24196APFLPCANTTO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Address
i n P�Ni N� AJ GA) No
PIRMITN
419
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
BULDING-LLECTRICALPLUMBING-M[CI IAMCAL
AL DA IL
c�yaAd• K QI yi(Oo Lic. No
13rU,13�
CATFCARY
Amhtect/EngnarLk. No:SPJBb-F,
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:' �'(,-. JLC Ll C— LN.9A4 (}j C(
lDi
Lc' L/ 194
PpAgTISSUANCE
LICENSED CONTRACTOR'S DECLARATION
]hcrcby affirm that l am licensed under provisions ofChapter9(mmmenc-
4/
3 APPOANCESRESIDENfIAL
JOB DESCRIPTION
PANELS
UP TO 200 AMPS
Ing with Section 7000)of Division 3 ofthe Buslnemand ProfesslonsCode, and my
licenm Is in
nxClamfull fqd efect G'�b-1T 4
Lk.N
ContndoQS\LreDate �
ARCHITECTS DECLARATION
I understand my plans shall be used as public records.
Licensed Professional/
tc'L+LR`- {v1 a��`
201-1000"I'S
OVERI000AMPS
SQ. IT, AREA
E IN 1
5/SQ, FI.
SIGNS ELECTRICAL s i t
SPECIALCIRCUIT/MLSC 1/ I
OWNER -BUILDER DECLARATION
Ihereby affirm that l amla
exempt from the Contractor's Lirense w for the
following Mason. (SeRion7031.5,Bu,Inessand Prefemlons Cads:Anycityor
county which mqulmsa pernuttoconstruct, alter, improve, demolish,or repair
anystructure priortoitsIssuance, also refulrealhe applicant for such permit to
file a signed statement that he is licensed pursuant to the provision of the
T E R
_ -
TEMP.METERORPOLEINST.
POWER DEVICES +1klaz
SWIMMING POOL ELECTRIC
o OUTLETSSWITCFffSFlXTIIRES
O
Contractor's License Law (Chapter 9 (mmmencing with Section 7DOO) of Divi-
sion 3 oflhe Business and Professions Code) orthat he is exempt therefrom and
the bast, for the alleged exemption. Any violation of Section 7MI-5 by any
Applicant fora permiteubjecb the applkanttoativll penalty dna mom than
VALUATIQ L_
V' [J
ba,
NEW RMDENTIAL ELECTR SQFT
_SQ.FT.
five hundred della.(5500).
nI, as owner of the property, or my employees with wages as their sale
compensation, wi ldothe work andthestructure is not intended or offered for
STORIES
TYPE CONSTRUCTION
sale See. 7014, Business and Profession, Code: The Contractors License Law
does nes apply to an owner of property who Wilds or improves thereon, and
who doessuch work himself orthrough hisownemployees, provided that such
OCC.GROUP
RES. UNITS
Improvements arc nes Intended oroffered forsals. If, however, thebuilding or
�a
Improvement issold Mthlnoneyearofcompldiogtheowner-W Bderwill have
Irden of proving that he did nes bulla or Improve for purpose ofsals.).
I L as owner of the property, am exclusively contracting with licensed
cout.dora to construct the Mind (Sec 70K Business and Professions Code:
QTY. PLUMBING PERMIT FEE
FLOOD ZONE
APN
PERMIT ISSUANCE /a
The Contractor's License Law tion nes apply to an owner of property who
Wilda or Improves thereon, and who contracts for such ptojeds with a
Cq➢tt ctor(,)bcenaed pursuant to the Contractors License Law.
IJ 1 am exempt under Sec. B & P C for this reason
ALTER -DRAIN VEM-WATER (EA)
FEE SUMMARY
RAIXFLOW PROTECT. DEVICE
OUTSIDE FEES
DRAINS FLOOR, ROOF, AREA, CONI.
SANITARY Y N
RECER'T N
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that 1 have a cedifiate, of consent to self -insure, or a
certificate of Workers'Compemztion Insurance or a certifkd mpythereaf(Sec.
3800, lab CJ
FIXTURES PER TRAP
IfRECFlPI'
SCHOOLTAX Y_ N_
N
GAS EA. SYSTEM -1 INCA OUTLETS
PARK FEE Y N
RECEIPT M
Policy N
Com
GAS EA. SYSTEM -OVER 4 (EA)
BUILDING DIVISION FEES
wmany
nified copy Is hereby furnished.
[jCeAified copy is filed with the city Inspection division.
CREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
SEWER -SANITARY -STORM FA 200FT
COMPENSATION INSURANCE
(Ihhsection need nes M complded lithe permit ailerons hundred dollars
(5100)orleas.)WATER
I mdifythat In the performance of the work for which this permit is named,
Date RCCCI I#
HEAT'LR W/VENT/ELECTR
ENERGY FEE Y_ N_
WATER SYSTEM/TREATING
I shall nes employ any person In any ,runner so as to become subject to the
Worken'Campensatlon Lawsof UBfamU. Date
Applicant
PAID
Date Remi t#
-
NEWRESIDENTIALPLMR. SQ.FT.
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the Workers'CompevaHon proishm of the Labor
TOTAL:
IL IN
Codi, you rust forthwith comply with such providers orthla permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirmthat there la a construction lending agency for the perform
SEISMIC FEE
ELECTRIC FEE
1.
ance of the work for which this permit is lvwed(Sec. 3097, C1v. C0
I.endsr's Name
Lenderspddrem
PLUMBING FEE
Q'rY. MECHANICAL PERMIT FEE
MECHANICAL FEE
I adRythat l haveread this appliationand sumAt the abavelnformal ion�•
iscofrect. Iagree m comply with all city an my inance,an d state lawn
` PERMIT ISSUANCE
FEES PAID:
relating tobullding construction, and 5_6y..Lbyame representatives ofthb
city to enter upon the aleo-mentio grope or inspection purposes.
(We) a to save, in ify o d armless the City of Cupertino
".lost Ries,pdgments, s nd neeswhlchmayinanywayamue
ALTERORADDIOMECH.
Date Receipt#
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER I O,OWCFM)
CONSTRUCTION TAX
Againdeity In consryu re grantingofthis permit.
/44
Si Applla C rad
EXHAUST HOOD(W/DUCT) r
CONSTRUCTION TAX PAID:
M IJOUS MATERIALSDISCLOSURE
Will the appliant ,future building occupantsmre or handle hazardous
HEATING UNIT (TO 10),"BTU)
Date RCCeI t#
material as defined by the Cupertino Municipal Code, Chapter 9.17, and the
Ilealth and Safety Coder �Section 25532(x)?
Yo, u No
Wlllthe Applicant or future building occupant use equipment ordevires
which emit hazardous air contaminants as defined by the Bay Arca Air.
Quality Management District?
❑ Y. No
]have read the has ous Materials requlrementsunder Chapter 6.95 of
HEATING UNIT (OVER I W,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE READ)
ISSUANCEtDATE
r iu4 0 W
SEP 10 1992
BOE.FR-COMP OHP OR 100,IX0 BTU)
BOILFR-COMP(OVER 100,000 BTU)
the CzlBomia health & Safety Code, Sections 25505, MS33 and 25534. 1
understand that if the building does not currently have a tenant, that It is my
responsibility to notify theoaopant of the requirements which at be mot
prior to issuance of a Certificate of Occupancy.
C(fY Ur t vrrrt�,
NEW RESIDENTIAL MECH. SQ.rr
ISSUED6
Owner or authorized agent Date
OFFICE COPY