23738APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Id-7flaBon _
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23738
'�`� aces:- one:
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
BUILDING[LECTRICA4PLIJMBING-M ECIAMCAL
A A
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enntr tt ,aces — Lie. rye_
L -A/67
A_m It neer. Lk. No:
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Address:Z (/ - L
s
CATECARY CONTROL X
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
PERMITISSUANCE
�j � ❑
I,LJ�
LICENSED CONTRACTOR'S DECLARATION
Thereby affirm that lamlkmsed under provBlonof Chapter9 (commm
ingwlth5 aloe 7000)of Dlvision3ofthe Businessand Profession Code, and my
luny Is m fuu a erreR.
License Cass LIC X__-���
Date Contractor Orys'"j'IZ,
ARCHITBCTS E LARATION
I understand my plans shall be used as public records
AI'PLIANCFSRESIDENTAL
� rq�
Ii1"s s L'D'i�
�Y
II \\ GG /�_{��"�_
55Qj'1 W R UiA S/SQ. Fr.
PANELS
OVER00 AMPS
OVER IOW AMPS
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
SPECIAL CIRCUIT/MLSC
TMARMETERORPOLEINST.
following reason. (Section 7MIS, Business and Pmfessloro Code: Any city or
county which requires a permit to construct, alter, improve, demolish, or repair
any strecture poor to its Usua net, alao requires the apphant for such permit to
file a signed statement that he is licensed pursuant to the provisions of the
Contractor, License Law (Chapter 9(commencing with Section 7000) of Divl-
sion3 ofthe Business and Profeviom CedOmfl tt he B exempt therefromand
the basis for the alleged exemption. Any violation of Section 7m L5 by any
applicant fora permit subjects the applicant to a civil penalty of not more than
POWER DEVICES
SWOtMING POOL ELECTRIC
VALUATIO64.
�) CJ�_a
//�
l
l V OUTLETSSWITC ITSFIXTURES4FI[sp
five F11, asrcwnelofthe W).
1M property, or employees with wages their sole
{/
NEWRESIDENTIALELFEIR
OWES
TYPECONSTRUCTION
e saowner l
compensation, wW do the rk, arta Ues not intended r
he for
7lon,
Bualness and
sale (Sec. Businessand Code: The
Cade: The Contractors me Taw
License 1,
- -
does whoductapply torn owner ofp self or rough who
apply f pmperty he
whodoementsas such nemorlmprovntMreoryand
hieowne.
ihatsuchimprovement
C.GROUP
RES.UNI'IS
notintendedorough
11,ho everthe
lnlendneyearfoompr offered ra)e. If,howevcyffider
issold illngor
haveimprovement Bsold withino�yearo(complelimq the owner-bu0dcrw111 havet
Nen of proving that he did nawudorimproveforpurpoacofsale.).
L as owner of the property, am exclusively contracting with licensedPERMR
to conswct the project (Sec. 7014, Bualness and Profession Code:the
QTy. PLUMBING PERMITODDTDNE
ISSUANCEcontractors
APN
Contractors License Iaw don not apply to an owner of property whoALTER-DRAIN
Wilds or Improves thereon, and who contract, for such p(ojeas with a
conn -dor(,) licensed pursuant to the Contractors License Law.
[:]I am exempt under Sec B k P C for thin reason
& VFM-WATER &I
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
)
l DRAINS FLOOR ROOF, AREA, COND. ��
FTXIIIRES PER TRAP ��
M
SATARY Y_ N_
RECEET p
Owner Date
WORKMAN COMPOQSATION DECLARATION
[]I hereby affirm that I have a certificate of consent to ,s - mum, or
t eo(WOrken'Compewationlwurance oracertlfled ropythereof
B00 LaEC.)" t w�
PO'`
SCFIOOL TAX Y N
RFEFR i—
- EA. -i ETS
,
GAS FA. SYSTEM -OVER b
PARK FEE Y_ N_
RFEFRaI' N
Com any
HUI LDING DIVISI ON FE ES
.-�Certlfied copy Is hereby fumishe i.
❑ Certified copy B filed with the city hupection division.
CERTIFlGTE OF E%Ehs[TION FROM WORKERS'
'
GREASE/INDUSIRL A� •i
PLANCHECK FEE
PAID
GREASE TRAP
,�-NIIAKI -
COMPENSATION INSURANCE
(fhissection need not be completed if the permit is forces hundred dolls`
Date RCCCI t#
WATER HEATER W/VENT'/ELECTR
ENERGY FEE Y N
(S10(amless.)
Icertifythat in the performance of the work for which this permit is Bayed,
WATfR SYSPGI/TREA77NG
I shall not employ any person In any manner so as to become subject to the
Workers' Compensation lawsof California. Date
PAID
Applicant
NOTICETO APPLICANT: If, Certificate Exemption,
NEW RESIDENTIAL PI.MB, SQFf.
Data RQCLd t#
after making thin of you
should become sub)ad to the Workers' Compensation prevulom of the Labor
TOTAL:
B 1 DI G -'E
�-
Code, you a. forthwith comply with such provisions., this permit shall be
deemed revoked.
-
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there B a construction lending agency for the perform
ante of the work for which this permit B Issued (Sec. 3097, Civ. C.)
lenders Name
Tender. Addmsa
1 certify that I haveread this appliallonand statethat theabove information
B correct. l agree to comply with all city and county ordinances and state laws
T .ter
ELECTRIC FEE
PLUMBING FEE
QTY, MECHANICAL PERMIT FEE
PERMIT ISSUANCE
MECHANICAL FEE
FEES PAID:
relating to Wilding construction, and hereby authorize representatives of thin
City to enterupon the above-mentioned property for inspection purposes.
(We) agree to , indemnify an d keep harmless the City of Cupertino
ALTBRORADDTOMECH.
Date Receipt#
AIR HANDUNG UNIT (70 I0,000CFM)
SUBTOTAL:
against Nabi a,' gmenB,ro ,.a dexpeneswhichmsylnmywaya¢rue
agalnt CI ca en 1FantrBg or this permit
AIR HANDLING UNIT (OVER l0,000CFM)
CONSTRUCTION TAX
fn phate
Hotta
EXHAUST HOOD(W/DUCT) ••
CONSTRUCTION TAX PAID:
'k=A i S MATERIALS DISCLOSUR
Will the appBant or( rebuilding ompart store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Health and Safety Code Section 25532(a)7
❑ Y. .- M No
-�
I rEATING UNIT (TO 100,000 BTU)
-
Date RCCCI t#
HEATING UNIT (OVER 100,000 BTU)
TO
VEN"IILATIONFAN(SINGLERESID)
-
ISSUANCE DATE.
Wllltheappliantorfuturebulldingompantuseequipmentordevrca
which emit hazardous air contaminantsas defined bythe Bay Area Air
Quality Management District?
YM No
D '
PAID
V
BORER-COMPOIIPOR100,0(011TU)
BOILER-COMP(OVERIW,000BTU)
4havemadtheh.RusmaterialsrequirementsunderChapter6.95of
,,,,-yys"ahh A Safety Cede, Scatioru 75505, 2513 and 7553d. i
Medi Is that 11 the building docs not currently have a tenant, that It Is my
n
(a 7 1992
MAY
NEW RESIDENTIAL MECI-I SQ.PT.
rispow mnefio notify the occupant of the requirements' which most be met
,vl
prior to Issuance Of a Certlfiate of Occupancy.
�tz,vL J
ISSUED BY:
Owner or authwb<d agent Date
TOTAL:
OFFICE COPY