25949APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BI:dLDIN^ DIVISION APPLICATION/PERMIT PLUM ROJECTIDENTIFIC
.l BUILDING PROJECT II)EN'1'IFICATION
PERMIT No.
6 �I 9
J v L�
25649
BUILDING ADDRESS:
SANITARY NO.
APPLICATIONSUBMfTTALDATE
��s '/ c yy11 Ave-�lI�Q/yi0
09�4/ /'/ r V lSrn AUNIT. LOTH
tb--2.
OWNErAME: �P�H�O�NE: a
C
ACfO.RS NANf; LIC NO:
L ll`11 O Rk
N/C
❑
CONTROL N
RCHI .CANGINEB: LIC NO:
ADDRE :
CONTACT PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BL G ELECT PLUMB MECH
PERMIT ISSUANCE
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I herchyaffirm that 1 am licensed under provislonsofCTapter9(commenciagwith
APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
PANEIS
Section 9000) of Division 3 of the Basitmss and Prefemioaa Cad., and an, license is in
full force and effect. -
License Class Lic.N
UP TO 200 AMPS
201 - 1000 AMPS
Dale Contractor
ARCHITECTS DECLARATION
1 understand my plats shall m used as public records.
OVER IMDAMPS
11 SQ. REA
ISI
SISQ. FT.
SIGNS ELECTRICAL
(T�
Licensed Professional'
OWNER-BUILDERDEC ON
SPEC.CIRIT/MISC.
WN
I actor, affirm that 1 am Curvatures
exempt from the Conwmola License law for Ne
following meson. (Section 7031.5, a Code: Any city or county
aims andProfessions
TEMP. METER OR POLE IN
demolish,
tee, de
which its a issuance, permit re construct, alter, improve, demolish, m mpair any twetum
t,
duee file statement
se
itspumumt
POWER DEVICES
provisant ions the Co tinNuo
That to thx Lice La
that he is licensed pursuant to Ne provisions of the Contractor's License Lew
9(mmmencing with Senion]l00)of Division Jof the Business and Professions
m Co Codee)d
SWIMMING POOL ELECTRIC
VAL
or that he is exempt Therefrom and the bazis for the alleged exemption. Any viole0on of
$permit aubjecm the epPlicant macivil penury a(
unyapplicdl
V K/
OUTLETS - SWITCHES - FIXTURES
act momhe fiveollars
than
nm m1,eownfvfthepmerty,ormycm).
❑ w wegcsasthei(sole compensation,
NEW RESIDENTIALELECfR_SQ. FT.
STORIES
TYPECONSTRUCTION
rk,run thearrrty,nrmyemdendedisro
willed othe r d imendedm ss
ra
e: The Contcturaw tot
romaxi s C ave dos noted
mJ Professions Code: The Contractor's License Law does apply to an owner
apply t an ownBuser of
or is
property whobuildsor improves thereon,and whodms h armadr doraff rmtlwughhie
wnemployees,provided Nm such improvetnensamnot imm�dedaroffemdforsale. If,
OCC. GROUP
RFS. UNITS
TOTAL:
however, the building or improvement is sold within one year of completion, the owner
builder will have the burden of that he did not build or improve fm f
proving prov purpose
le.).
ElI,ur ownerofNc property.umexduaivelyconaacting with licensed<onuactmsm
QTY. PLUMBING PERMIT FEE
FLOOD LONE
APN
construct the project (Sm. 8114, Business and Professions Code:) The Conffai
License Law does not apply manownerofproperty who builds orimprovesthemomand
PERMIT ISSUANCE
whocon,racisforsuch projects withacontracmr(s) licensed pursuanuo the Conuutor's
LiceneLow.
ALTER VENT -WATER (FA)
FEE SUMMARY
❑ 1 am exempt under Sec. , B & P C fo this maven
BACK FLOW PROTECT. DEVICE
TSIDE
SANITARY YN
RECEIPT is
Owner Date
DRAWS - FLOOR, ROOF, AREA, COND.
WORKAN COMPENSATION DECLARATION
M
SCHOOLTAX Y N
❑ I hereby affirm that l have a modicum ofconsent to self -insure, or a cenificate of
Workem'CompensationfnsumncanracenifiedcWythemof(Sec.38W,Lab CJwhich
covers all employee's under this Permit
Poli"N
RECEIPT#
FIXTURES - PER TRAP
PARK FEE Y N
RECEIPT #
GAS - EA. SYSTEM -I INC.4 OUTLETS
BUILDING DIVISION FS
Company
GAS - G. SYSTEM -OVER 4 (EA)
PLANCHF.CK FEE
❑ Certified copy is hereby famished.
GREASFJINDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ Certified copy is filed with The city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
OREASETRAP
SOUS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 20l
ENERGY FEE
(This section need not be completed ifthe permit is foram hundred dollars (5100)
or less.)
WATER HEATER W(VENT/ELECTR
I certify that in the performance of Ne work fmwhich this permit is issued, l shall
not employ my Person in any matmer so as to become subject in the Worker'
PAID
Compensation Iawsof Califmnia. Dam
WATER SYSTENI TREATING
Date Receipt N
Applicant
NOTICE TO APPLICANT: If, after making this Camficam of Exemption, you should
NEW RESIDENTIAL PLMB. SQ. Ff.
TOTAL:
become subject m the Worker's Compenaalion provisions of the Labor Code, You must
forthwith comply with such Provisions or this permit shall he domed mvmked.
BUILDING HE l%
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm That hem is a convection lending agency fm The performance of
work for which this permit is issued (Sec. 300]. Co. CJ
TOTAL:
ELECTRIC ME
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
Lender's No=
Lender's Address
1 certify that I have mad this application and sum That the above information is
correct, l agree to comply with all city and county ordinances and state laws relating in
PERMITISSUANCE
MECHANICAL FEE
building construction, and hereby avthmim representatives of This city to enter upon the
above-mentioned property for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTIONTAX
-
AI0. HANDLING UNIT (TO 10,000 CFM)
(We) agate to save, indemnify and kap moonless the City of Caption. agvnn
limilities,judgments, costa and expensm It It may in any way eccme egeimt said Ciry
AIR HANDLING UNIT (OVER 10,000 CFM)
in cons sec of thii,congof this it
i0 -au -3
EXHAUST HOOD(WMUCT)
PAID
. gnmump Plian4Commctar Dam
HEATING UNIT (TO 100,0011 BTU)
I IALARDOUS MATERIALS DISCLOSURE
Dam Remipt N
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
Will t ac it, icwt or home building atopen, acre or handle hmardous materiel
as defined by the Cupertino Municipal Cade, Chaim, 9.12, random Health and Safety
VENTILATION FAN (SINGLE RFSID)
Code. Section 25532(x)?
❑ Yes ❑ No
ISSUANCE DATE
Will thea lieamofmarebuildin cuant use mrdeviceswhichemlt
OP d b P Am. Air
hasmdous sin cnnlnminants as dmfined by the Bey Ama Air Quality Management
DisWm?
BOILER- COMP(3HP OR INTOW BTU)
p�
PAID
9
BOILER - COMP (OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ. FT.
❑ Yes ❑ No
I
/1
0"
I have read the baaaNmm materials "Wo m os under Chapter 6.93 of the
California Health & Safety Code, Sections 25505.25533 and 25534. 1 understand that
if the building does not current have a means, that it is my responsibility in notify the
1 2 U V93
r
C 11
occupant of the requirements which must be met prior to issuance of a Cenificate of
Osm,mcy.
" Ur (;(Jr" T -
ISSUED BY:
Owner go rmlarised agent Data
TOTAL:
OFFICE
•
OUR
28p�
0
0
5 Dc.7 ✓COro
PLOT PLANS
MCNED BX
i
e�
FLAI/SIV NG DEPT.
DATE�I
PLDG• DEPT.
I
I4b t)S15�
EDD WE
OCT 2 U 1993
OLDO.INSPECTION DEPARTMERT
CITY OF CUPERTINO
I�OT TO SCl\Lt
9
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