23424APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
Building Project Identification
Building Address:
7S S0S" P c ,B1- osso M7 Ri IJE'
PERMITTING.
-23424
one:
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
APPLICAA A
Z q
3 -L
cono-act aName: Ue. o:
E
BUILDI NG.FLECTRICALPLUMBING-MECHANICAL
CATEGORY CONTROL
BUILDING PERMIT INFO
Architect/Engineer. _ Lk. No:
Chi
QTY ELECTRIC PERMIT FEE
Address:
PERMBTISSUANCE
f
u r 2-
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under pmvbims of Chapter 9(commen
APPLIANCESRESIDENIAL
JOB DES IWMON
PANELS
ingwith Sedion7(10D)of DiNs m3ofthe Businemand Professions Code, and my
license I. I. full to. and effect
L
License Class LION
Date Contractor
20I-10WAMI'$ -
ARCHITECTS DECLARATION
shall be used as public recas.
I understand my Flare N
OVER 1 WO AMPS
� y 4. fL 1 EA
$/SQ. FT.
Licensed Professional
SIGNSELECTRICAL
U E f,'�
SPECIALCIRCU1T/MISC �le 0
' /
OWNER -BUILDER DECLARATION
I hereby affirm that( am exempt from the Contractor's License law for the
(allowing mason.fSection70315, Businmand Professions Code:Anycityor
cmntywhichrequiresapermittocomtmd,alteg Improve,den lbh,orrepair
I
d ab�ll
o
'
TEMP. METER OR POLE INST.
POWER DEVICES
anystmcture priortu its Issuance, also requires theapplicant forsuch permit to
file a signed statement that he is licensed pursuant to the provisions of the
SWIMMING IDOL ELECTRIC
/ OUTLETSSWITCRESFIXTURES .Z.
Contractor's License Law (Chapter 9(commencing with Section 7000) of Divi-
slon30(the Business and Profesioru Code) orthat he Is exempt therefromand
the basls for the alleged exemption. Any violation of Section 7031.5 by any
appliantforapemdtsubjedseheappbcantioaclvilpemltydna=mthan
VALUATION O
a
� D
I
NEW RESIDENTIAL ELECTR SQ.FT.
five E]1, asrcwnerofthepr. thele sok
I, as owner the property, or employed with wages
STOW
TYPECONSTRUC'I'ION
will he
work and thes eh not Intended oroffered for
compensation, r
sale (See. 7044, Business and Professions Cotle:7he Contractors License Taw
Business Cads:
TOTAL: .
does not apply to an owner of property who Wilds or improves therms,and
who doessuch work himselforthrough hisown employees, provided that such
Improvements are not Intended oroffered for sale. If, however, the building or
OCC. GROUP
RES. UNITS
Improvement issoldwlthin oneycarofcompletion,theowner-b flderwill have
Xt rden of proving that he did not build or improve for purpose of ask.).
B(j S as owner of the property, am exclusively contracting with ticenxd
nttn,ctors to construct the project (Sec. 7004, Business and Pro(essiom Code:
QTY, PLUMBING PERMIT FEE
FLOOD ZONE
APN
PERMIT ISSUANCE p`
' �1
The Contractor's License Law does not apply to an owner of property who
Wilds or Improves thereon, and who cmuncts for such pWjeats with a
) licensed pursuant to the Contractor's Limn Law.
CQatt dor(.on
1_J [ am exempt under Sec. B k P C for this reasOUTSIDE
ALTER -DRAIN k VENT -WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
FEES
DRAINS. FLOOR RODE, AREA, COND.
SANITARY Y N_
RECE PT N
Owner Date
WORKM C M LTJ NDECLARA ION
❑1 hereby affi at I have • (late of consent to self -insure, or a
certificate of Worker Compemationlrmuranceoramnified copythemof(Seo.
3800, Lab C.)
FD(TURESPER TRAP 6O
t
SCHOOLTAX Y_ N_
RECEIPC N
, GAS EA. SYSTEM -1 INC.40I17LEI5 3,0f'V
PARK FEE Y N
RECEIPT N
Policy p
Com any
C.
GAS EA. SYSITM-OVER4(FA)
BUILDING DIVISION FEES
edlfied copy is hereby famished.
rjCertified copy In filed with the city inspection division.
GREASE/WDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF E)(EMPTION FROM WORKERS'
PAID
SEWER.SANITARY-STORM FA 200FT
COMPENSATION INSURANCE
(1'hissenion need not W completed if the permit ls formic hundred dollars
($10(fiarless.)
I certify that N the ped.... of the work forwhich this primal is issued,
Date RCCfi [#
WATER IiFATER W/VENT/ELECTR
ENERGY FEE Y_ N_
SYSTETREATING
WATER M!/
I shall not employ any person In any manner so .{p bqcome subet to the
Workera Com ation Law of a f I Data,`PAID
Applicant .
NEW RESIDENTIAL PLMB. SQFT.
Date Remi t#
NOTICET APPLIC after g this Certificate of Exemption, you
become should bee subje the Worl .ripsmatlon provisions of the Labor
TOTAL:
BUILDING FE
Cade, you most forthwith comply with such provisions or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there h a construction lending agency for the perform
ance of the work (or which this permit b issued (Sec. 3097, Civ. C.)
1,enders Name
I.ender'e Address
I certilythat I have read thls appeati . and Mamthatths above W0.tbn
is correct. I agree to comply with all city and county ordinances and Mate laws
SEISMIC FEE
d
TOTAL: ,U'�
ELECTRICFEE
,7S
PLUMBING FEE
O
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
4s
PERMIT ISSUANCE -�(y
FEES PAID:
relating tm W Ilding construction, and hereby authorize representativesof this
city to enter upon the aWve-mentioned property for Inspection purposes.
(We) agree to ave, indemnify an d keep harmless the City of Cupertino
d ts, ms and ex rases which may in an a scone
against liabilities, Y gme a Y any Y
ALTERORADDTOMECH.
Date Receipt#
AIR HANDLING UNIT 10,000 CFM)
SUBTOTAL:
against s ty In con ue e t gra ng of this permit.
r }
AIR HANDLING UNIT (OVER IO,ODO CFM)
CONSTRUCTION TAX
!�
Signstureof Ap ot/Confiractoof Data
E%HAUSTHOOD(W/DUCT) O
CONSTRUCTION TAX PAID:
AlARDOU ERIAI S DI SCLOSU RE
Will the a ppllant or future building occupant store or handle hazardous
HEATING UNIT (TO 100,000 BM
-
Date RQ ci t#
material as defined by the Cupertino Municipal Code, Chapter 9.1 2, and the
HealthandSafetyCod Section25532(a)I
❑ Yea No
Willthe applianto fu mWildingoccupantuseequlpmentordevims
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
lb
VENTILATION FAN (SINGLE RFSID)
ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management D'utrict2
No
PAID
BOILER -COMP OIJ' OR IW,M BTU)
BOILER -COMP (OVER 100,000 BT U)
4Yrs
havrmail the h zKsmaterialsrequirementsunderChapeer6.95of
the California Health 6 Safety Code, Sections 25505,25533 and 25534. I
understand that if the Wilding due. not currently have a tenant, that it Is my
[IQ 7 a�
MAR 2 e 1992
NEW RESIDENTIAL MECH SQ.FT.
m.ponsibllity to orally the occupant of the requirements which most be mot
pmrt of Carli0cate ofOc any.
3
CITY Vt :UNtnu`w•kl
ISSUEDBY: Tf\�%� ,
Owner ora agent ate
OTA L:
OFFICE COPY