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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identiflcatlon
Building Address:
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
9U[LDING-ELFCTRICAI PLUMBING_W pL
Q _14 / � b
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can r'aNa_me- ue•No:
CATEGORY
CONTROL
Archl ect/Engineer. � —_ I-� ;
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QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:
`" ❑
Lr l.y`J
PERMITISSUANCE ax�e�7
LICENSED CONTRACTOR'S DECLARATION
IMreby affirm that l am Licensed under provisions of Chapter9(mmmarnc
inausel i.fan70(10)a d ff.on3ofthe Bualnneand Pro(eWonaCade, and my
licLice. Is Ins and
APMANCES-RESIDEK176L A
JOB DESCRIPTION
PANELS
c, If
,gym M 9,3
�.
Date Co
Date. f-`l¢-—Canendor,
XII- SAM
ARCHITECT DECLARATION
I understand my plan shall be used as public remade.
OVER 1000 AMPS
SQ.PT,FLOORAREA
f/SQ. FT.
SIGNS ELECTRICAL
Liceneed Pm(ekanal
OWNER -BUILDER DECLARATION
I hereby af@mthat I am exempt from the Contudor's License Law for the
SPECLILCIRCUIT/M]SC
TEMP METER ORPOLF INST.
following roman. (See lone 70315, Business and Profession@ Code: Any city or
county which requlrna perretrocontruct, alter, bnprove, demo Wh, arrepalr
anystructure priorm Its Issuance, also requlrestheapplicant formch permit to
file a signed statement that he b licensed pursuant to the provisoes of the
Contractor's Licence Law (Chapter 9(mmmencing with Section 7000)of Divi.
sion 3 of the Business and Pirand is Code) mthat he is exempt therefrom and
POWER DEVICES
SWIMMING POOL ELECTRIC
the basis for the alleged exemption. Any violation of Section 7031.9 by any
applicant fora permit subjedatheapplicant to a civil penalty of not more than
(m E(�q(yI•ICIIF&RXfI1RES
/VALUATION
J I yA
l Cl L
five hundred dollars (5500).
I, as owner of the property, or my employewith wages as their sol"
❑ e
NEW RESIDENTIAL ELI:CTR _SQ.F'
STORIES
TYPE CONSTRUCTION
compensation, will do the work and the stnrdum is not Intended or offered for
vie (Sec. 7096, Business and Profession Code: The Contradnys Lim. Law
doe not apply to an owner of property who builds or Improves thereory andOCCCROUP
who does such work himselforlhrough his own employees, provided that such
RFS. UNITS
Improvements are not intended proffered forule. If, however, thebuilding or
Improvement build withlnonyearofcompletb theowner-bu0derwlll have
TOTAL:
t"rdenofpmving that he did not build or Improve for purpose of sale.).
LJ L as owner of the property, am exclusively contracting with licensed
mntrtdam to maximal the project (Sm 7097, Business and Prolculan Code:
QTY, PLUMBING PERMIT
PERMIT ISSUANCE
DZONE
APN
The Contractor's License Law dm nor apply to an owner of property who
Wilda or improves thereon, and who contracts for such pilled. with a
c or(s) licensed pursuant to the Contract's License Law.
ap3T+dor
E31 am exempt under Sm B & P C for this reason
ALTER -DRAIN &VENT -WATER (FA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINSIA
FOR, ROOF, AREA, COND.
FD(TURES PFA TRAP IBM—R—
SANITARY Y_ N_
RECEIPT a
Owner Date
WORKMAN COMPENSATIONDECLARATION
❑I hereby affirm ve that I haa certificate of concent to self -Insure, or •
copylhenro(lSee.
3800
3800, LabCJ
55100LTAX Y N
NM
GAS F.A. SYSIFM-1 INC.4 OUTLETS
PARKFEE Y N
pacy f
M
ITL SYSTEM -OVER 4 (EA)
Com any
CaCCAS
DING DI
BUILDING DIVISION FIGS
�CertNed copy is hereby t
Certified copy b filed withh the
hthe cityinspection division.
❑e
CREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECKFEE
GREASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
TThbsedn need not becompleted Bthe pemdt b s formhundred dollars
M700)oify that
Ice am teat Nthe performance ntthe work for which this permit Is bathe
I shaft not employ any person In any manner n u `mr�ubled to the
Workers' tion olC✓aIB ;"e j�
PAID
19b
Date Reaal to �,O
SEWER -SANITARY -STORM F.A.Man
WATER HEATER W/VRNT/ELECTR
ENERGY FEE Y N
PAID
WATER SYS.ITM/TRFA,IING
A ITCH
NOTICEcames a The after Ing ompo urtionCertifipro is Exemption, you
become subject to the Workers'Comp Labor
Date Reset t#
NEWRFSIDFNTIALPLMB. SOFT.
TOTAL:
Code, rovisinprovisionofthe
Code, you arse( forthwith comply with such proviabn arthb permit 6.11 be
deemed revoked.
FEE Let QV
IBUILDING
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby a(Brrn that there is a construction lending agency (orthe perform
anceofthe work for which this permit is Wued(Sec- 3097, CIv.C.)
T L. ��
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PERMITI.SSUANCE
PLUMBING FEE
hander's Name
Lenders Address
I anifylhat I havereadthieapp0atbnand @tatethatthe above Infomution
brornat. l agree to complywithaR dtyand county ordinances and gate laws
relatingto Wllding construction, and herebyauthoriunpresentativesofthis
MECHANICAL FEE
FEES PAID:
eC 11 qq2_
city to enter upon the abovcmentloned property for Inspection purposes.
(We) agree to uve, Indemnify an d keep harmless the City of Cu part I.
ALTER OR ADDTO MUCH.
_
Date RBCeI tN
SUBTOTAL:
ag.mkIlaudgments, mate and expenseswhlch may in anywayacame
against ence a/t grantln o(IMs pam
Az ;�Aih �
AIR HANDLING UNIT(TO10,ODOCFM)
AIR HANDLING UNIT (OVER IO,ODOCFM)
CONSTRUCTION TAX
S (A pplicamContra ate
EXHAUST HOOD(W/DIRT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BILL)
Will the applicant orfutun building occupant store or handle haaardous
matedal as defined by the Cupertino Municipal Code, Chapter 9.12 and the
Ilealth and Safety Code Section 75532(a)?
❑ Ye M No
Date Recei tp
HEATING UNIT (OVER 100,000 BTU)
TO
VENTILATION FAN( SINGLE RESID)
ISSUANCE DATE
Will the applicant or future bu llding oovpant use equipment or devices
whichemit haeardous air conte minarets as defined by the Bay Area Air
oality Management District?
p� p
P A
BOILER -COMP OFT' OR 100,000 BTU)
I Ye No
Oaxdedabmqulnments
BOILER-COMP(OVER 100,000 BTU)
va mad the b.9 under Chapter 6.95 of
the California Health & SofdyCode, Sedlon 25505, 75533 and 75534. 1
undenta cad that if the building does not currently have a tenanq<hat it b my
APR 13 199
.992
NEW RESIDENTIAL MECH, SQ.FT
responsibility to ndlfy the occupant of the requirements which moat be rtM
prior to Lssuanm of a Certificate of Occupancy.
01YCrr Urtf,lrr@v
- 1 s
ISSUED BY�a S-L�!IAII i[
Owner or authorised agentDate
TOTAL:
OFFICE COPY