23519APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
PERMIT NO.
Building Address:A L-reL.
23519
nersone:
Lj Q T&2
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
p
( C L
Contr cion spm: T LIc.Nox
CATEGORY
CONTROL X
`
BUILDINGELECTRICALPLUMBINGMECHAMCAL
ArcMted/Engineer. Lie No:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
PLUMB
Address
PERMITISSUANCEI
1:1 ❑ O
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am Restated under provisions of Chapter 9(commenc
Ingwlth Sedion7000)of MWision3ofthe Businessand Pmfesslom Code, and my
license lainfu ort!and effect.
License Class Lie. p_-- !I
APPLIANCES -RESIDENTIAL
JOB DFSCRB'TION
l
PANELS
Dat Contracior
— UP TO 2DGAMPS
M l.i
IDI -IOW AMPS
ARCHITECTS �CrLARATION
OVER IOW AMPS
SQ. F.T. FLOOR AREA
$/FR. Fr.
I understand my plans shall be used u public records.
SIGNS ELECTRICAL
Licensed Procialunal
SPECIALCIRCUUT/MISC
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
TEMP METER OR POLE INST.
following reason. (Section 7031.5, Business and Professions Code: Any city or
countywhich requiresa pemUttoconstruct, alter, Improve, demolish, orcepair
anystmu mpdorto Ralawance,alaarequlmtheappbcantforsuchpermitto
file a signed statement that he It hunted pursuant to the provisions of the
POWER DEVICES
SWIMMING POOL ELECTRIC
Contractors License Law (Chapter 9(commencing with Section 7000) of DIW-
sion3 of the Business and Pros esslons Cade) mthat he la exempt therefromend
VALUATION
the basis for the alleged exemption. Any violation of Section 70)15 by any
applicant fora permit subjectathe applicant to a civil penalty d act more than
OUTLETSSWITCHEBFIXTURFS
NEW RESIDENTIAL ELECTR SQ'FT'
five hundred dollars (SW.
❑ I, as owner of the property, or my employees with wages as their sole
STORIES
TYPE CONSTRUCTION
compensation, vvW doths, work, and thestNdure is net Intended or offered for
sale (Sec. 7074, Business and Professiona Code: The Contractors License Taw
does not apply to an owner of property who Wilds or Improves thereon, and
who dosuch work himseRorthreaugh Msman employees, provided that such
n
OCC. GROUP
RES. UNITS
improvements are not intended or offered for sale. If, however, the building or
TOTAL:
'
improvemcntbsoldwithnomrarofcompIMbM1theowner-WRderwdlhave
UjejZurden of proving that he did net build or improve for purpose elastic.).
u 4 as owner of the property, am exclusively contracting with licensed
e.m.Rors to construct the project (Sec. 7074, Business and Professions Code:
QTY, PLUMBING PERMIT FEE
FLOOD ZONE
APN
PERMITISSUANCE
The Contractor's License Law does not apply to an owner of property, who
Wilda or improve thereon, and who contracts for such ptojeds with a
dor(a)licensed pursuant to the Contractors License Law.
cf_I,BtlaI am exempt under Sec. B & P C for this mason
ALTER -DRAIN &VENT- WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y N_
RECEIPT X
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificate of consent to selfdnsure, ora
cedificateofWorkers Compewtion lnsuranceora certified copy thenc((Sec.
3600, Labc) r�-�l
�nWs7ro'
pD(TURES PER TRAP
SCHOOLTAK Y_ N
RECEIPT— X
GAS EA. SYSTEM -1 INCA OUTLETS
PARKFM Y N
RECUPTN
Pa1kyX !,(
m Y
GAS EA. SYSTEM-0VER 7 (EA)
BUILDING DIVISION FEES
CedlRed copy is herebyfurnished.thehed.
edified copy is filed with the city Inspection division.
_
GREASE/INDUSML WASTE INTERCEPTOR
PLANGHEGK FEE
GREASE TRAP
CERTIFICATE OF E-%EMPTION MOM WORKERS'
PAID
gE}ypR.SpMT,V2Y-SroRM EA zooFT.
COMPENSATION INSURANCE
(This section need net be completed if the permit Is for one bund and dollars
Date Remi tic
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y_ N_
(SIW)nrles.)
I certify that N the performance of the work for which this permit is Issued,
WATLR SYSTCM/TREATING
I shall not employ any person in any manner so as to become subject to the
Workers'Compenaatlon laws of California. Date
PAID
NEW RESIDENTIAL PLMB. SQ.FF.
Applicant
Date Recel ted
NOTICE TO APPLICANT: IS after making thla Certificate of Exemption, you
should become subject to the Workees' Compensation provisions of the Labor
TOTAL:
BUILDING
Code, you must forthwith comply with such provisions orthis permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I herebyaffirmthat there isaconstroctlon lendingagency forthe perform
ance of the work for which this permit is lasued (Sec. 3097, Cie. C.)
Lender's Name
Lenders Addmss
Icitbnanduntyordinances eddateaaws
I"od. Ia !read with Idtyand countyordlnancesand Gate laws
iscormR. Its
TOTAL:
ELECTRIC FEE
PLUMBING FEE
Q TY. MECHANICAL PERMIT FEE
MECHANICAL FEE
..(t��
PERMIT LSSUANCE ,/�y
FEES PAID:
legromp�wlth
relatingto it, assns) ell , a d hereby authorize representatives ofthls
etywenter Furtive Bove, est nod property for Wpedlon purpceca.
(We) agree o , In I and keep baroness the City of Cupertino
aga [nets, �dg ad expenses which may lnanywayacoue
ALTER OR ADD TO MECH.
Date Receipt#
ATR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
against uld ref <y she gran ting Ottm. permit.
lU en W.
ATR HANDLING UNIT (OVER 10,000CFM)
CONSTRUCTION TAX
signaturco AI pRcent/Contractor Date
EXHAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appRant orfutumbulldleg occupant store or handle hazardous
HEATING UNITGO lfflW0 BTU) —Llh
Date Rece1 1#
material as defined by the Cupertino Municipal Code, Chapter 933 and the
Hnith and SafetyCode Stolon 25537(a)7
❑ Yes M No
Will the a pplicant or future building occupant use equipment or devices
HEATING UNIT (OVER 100,0W BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
-Quality, Management Dislrid7
Yes No
PAID }&
V- PY D
BOILER -COMP PFO' OR IW,= BTU)
BOILER-COMP(OVER100,000 BTU)
f have read the haze ousmatcrlals requirements under Chapter 6.95 of
Hb California Health & Safety Code, Stolons 75505, 75533 and 25537. 1
understand that ifthe Wis building does not currently have a tenant, that itmy
APR 14 1992
NEW RPSIDEN77ALMECH. SQ.FT
reporsibility to notify the occupant of the requirements which must be met
prior to issuance of a Certificate of Occupancy.
C`IITY Wr Wrcnit,at!
ISSUIiny:! `
Owner or authorized agent Data
R
TOTAL: (/
OFFICE COPY