATION INSURANCE
(TBbaectionneed not becompleted tithe permit bfor hundred dollars
(S100)mlea.)
I certify Nat lo the pedormana of thework forwhlch this permit is issued,,
Date Recei tit
WATER HEATER W/VENC/ELECTR
ENERGYFEE Y_ N_
WATFt SYS[I3/fREAING
I shall not employ any person In any manner so as to becor m s0b!V w the
uo
Worke., f D 30._2
Co.
Applicant
NOTICETO APPLICAND. , lf,aher Wng thisCertificate of EAempdun, you
should become subject to the W.rikend Compensation provisions ofthA Labor
Code, you must forthwith mmplywlth such provisions or this permit shill be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I heabyaffiranthatthere ba constmction lendingagency forthe perform-
Ance of the work for which thin permit b hsued(Sec. 3097, Civ. C.)
LAMerlName
LendersAddress
PAID-
Date Remi tis
NEWRESIDFh1ALPLMB.
TOTAL:
13UILDING
SEISMIC FEE -�
TOTAL: ,iii
ELECTRIC FEE (% 2
PLUMBING FEE -
- - _
QTY. , -MECHANICAL PERMIT FEE?'
MECHANICAL FEE _
Iwriffythat I have mad th&appliation And siatethatthe above information
incorrect.lagceetocomplywlthalleityand countyordinancesandstatelaws
PFRMITLSSUANCE (%0
FEES PAID.
relating tobulidtng.nst udion, And hereby authorize representatives of thio
city to enter upon the above.mentlored property for inspection purposes.
(We) agree to save, indemnify an d keep harmless the City of Cu ped Ino
agaWtB bWtles,)udgmenb, azaMeapeneeswhic&maylnanywayaccrue
ALTER OR ADD TO MECH.
Date Receipt#
AIR HANDLING UNIT (TO 10,1100 CFM)
SUBTOTAL:
galnstse by lo consequen fthe gra rat' g APermlt.
ATR HANDLING UNIT (OVER 10,1DOCFNI)
CONSTRUCTION TAX
'f
Signature of AppOcam/Cont ami rZ' Data
IXHAUST HOOD (W/DUCT) S�
CONSTRUCTION TAX PAID:
HA R11 ATERIALS DISCLOSURE
Will the applicant or futumbullding occupant store orhandle hmrdous
Date Reaei iii
HEATING UNIT (TO 100,000 BTU)
material as defined by the Cupertino Municipal Code, Chapter 9.1Z and the
Health and Safety Code Section 25532(a)2
❑ Yes No
Wlllthe applicant oriuturebulldingomvpant use equipment ordevices
which emit havrdous air contaminsnts as definedby tat Bay Arca A&
Q+lity Management D'urictl
?Yes ❑ No
1uw` mad the haradousmaterials requirements under Chapter6.9iof
the CAIBornia Health & Safety Code, Sections 25505,25533 And 25536.]
tenant, that it my
uMastand that lithe building does not currently have a b
HEATING UNIT (OVER 1WM BTU)
TOTAL: •.Z�
vFxnunoN FAN (sweLR RFSTD)
ISSUANCE DATE
P A I D
MAR 30 1992 .
BOILER -COMP DHPOR 1W,000 BTU)
BORER-COMP(OVER IW,OW BTU)
N RESIDENTIAL MDCH SQFT.
responsibility to notify the occupant of the requirements which must be met
prior to issuance of a Certificate of Occupancy.
C� V V VY L-- Ya t 1110
ISSUED BY: _`1!. s
Ownerw authod <d agent Date
.TOTAL:
OFFICE COPY