22810APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification
wo"-7o yip
PERMIT NO.
22810
Phone:
�,15M
1-67,15Mc^mrsd^ra
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
APPLICArn73U7MTrrXt
/Aa_I� A
16 l
am: Lix.No:
BUILDING-ELECnUCALPLUMBINGMECHAMCAL
CATEGORYCONTROL
N
Architect/En neer. Lk. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address
PERMITISSUANCE
❑ ❑ [1j�
LICENSED CONTRACTOR'S DECLARATION
I hereby offlmn that lam licensed underprovL+ions of Chaptcr9(rommenc
AITUANCESRESIDENTIAL
JOB DESCRIPTION
PANELS
Ingedth Srs1ton7(XW)of Division 3ofthe Busiuvand ProfesslonsCode,andery
license Is In fuR force and effect.
Licence Class LIt.N
Date Contractor
UP TO 2DO ANTS
—
201-1000 AMPS
ARCHITECTS DECLARATION
I understand my plain shall be used a public records.
OVER 1000 AMPS
SQ. Fr. FLOOR AREA
$/SQ. FT.
SIGNSELECTRICAL
Licensed Professional
LED IN
SPECiAl CIRCUIT/MISC
OWNER -BUILDER DECLARATION
Iwingrason.(that lam31.5, Business from the d Protdtors Cnse Law for t he
followingichrN(Smtlon7Bittocoand Protectors Code: Mydtyor
countywhichrequlreaa prove, demolish, or
�� T E R
T[Tdp.MEfLA OR IOLEINSr.
mi tc,
asuarcoconslm mals thea ofNt a
any atmaurc statement
file a signed statement that he V Bcensed pursuant to the provksions of the
that he at aborsed pursuant t the provisions
POWER DEVICES
//''
iso �(/p K
I
— DATE
SWIMMING POOL ELECTRIC
Contrador's License Law (Chapter 9(commencing with Section 7000) of Dlvb
sion3 of the Business and Porde aloe Code) orthat he b exempt therefromand
VALUATID
the basis for the alleged exemption. Any violation of Section 7x)1.5 by any
appliant for a permit subjeds the applicant to a civil penalty of not more than
OUILETSSWITCHESFIXTI RES
five hundred dollars (5500).NEW
❑I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure l not Intended or offered for
RESIDENTIAL ELECTR �'�'
STORIES
TYPE CONSTRUCTION
sale (Sec. 7034, Business and Profealoes Code: The Contractors License law
does not apply to an owner of property who builds or improves thereon,and
whodoesauchwork him Borthraagh Msownrmployees, provided that such
OCC.GROUP
RES. UNITS
improve^pnts are not intended oroffered forsale. If, however, thebuilding or
TOTAL:
improvement Lssold within oneyearofcompldloe,theowner-buliderwill have
th,�urdcn of proving the he did not build or improve for purpose ofsale.).
L -J L as owner of the property, am exclusively contracting with licensed
contractors to roestruct the project (Sec. 7044, Business and I'm(ralov Code:
QTY. PLUMBING PERMIT FEE
FIADD TONE
APN
PERMIT ISSUANCE
Tlae Contmdor's License Law does not apply to an owner of property who
Wilda or Improves thereon, and who contracts for such pwjeds with a
gqttLLBrradods) licensed pursuant to the Contractors License Law.
o LJI am exempt under Sec. B & P C for this reasonOUTSIDE
ALTER -DRAIN & VENT- WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
FEES
DRAINS- FLOOR ROOF, AREA, COND.
SANITARY Y N
RECEI'rN
Owner Date
WORKMAN COMPENSATION ffiDECLARATIONFIX.N,
❑I hereby arm that I have a certificate of consent to self -Insure, ora
certificate ofWorkeri Compensation lrouranoeora certified copy thereof(Sec.
3800, Lab C.)
SCHOOL TAX Y_ N_
RECEIPT N
GAS FA. 5YSTEM.1 INCA OUTLETS
—
PARKFEE Y N
RECER'r N
Policy tl
�m any
GAS EA. SYSrEId-0VFR d (EA)
BUILDING DIVISION FEES
[�Cedified copy is hereby fdelshed.GREASE/INDUSI'RL
r7 Certified mpy is filed with the city Inspection division.
WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEM PTION FROM WOR K ERS'
PAID
SEWrER.SANITARY-STORM EA 200FT
COMPENSATION INSURANCE
(Thissedion need not be completed 0 the permit bforom hundred dollars
Date RCCCI t#
wAT4R FIFAr4R w/vENT/ELECTR
ENERGY FEE Y_ N_
(s10(fiorlea.)
I certify that In the performance of the work forwhkh this permit is issued,
SYSTEM/TREATING
1 shag not employ any person In any manner m as to become subject to theWATER
Workers' Compensation Laws of Callfomia. Date
PAID
NEWRESIDENTIALPLMe. SQ.FT.
Applicant
NOTTCETO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the Workers' Compensation provisions of the Labor
Date Recel t#
TOTAL:
BUILDING FE
Code, you most forthwith comply with such provisions orth4s permit shall be
m
deeed revoked.
consrgucrloN LENDING AGENCY
SEISMIC FEE
TOTAL:
ELECTRIC FEE
I hereby affirm that there ba construction lendingagency forthe perform-
ance of the work for which this permit Is Lsseed (Sec. 3097, Clv. C.)
Lender; Name
I<nders Address
I certifythat l have read thisappllmaona.d Aidethattheabove information
bedded. l cgres to comply with all City and county ordinances and state laws
PLUMBING FEE
QTY. I MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMITISSUANCE W
,
FEES PAID:
relating to building construction, and hereby authomm representatives of thio
city to enter upon the above-mentioned property for Inspection purposes.
(We) agree to ave, indemnify an d keep harmless the City of Cupertino
agairetllabiilties Q enls, costs and expenses which may in any way accrue
ALTER OR ADD TO MFiCH.
Date RCCeipt#
AIR HANDLING I1NI"p (TO 10,000 CFM)
SUBTOTAL:
against qty ro ".onre of the granting of thin —rparmit. ��
AIR HANDLING uMr rovFR lo,000 cFM)
CONSTRUCTION TAX
Signa of /QQ tractor Date
ExHAus r HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
H ZA$DOUS MATERIALS DISCLOSURE
Will the applicant or future building ocmpant store or handle hanrdous
HEATING UNIT (TO ID0," BTI) tl� -
Date RCCCI t#
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Iiralth and Safety Code Section 25532(a)i
❑ Yrs M No
Will the applicant orfuture building occupant use equipment or devices
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Maagc..t Dist rid?
Yrs No
have read the bazar ones materials requirements under Chapter 6.95 of
the Glifodua Health&SafetyCode, Sections 25505,25533 and 25534. 1
understand that if the building does not currently have a tenant, that it is my
HEATING UNIT (OVER 100,0(10 BTU)
TAG
RA
ISSUANCE DATE
OCT 1 1981
ANsa �nne'la�
VENTILATION FAN (SINGLE RESID)
BOILER -COMP OHP OR 100,000 BTU)
BOILER-COMP(OVERI K000 BN)
NEW RESIDENTIAL MECH. SOFT.
repoexibilityllonotify the occupant of the requirements which must be med
/\
prl u aCertificideof Occupancy.
ISSUED BY:VBs�—QI
01
sero o gent Dae
OTA L:
OFFICE COPY