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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Proort Identification
B°°ding Address:
PERMIT NO.
D (\,J re 'T IOp� r as u o f
23403
ners ams 4o}�,ii�'3ut
TU l� `I i H— 1[ 1 avu i
cp^tractor'°Name: Lie. No:
y
S CITY OF CUPERTIN68UILDINC DIVISION
APPLICATION / PERMIT
BUILDING ELECTMCAL-PLUMBINC.MECHAN7CAL
A
13
CATEGORY CO
BUILDING PERMIT INFO
Architect/Engtn¢r. Llc. No:
L.en
/ QTY ELECTRIC PERMIT
Address .0 f—
PLUMB MECII
❑ ❑ ❑
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Ch pier 9(aommen
Ingwlth5eeton700D)of Dlvlslon3ofthe Businessand Pro! on,Cq�e
license le In full fo.Vd effect. rr C-
LI¢nse Clam A41 IS LIeN a
Date 2 .12 `Z2Contractor L.i P <r.. C", a
APPLIANC DE
PANETS
A 41
JOB Of OIy
�1,A e11 7f1 1
V V M �+0
[/JaCYR.La,
201-1000
ARCHITECT'S DECLARATION
I understand my plane shag be used as public records.
OVER 1000 AM
SQ. FI. FLOOR AREA $/SQ. FI.
SIGNSELECTRI -4 ZZ
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I amexempt from the Contractor's License Law for the
SPECIAL CIRCUIT/MISC
7'FA4r MEIIX OR POLE] SI.
g
following reason. (Section 70315, Business and Professions Code: Any city or
muntywMch requires permittomromuel, alter, bnprove, denslish,orrepalr
n /�
any structure prior to its issuance, also requires the applicant forsuch permit to
file a signed statement that he b licensed pursuant to the providers of the0,
Contractor's Lice"+•Law (Cha pter9(commencing with Section 7000) of Divi-
Buslnmsand Profms .Code)°rthathebexemptth,mfmmand
POWER DEVICES
//`\
U
SWIMMING POOL ELECTRICsloes3ofthe
VALUATION
the bash for the alleged exemption. Any violation of Section 7031.5 by any
applicant for a permit subjects the applicant to a civil penalty of not room than
DUTLETSSWITCH[SFIKTURFS
flu undreddollars($500).
5,NEW
L a, owner of the property, or my employees with wage. as their sole
compenmtion,w111dothe work and thestroclure b not attended or offered for
RESIDENTIAL ELECTR SQ. a
STORIESO TYPE CONSTRUCTION
sal° (Sec. 7064 Business and Professions Code: The Contractor'. Lt.. law
doe, not apply to an owner of property who Wilds or improves thereon, and
does such work hinselforthrough Ms own employees, provided that such
OCC. GROIII'
RES. UNITS
Improvements are not intended proffered for sale. I( however, thebulldingor
Improvementbwldwlthlnomyearofcompieion the w er-buBderwillha e
TOTAL:
thiLilurdenofprovingthathedid not build or Improve for purpose ofsale.).
uU L as owner of the Property, am exclusively contracting with licensed
chroacton to construct the project (Sec 7D64, Business and Professions Code:
The Contractor'. License Law don net apply to an owner of property who
Wre
builds or improves thereon, and who contrera for such pWJeata with a
cgR(Iadoris)licensed pursuant to the Contractors License Law.
IJ I am exempt under Sac. B k P C for this reason
QTy. PLUMBING PERMIT FEE
FLOOD TONE
-
APN
PERMIT ISSUANCE
ALTER -DRAIN hVENT - WATER (FA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOP, ARRA, CONTI.
pp(TUgpg PER TRAP
SANITARY Y N
RECEIPT N
Owner Date
9r�{� WORKMAN COMPENSATION DECLARATION
1 hereby affirm that I have a certificate of consent to asiNnsure, ora
3NOOt1IabC cate of Worken'Compematlon Wuran¢ora¢rtl(led copy lhereof (`Sec.
SQi00L TAX Y_ N_certiRECEIPT N
GAS EA. SYSIT7d-I INCA OUTLETS
PARKFFE Y N
Policy#
C�ny,_K y CN
RECEIPT If
GAS EA. SYSITM.OVER 4(EA)
BUILDING DIVISION FEESo
onlfied copy is hereby t
Ccrtl/ed copy Is filed with the city Inspection dvidon.
TNCHECK FEE
I I IL
/
L
CERTIFICATE OF EXEMPTION FROM WORKERS'
GR FA
PAID
J
COMPENSATION INSURANCE
(This aectlpn need not be completed If the permit b forone hundred dollars
(8100)orles.)
I ¢not that In the ppefo on in an th. weal,manner f.se as t cb co eermit isauDlec blued,
I shall not employ any [Am In any mannerseas as to become eubkct to the
W Compensation Lusao(CalEom6. Date
SI:W'ER R
I t:
Date RCCCI tat
WATER HEATER W/VENT/ IZ7E
WATER SYS
ERGYFEE Y N —
ID
plica
Applicant
NOTICE TO APPLICANT: a after making this Certificatepo of Exemption, you
should Wcomeaurthwitect the ply Mth..eh pneatl.eprovblomr its Labbe
Mgt forthwith comply with ouch provl.lors canthi permit shall be
deemed
dmmed revoked.
Date Recei fit
NEW RESIDENTIAL PLMB._SQ.Ff.
IOTA
'
TWILDINC
�y
SEISMIC FE
CONSTRUCTION LENDING AGENCY
Therhe%wric tothat rwlhe¢bamruwRosuedion c.3097ng ncyfor,) perform
er'the work forwhlch this permitbbaed (Bee. 3097, CIv,CJ
TOTAL:
EL FE t
QTY. MECHANICAL PERMIT FEE
PLU FEE rie
Len
Lender's Nacre
Lender'.Address
I moifythat I have readthlsappllcationand a tatethattheahove Information
mm ¢
I.ect.Iagrtoeomplywithallcityand countyordlnancesand nate laws
relating to building construction, andhereby authorize representatives of this
MECHANICAL PEE
PERMIT ISSUANCE
Ctj �'iCt_/� p2.3
city to enter upon the above-mentioned property for impection purposes.
(We) ages to save, IndemNfy an d keep harmless the City of Cu pert Ina
against llebllltics, Judgmmu, cons a rW expenses which may In any way accrue
against said City in consequence of the granting of this period.
;� Y /Y_
ALTER OR ADDED MECH.
AIR HANDLING UNIT (TO 10," CFM)
Date Reeei t#
SUBTOTAL'
AIRHANDLING UNIT (OVER lO,=CFM)
CONSTRUCTION TAX
Signature of Applicant/ onra t? .2
Damsr HooD(w/DucT) -
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HFATING UNIT (TO 110,000 BTU)
Wllltheapplicant or future building occupant store or handle hazard...
materlA as defined by the Cupertino Municipal Code, Chapter 933 and the
Safety Code $colon 25532W?
❑ Y. No
Will the applicant¢ tore building occupant use equipment or devices
which emit hazardous air contandrants as defined by the Bay Area Air
Date
Date RCCCI lif
HEATING UNIT (OVER 100,000 BTin
TOTAL:1-560
VENTILATION FAN(SINGLE RESID)
�Q ''eT���t-
I�$W I ✓DA'L'E
u
BOILER -COMP OHP OR 100,000 BTU)
Quality Management District?
P4 Yes N No
h read Healthe h ls SM]..255 S, 2553underChapter 22534. I5 of
Is out rrat Conic,
the Califomla Health k Safety Code, Sections 25505, 25533 and 75534. 1
TOPS
APR 14 1992
BOILER -COMP (OVER 100,000 B'IU)
NEW RESIDENTIAL MECH. SQ.FT.
understand that if the building does not currently have a tenant, that it I. my
ropomibillty to notify the uecupa in of the requiroments which moat W met
prior to Issuance of a Certificate of Occupa nry.
CIIY UJ- (;Ur C Tt 11140
ISSUEDBY: F3 IkVCG..
Owner or authorized agent Date
TOTAL:
OFFICE COPY
7