23428APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification
Building Address:
PERh0TNO.
/ jos UE.P/7fS
23428
wnaera ante: one:
A1104-lW25 ;?6 -;?1/3Z
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
p
�l
tractor's Namc: Lic. No:
E
BUILDING -ELECTRICAL PLUMBING -MECHANICAL
CATEGORY
CONTROL M
Archdret/Engineer. Lle. No:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address:
❑ ❑ ❑
PERhITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
thereby 70that la 9(coandm
AI'PIAANCESRESIDF.NTIAL
JOB DPSCI(I'770N
PANELS
ection
ingwitlice.h Inisi.0e1thelh louseaomofCsi.o.
BusinevandProlesalonaCode,and my
force
license bin toll forac and effect.
�r
` _rf R a folia s/e' G�
License Class Lie.
�f Va,7���
Date Contractor
r
201-1000AMPS
ARCHITECTS DECLARATION
I understand my plans shall W used as public records
OVER1000AMPS
SQ. FT. BOOR AREA
$/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
SPIKIALCIRCUIT/1,119C
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt fromthe Contractor's Llrense law for the
TEMP. METER OR POLE INST.
following reason. (Section 7131.5, Business and Professions Code: Any city or
ounty which requires a permit tommtmM, alter, Impmve, demolbh,orrepair
anystructure poor to its insuince,also requnestheappllcant forsuch permit to
file a signed statement that he is licensed pursuant to the provisions of the
POWER DEVICES
SWIMMING POOL ELECTRIC
Contractor's License Law (Chapter 9(commncing with Section 7000).( Divi-
si.n3 of the Business and Professons Code) orthat he is exemprtherefromand
VALUATION
the basis for the alleged exemption. Any violation of Soction 7001.5 by any
applicant for a permit subjects the applicant to a civil penalty of not more Iban
OUTLETSSWITCHESFIXTURES
f ve hundred doI an' ($S00).
as owner of the property, or my employees with wages as then sole
on pensation,willd.the.1, andtha strumme b not Intended or offered for
NEW RESIDENTIAL ELECIR SQ.
rLMUTUTER
TYPECONSIRUCTION'
sat a (Sec. 70K Business and Professions Code: The Contractor's License Law
does not apply to an owner of property who Wilds or Impmve. the., ml
who does such work himself or through his own employees, provided that such
RIS, UNITS
T
Impmvements are not Intended oroffered for ale. If, l o scomr,the W Ilding or
improvement b sold within one yearofcomplMlon, the owner-bullderwlll have
t"oden of provingthat he did rot Wild orlmprove for purpose otsale).
LJ I, as owner of the property, am exclusively contracting with licensed
contract., to construct the project (Sec. 7040 Bu,oess and Professions Code:
QTY. PLUMBING PERMIT FEE
FLOOD ZONE
APN
PERMITeLSUANCE
The Contractor's License Law does not apply to an owner of property who
Wilds or Impro.a vthereon, and who contracts for such pWorts with a
oI ar (s) licensed pursuant to the Contractor's License Law.
ffl exempt under Sec. B & P C for this reason
ALTER -DRAIN VENT -WATER (EA)
FEE SUMMARY
RYam
BACK FLOW PROTECT. DEVICE
OUTSIDE ITES
DRAINS FLOOR A, ROOF, ARECOND.
SANITARY Y N
RFCFRPT N
Owner Date
WORKMAN COMPENSATION—DECLARATION
[]I hereby affirm that I have a mrtlRote of consent to self -Insure, ora
certificate of Workers'Compensatl.n lmursom or a notified copy themof(Sec'
3800, lab C.)
FIX.fUfiFS PER TRAP
SCHOOL TAX Y_ N_
RECEIPT If
GAS F.A. SYSTEM -1 INCA OUTLETS
PARK FEE Y N
RECEIPT M
Polley P
Com any
Go
GAS F.A. SYSTEM -OVER 4 (EA)
BUILDING DIVISION FEES
ertified copy is hereby furnished.
❑Certified copy b filed with the city Inspection division.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
SEWER-SAMTARY-STORM EA. 300FT.
COMPENSATION INSURANCE
If the pert Is for one hundred dollars
(1'hb section need not be completed mi
Date Remi ttf
W/vEvr/FLECTR
ENERGY FEE Y_ N _
($1m).r.less.)WA.�E�,pTpR
I terrify that I, the perf.rmanm of the work forwhIch this permit b Issued,
ce
WATERSYSTEM/TREATING
1 shall not employ any person In any manner so as to become subject to the
Warless Compensation Taro of Gllfomb. Date
PAID
NEWRESIDENTIALPLMB. SQ.FT.
Applicant
NOTICE TO MPLICANT; If, after making this Certificate of Exemption, you
should become subject to the Workers' Compensation provisions of the Labor
Date Reeel ted
TOTAL:
BUILDING FE
Codeyou mass forthwith comply wlthsuch provisions mthis permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
TOTAL:
ELECTRIC FEE
Thereby orkfrwhic tbammwctlonlendingagency 097, Ciforthe perform
ce of the work for which this permit b Lowed (Sec 3097, CIv.CJ
Lender's Name
Lcnd.rsndhatI
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
tan��
hat ondtheabove Id gain laws
I rect. I a at I have ready with aBcaty n do stacounty
bmmct. Iagreeto comply with all cityand countyordlnano_s and elate laws
PERMIT ISSUANCE
FEES PAID:
ALTER OR ADDTO MECH.
relating to building construction, and hereby authorize representatives of this
city to enter upon the abovo-mntloned property for inspection purpose.,
(We) agree t. sat demN/y an d kee rmless the City of Cupertino
against babillti , nb,cwtsande nw maylnanywayacvue
Date Receipts:
AIR HANDLING UNIT (TO 10,00(] CFM)
SUBTOTAL:
aims said y scquen .(t gr ng his pe
AIR HANDLING UNIT (OVER 10,001) CFM)
CONSTRUCTION TAX
Signs of Applicant/ .,tractor toI
EXHAUST FLOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT CFO 100,000 BTU) r.�
Date Recel tit
Will the appllcant or future building .capant store or handle hazardous
material .lth..sd.MyCvdc the SCupertino Municipal Code., Chapter 9.1 7, and the
Eimlth and Safety Cade (i Non 25532(a)t
r7 You r] No
Will the applicant w device.
lay
HEATING UNIT (OVER 100,000 BTU)
TOTA .
VENTILATION FAN (SINGLE RE9ID)
ISSUANCE DATE
which eManaement airdefine bythe Area
trfcL7 nsnH as defined bythe Bay Arca Air
Illy Management Dirtrlcti
PAID
IT P9
BOILER -COMP QEE'DR 100,0(0 BTU)
L'i Yc. IL�J1 No
I have read the haat Nonsterlab requirements under Cha For 6.95 of
the California Health &Safety Code, Seaons75505,75SU and 25534.1
understand that if the building does not arrently have a tenant, that it Ls my
pa of of the requthich t be
responsibility to notify the ocarequirements wmuse me
prior t. Issuance a. Certi fi.m.f Ocapa ocy.
PJ1pR 19 X992
y
C�iti Ury `UJ t:nIII
BORER-COMP(OVER 100,0110 BTU)
NEW RESI DENTIAL MECH. SQbT.
ISSUEDBY
Owner or authorised agent Date
OFFICE COPY