24186APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
N Wildln Preen Identification
PEIMITNQ,
Building Address:
Z 418
6
�lACPTd �/04C� S/Y6�/sS
CITY OFCUPERTINO- BUILDING DIVISION
APPLICATION / PERMIT
BUILDINGELECTWCALPLUMBING-MECHAMCAL
APPLICA IIUN bUtiMli [AL UAIJ,
r] L
Cnn/o-]tt�' NName: / Lic.No: 9
< 1/Y,J A
CATEGORY
CONTROLN
Archlett/—i- /Engineer Lic. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address /0(2PERh9TIS5UANCE
❑ 11LICENSED
CONTRACTOR'S DECLARATION
I hereby affirm that l am Licensed under provisions of Chapter9(commmc
Ingwli ISI fall 7000)of Di effect o(the Bualnesaand proleadonsCadeand my
I bin full (o and d(m.
L Clan Lle. Y
APPLIANCES RESIDENIAL
BDESCRETION
`
j`�/1T�xJ `• \r]
PANELS
_
Date Contractor ti ti'
—UP TO 200 AMPS
ARCHITECT'S DECLARATION
I understand my pbm shall be used as public records
201-1000 AMPS
OVER1000AMPS
SQ. FT. FLOOR AREA
S/SQ. Fr.
SIGNS ELECTRICAL
Licensed Professional
SPECIALCI(CUIT/MISC
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contradoes License Law for the
TEMP METER OR POLE INST.
following reakn.(Setion 70315, Business and Professions Code: Any city or
muntywhich requkesa permlttoconstmct, alter, improve, demolish, ormpalr
anystmMmpdortotm LwancgaL requlmstheappBraniforsuchperMtm
file a signed statement that he is licensed pursuant to the provlalom of the
POWER DEVICES
IDOL ELECTRIC
is—
Contradoris License Law (Chapter9(commencing with Section 7000) of Divi -NG
don3o(the Businewand Pro(ea,lom Code)orthat heb exempt thercfromand
the basis for the alleged exemption. Any violation of Seaton 7MI5 by anyUTLETSSWITCHFSSFlXTITRES
applicant fora permit subjeatstheapplicant to a civil pemlty of nor exam than
VALUAATIO
It
NEW RESIDENTIAL ELECTR SQ'FT.
five hundred dollars ($SM.
❑ 1, as owner of the property, or my employees with wages as their sale
STORIES
TYPE CONSTRUCTION
compensation, will do the work and the structure Is not Intended or offered for
sale (Sec. 7044, Business and Profesdom Code: The Contractors License Law
does not apply to an owner of property who build, or improves thereon,and
who does such work himself or through hisown employees, provided that such
OCC.GROIIP
RFS. UNITS
Improvements are not intended oroffered forsale. If, however, thebullding or
TO
Improvement issold withinoneycarofcwnpl6ioNtheowner-bu0derwill have
t119-(,iuMen of proving that he did not build or improve for purpose ofsalc.).
"b as owner of the property, am exclusively contracting with licensed
contractwa to comtract the oroject (Sec. 7044, Business and Prolassiom Code:
QTY. PLUMBING PERMIT FEE
}TODD TONE
APN
PERMIT LANCE
The Contractor's Lkznse Law does net apply to an owner of property who
Wild. or improves thereon, and who contracts fou such project. with is
contractor(s) licensed pursuant to the Contrader's License Law.
LI I am exempt under Sec B & P C for this reason
ALTER -DRAIN & VENT - WATER CPA)
FEE SUMMARY
BACK FLOW PROTECT, DEVICE
OUTSIDE FEES
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y_ N_
RECEIPT N
Owner Date
WORKMAN COMPENSATION DECLARATION
01 hereby affirm that I have a mdiflrate of consent to self -insure, or a
certificate of Workers'Compemation lmuranm ora certified copy thermf(Sec.
3800, Lab C.)
pl%'IVRES PER TRAP
SCHOOLTAX Y_ N
RECEIPT M
GAS EA.SYSfEM-]INCA OITILEffi
PARK FEE Y N
AECEIPf N
Policy N
Com any
GAS EA. SYSTEMOVER d (EA)
BUILDING DIVISION FEES
;Certifted copyuhercby furnished.
edified copy b filed with the city Inspection division.
CERTIFICATE OF O(EMPTION FROM WORKERS'
CRFASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
GRFA.SE'IRAP
SEWER -SANITARY -STORM EA 2(M7
COMPENSATION INSURANCE
(GMs section need nd b campleed if the permit la forone hundred dollars
Date Receipt#
WATER HEATER w/VENT/ELECTR
ENERGYFEE Y_ N_
($100)orlC98.)
I modify that In the performance of the work for which this permit is laked,
WATERSYSTEM/TREATING
I shall not employ any person in any reanner so as to become subject to the
Workers' Compensation Laws of California. Date
PAID
NEWRESIDPNTIALPLMB. SQ.FT.
Applicant
Date Remi t#
NOTICE TO APPLICANT: If, after making this Certificate m Exemption, you
should become subject to the Workeri Compemadon provisionsof the Labor
TOTAL:
BUILDING FEE
Code, you most forthwith comply with such provisions orthts permit shall be
deemed revoked.
CONSTRUCTION Isa ons LENDING Acwe c'
IMrcby cork for mthereisacomtaction landing ag7,Civ. .) perform
Ince of the work for which this permit b issued (Sac. 3097, Civ. C.)
E<naer, Name
I<nacr',Add.
I codifythat I have rend thisappBration and date thatthe above Information
isconect. Iagree to comply with all city and county ordinances and date laws
TOTAL:
SEISMIC FEE
ELECTRIC FEE
1
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relating to building comtmuction, and hereby authomm representaavea 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 liabilities,judgments, coda and expenses which may In any way accrue
ALTERORADDTOMECH.
Date Receipt#
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
against mid City In acmaquenm of the granting of this permit.
AIR xANOENc unIT (ovEz ]o,BBocFM)
CONSTRUCTION TAX
Signature of Applicant/Contractor Date
EXfLAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HATARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
-
Date Recel
WIIltheappliant orfutum building occupant store or handle hanrdous
material as defined by the Cupertino Municipal Code, Chapter 9.1 2, and the
I Italth sad Safety Code Section 25532(a)7
Yn
Willsthe applkan�t or(acturebuilding wm
occupant equipment or
HEATING UNIT (OVER 100,000 BTU)
TOTAL'
VENTILATION EAN(SINGLE RESID)
ISSUANCE DATE
which cook hav,dous air contamianb as defined by the Bay Arca Air
Quality Management Distrid7
m
iA G u
P A 7
BOILER -COMP OHI' OR 100,M BTUs
BOILER-COMP(OVER 100,000 BTU)
haveYread the hazy ous materials requirements under Chapter 6.95 of
the California Health & SafetyCode, Swt Eons 25505, 25533 and 25534. 1
understand that ift?,, Wildingdoea not currently have a tenant, that it is my
SEP - 4 1992
NEW RESIDENTIAL MECTL SQ.FL
,expansibility to notify the occupant of thLeraquirementgasshich must be met
prior to issuance of a Certificate of nry.
��CITYut-
ISSUED BY: -_ \- Yk
Owner or authorized agent Date
TOTAL:
OFFICE COPY
DAN A. HUNTER CONSTRUCTION
7791 Lilac Way
Cupertino, California 95014
(408) 255-4931 • License No. 575687
/66/ A1de1C,,v,6&4 ,oe.vc
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SEP 4Q1992
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