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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project/ Identification
PERMIT NQ
Building Address:
Z 4 3 6 6
mer., hone:
A IAL DAIL
O
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUfLDINGELECTRICAL-PLUMBINGMFGHAMCAL
!
I O X26
/q�lra �• LTC N.:
.K X91 c� ►
CATEGORY
CONTROL X
Archllet/Engineer. Lk. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
�5'31
Addrcs i'1-
PERMIT ISSUANCE
1:1 E:1❑
LICENSED CONTRACTOR' DECLARATION
Ihereby affirm thatlamlicensed underprovblonaof Chapter9(com,m
ingwith Setion7000)of Divisim3ofthe Buslncessand ProfesecesCode,and my
licertscutfitfullfarmand.ffect. i
License Ch Lk. �
Date/._��Contnctor 3/No
r+— r iCN�HITECTg DE RA ION
I understand my plans shag W used ate public records.
APPLIANCESRESIDENTIAL
JOB DE9C ON
/� I / r
PONTIS
201-1000 AMPS
OVER1000AMP5
SQ. FT. FL AREA E/nQ. IT.
SIGNSELECTRICAL
Licensed Professional
RI A L E D
SPECIAL CIl2CUfT/MISC
OWNER -BUILDER DECLARATION
Iherebyaffirmthrtlemexempt fromthe GmAraunr.License Lawfmthe
(� /J a it g�-
TEMP METER OR POLE INS(.
following reason. (SMIon 7031.5, Business and Professions Code: Any city or
ouelywhich requires a permit to commact, alter, Improve, demolbh,orrepair
'VO P T
U C
anystructure prior to its usuance,alsorequirmtheappllmnt for such permit to
file a signed statement that he b ns licensed pursuant to the prewbioof the
POWER DEVICES
O
TE 30
SWIMMING POOL ELECTRIC
Contractor's Liceraelaw(Chapter9(commencing with Section 7000)of Divi-
ston3 of the Business and ProffessionsCode) orthat he he exempt therefromand
VALUATION
the basis for the alleged exemption. Any, violation of Section 7MI.S by any
applicant for a permit subjects the applicant to a civil penalty of not more than
OUTLETSSWITCHFSFIXTURE5
NEW RESIDENTIAL ELECTR SQJFr.
five hundred dollars (5500).
I, as owner of the property, their sole
p perry, or my employees with wages
STORIES
TYPE CONSTRUCTION
compen❑ r
alnowand Professions Code: The License Law
.le(Sceat0K BusBotheworkandlbee Coderebrwemtrac a License Law
does not to ori improves thereon,
apply oryand
dons o apply torn imserof property hi. wnemporee.,pr provided
whodoes orkhimse hisow providedthatsuch
OCC.GROUP
RFS. UNITS
TOTAL:
ntsach do oroffe forsele. If, however,
improvementsarenot Intended le. It ow
earofoo cider ill have
Improvement b sold within oneytaro(compltlory the owner-bullderwlll have
to,t¢+rderof proving that W did notbundorimprovefmpurposeofrale.).
LI L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (See 70K Business and Profession, Code:
QTY. PLUMBING PERMIT FEE
FLOODZONE
APN
PERMIT ISSUANCE
The Contractor's License Law does not apply to an owner of property who
Wilds or improvry es thereoand who contracts for such Inpects with a
c adents) licensed pursuant to the Contractor's License Law.
o f am exempt under Sec B k P C for this reasonOUTSIDE
ALTER -DRAIN k VENT -WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
FEES
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y N_
RECEIPT p
Owner Date
WORKMAN COMPENSATION DECLARATION
Of hereby affirm that I have • certlRate of consent to eel( -Insure, or
certificate of Workers'Compemation Insurance or a reftiffincl copy thereof(Sec.
3B � b C.) ry ('_ A
l
FIXIURFS PER TRAM
SCHOOL TAX Y_ N_
RECEIPT N
GAS EA. SYSTEM -1 INCA OUTLETS
PARKFY N
E RECEIPT' M
Com any _q G��(u))i
GAS FA. SYSTEM-OVER4(EA)
BUILDING DIVISION FEES
_
GREASE/WDUSTRL WASTE INTERCEPTOR
PLANCf-IECK FEE
rCertNrd <o b ehHi'Mlifiduhl.��
ertified copy is filed with the city Inspection division.
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
SEWER -SANITARY -STORM EA 200P1'
COMPENSATION INSURANCE
(rhes section need not be completed lithe permit b far one bundred dollars
($100)mlea.)WATER
I really that to the perforance of the work forwhlch this permit is Issued,
m
Date Recei t#
k3FATFR W/VENT/m cr.I.R
ENERGYFEE Y_ N_
WATER SYS.IFM/.TRG.DNC
I shall not employ any person in any manner so as to become subject to the
WorkersCompensation Tawe of California. Date
PAID
NEWRESIDFMTALPLMB. SQ.FF.
Applicant
Date Recei t#
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you
Compeation provisions of the Labor
should became,subject to the Workeri ns
TOTAL:
BU N
Code, you must forthwith comply with such provislora orthb permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I hereby affirm that there is a construction k cling agency for the performELECTRIC
ante of the work for which this permit le boated c. 3097, Civ. C.)
Lerderb Name
Lender's Address
I certiflethat I have read this application and statethatthe above Information
bcorrect. l agree to comply with all city and county ordinances and slate laws
TOTAL: 3
FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relating to building construction, and hereby authomm representatives of this
city to enter upon the above-mentioned property for inspection purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cupertino
against IM1,111aes, jadgments,costs and expenses which may in anywsyaccom
ALTER OR ADD TO MICH.
Date Receipt#
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
against sal ity In ern u ce of the granting.f this pe It.
AIR IiANDLINC UMT(OVQt 10,000 CFM)
CONSTRUCTION TAX
Igwwm of Applicant/Contractor to
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTO
Date Recei t#
Will the applicant or future building occupant store or handle haeardous
material as defined by the Cupertino Municipal C.dq Chapter 9.12, and the
EleaRh and Safety Code/. -S�etlon 25532(a)?
F-1 Yes u No
Wllltbeappliartorfuture building occupant use equipment ordevices
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENILATIONFAN(SINGLERESID)
ISSUANCE DATE
which emit becardous air comamiwnn as defined by the Bay Arca Air
Quality Management District?
F1� Yta N.
.P A 10
BOILER -COMP OMI' OR 100,000 BTI)
BOILER -COMP (OVER 100,000 BN)
aea ohave read the hus materials requirements under Chapter 6.95 of
9
the California Health 6 Safety Code, Sections 75505, 25533 and 25534.1
and ersm is tand that 11 the building does not rrently have a tenant, that it my
OCT 26 1992
NEW RESIDENTIAL MECH. SQ.Fr.
responsibllily notify the occupant of the requirements which most W met
priortolsau mofa Cartifl sof Ocrupanry.
VY Uf CT1111YU
t gen ate
ISSUED BY: 4-1'L i.:-•
TOTAL:
OFFICE COPY