23467APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pro' ed identification
Building Address:
PERMIT NO.
o ss Pasood o Rv<
23467
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ae: ` Flume:
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDINGELECTWCALPLUMBINGMECHAMCAL
A A
�—
Comr,!VName: / Lie. No:
C-1/i 5 5,0
CATEGORY
CONTROL N
Architect/Engineer. Lk. Na:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
/ pp��
Address: /1 S% /Y(/ijc�A�Q 5/ ^C S �e�
❑ 1 KA
21 -El El
PERMITISSUANCE Q
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(mmmenc-
APPLIANCES -RESIDENTIAL
JOB DESCRIPITON
PANELS
UP TO 2DO AMPS
Ingwith Sectio ,M)of Division3 ofthe Busincssand PrefesclonsCode, and my
lice...Ch full force and effect.
License Ch® LION#
Date Corrcvctor
ARslull W used as public
I understand my pions ehaB be used u public records.
/
201 -IMO AMPS
OVER 1000 AMPS
SQ. FT. FLOOR AREA 4/SQ. Fr.
SIGNS ELECTRICAL
Licensed Pe fessianal
SPECIAL Z .
OWNER -BUILDER DECLARATION
(hereby affirm that Iam exempt the Contractors License Law for the
following reason.(Section 7MIS,Business and Pmfevlone Code: Any city or
c ntywhichrmpu apermlttomrut Midter,Impmve,dem hsh,orrepalr
any structure prior to its Hustance, also requires the appllant for such permit to
file a signed statement that he Is ecerued pursuant to the provisions of the
S V A L E D IN
® f1 n rte., ►`�
NI\V/71 EYE PK
Is � ■
TENIpMEfERORPOLEINST.
)OWER DEVICES
SWEdMING IDOL ELECTRIC
—)ATE
OUTLETSSWIT'CHE6FLXTURES e 0
Contractor's License Law (Chapter 9 (commencing with Section 7000) of Mel-
slon3 of NeBminen and Profenlons Code)orthat he6exempt thercfromand
the base for the alleged exemption. Any violation of Section 7071.5 by any
appBant fora permit subjectstheappgcant to a dvil pemlty o(nat mnrctlun
11 N
j
five hundred dollars ($500),
ages as their
I, net of the property, or my employees with wr m
F1 1,
compenadon, will d o the week and the structure Is not intended or offered for
NEW RESIDENTIAL ELECTR SQA.
SIOWFS
TYPECONSTRUCTION
sale (See. 7014, Business and Professions Code: The Contractors License Law
docs not apply to an owner of property who builds or impmve thereon, and
whodo ssuchworkhbruelforthrough hisownemplayees, provided that such
Improvements are not intended oroffered for sale. If,however,thebuildingor
OCC. GROUP
RES. UNITS
TOTAL: q jO
Improvement 6 sold within oneyearofcomplentlon, the owner-butIderw111 have
tkLLrden of proving that he did not bund or improve fee purpose of sale.).
"L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business ami Profemioro Code:
QTY. PLUMBING PERMIT FEE
FLOOD ZONE
APN
PERMIT ISSUANCE
7Tc Contractors Ltmnse Law does not apply to an owner of property who
thon, and who contracts for such pWifets with a
Wilds or improve ere
CqLt[+,tr(e)licensed pursuant to the Contractor's License Law.
LJ f am exempt under Sec. B & P C for this reassan
ALTER -DRAIN -WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
FOR ROOF, AREA, COND.
DRAINS. LO
SANITARY RECEIPT If
OwnerDate
WORKMANCOMPENSATIONDECLARATION
❑1 hereby affirm that I have a certificate of consent to self -In ure, or a
certificate of Workers' Compensation Issuance or a certifiM copy thereof (Sec.
3800, Lab C3
FIXTURES, PER TRAP
SCIdOOLTAX Y_ N_
RECEPT N
GAS EA. SYSTEM -1 INCA OUTLETS
—
PARK FEE Y N
RECEE'TR
Policy p
C°�y
GAS M. SYSTEM -OVER 4 (EA)
HUI DI VISION FE I'S
Certified copy 6 hercbyth the cid.
Certifed copy 6 filed with the dry Inspection division.
GREASE/INDUSIRL WASTE INTERCEPTOR
FEC
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
SEWER -SANITARY -STORM EA. 200FT,
COMPENSATION INSURANCE
This section need not be completed if the permit b fee one hundred dollars
($100)of len.)
I certify that In the performance of the work forwhlch this permit Is Issued,
DatC RCCCI t#
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y_ N_
WATER SYSTEM/TREATING
1 shall nm employ any person In any manner m in; to become subject to the
Workers Compensation Laws of California. Date
PAID
NEWRESIDENTIALPLMB. SQ.Fr.
Applinnt
NOTICE TO APPLICANT: If, after nuking this Certificate of Exemption, you
should become subject to the Workers' Compemat[on provisions of the Labor
Date Recei t#
TOTAL:
BUILDING FEE
Code, you must forthwith comply with such provisions or this permit shall be
deemed revoked.
consraucrloN LENDING AcwcY
SEISMIC FEE
TOTAL:
ELECTRIC FEE
_1>
I hereby affirrn that there 6 a construction lending agency for the perform
6 097
ance of the work for which this permit Issued (Sec. 3, Civ. C.)
Icndcr'. Name
L.dcea Aadmss
PLUMBING FEE
QrY. MECHANICAL PERMIT FEE
MECHAMCALFEE
I cedifythat l havereadthbapplkztlonand statethaf theaboveinformation
6 cormct l agree tocomply with all city and county ordinances and nate laws
PERMIT ISSUANCE
FEES PAID:
ALTERORADDTOMECH.
relating tobullding construction, and hereby authorize representatives of fhb
city to enterupot the above-mentioned property for inspection purposes.
(We) agree to save, Indemnify an d keep the City of Cupertino
which
age Wt 166111t1e, judgmenb, con.and expense which may In anywayacdue
Date Receipt#
AIR HANDLING UNIT (TO 10,0D0 CFM)
SUBTOTAL:
against said City in con ce (the ting of this permit.
X/,p f
a,
AIR HANDLING UN7T(OVER 10,000 CFM)
CONSTRUCTION TAX
a�%en
Signature ofPA•ppNant/Contractor Date
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appllaot or future Wilding occupant store or ha od If hazardous
HEATING UNIT (TO 100,000 BT 11)
Date Recel t#
mated.) as defined by the Cupertino Municipal Code, Chapter 9.1Z and the
I ealth and Safety Code Section 2M32(a)7
0 Yes M No
Will the applicant or futurebuildingecmpant use equipment ordevices
which emit hazardous air contaminants.. defirsed by the Bay Arca Air
Quality Management District?
4Ye n❑
have redthe haz rdoNoas maferi.Is requirements under Chapter 6.95 of
the Califmla Health & Safety Code, Sections 25505, 25533 and 25534. I
understand that if the building does not currently have a tenant, that It 6 my
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
P A I D
111/18 1992
BOILER -COMP (311P OR 100,000 BTU)
BOILER -COMP (OVER 100,000 BTU)
NEWRMDENTIALMECH. SQ.FT
responsibility, to notify the occupant of the requirements which must be met
prior to Issuance of a Certificate of Ocrepa ecy.
ClIY VE Cz IJI Mn 1040
ISSUED By
Owner or authorized agent Data
TOTAL:
OFFICE COPY