22934APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Address:
y � - �Gv�, L�ss�-, x-
PERMIT NO.
f7 f7 n
229J
Owners LNdrve
M2 ,
Phone.
P a -p%$%
CITY OF CUPERTINOLBUILDING DIVISION
APPLICATION / PERMIT
BURDINGELECTRICAGPLUMBINGMECHAMCAL
APPLICii, HUN SUBMIFiAL DA IL
/ Il
C°ni"apre . : �y 0�
i LI
CATEGORY
CONTROL#
Architect/Englrieer. Lie. No:
QTY ELECFRICPERMIT FEE
BUILDING PERMIT INFO
Address l . `] �%
PERMIT ISSUANCE
LICENSED CONTR OR'S DECLARATION
Iherebyafflrm that l am licensed under provbloes of Chapter9(oummenn
Ingwlth Sedlon 7000)of DiAsim3ofthe Buslnessand PmfessionsGode,and my
Ifcense arrrrrr¢¢¢555eeea d dbI
License I o# 35
Date Contactor 2�UP
ARCHITECTS DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
OWNERBUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
following reason. l5rtion 70113, Business and Pretensions Code: Any city or
county which requirasa permit Wconstruct, slteplmpmve, deme ish,or repair
anystrectem phorto Its Issuance, also requlrestheappRrent for such permit to
file a signed statement that he b licensed pursuant to the provisions of the
Contractors License Law (Chapter9(commencing with Section 7000) of Divi-
ofthe Budneneaad Professions Code) orthat he I, exempt therefromand
the basis for the alleged exemption. Any vlatation of Scctlon 7(113 by any
appbont turn permit subjects the applicant to a dull penalty of not more than
five hundred dellen (;500).
❑I, as owner of the property, or my employees with wages as their sok
compensation, will do the work, and the structure Is not intended or offered for
sale (Sec. 7044, Business and Pretensions Code: The Contractors License Law
does not apply to an owner of property who builds or Improves thereon, and
does such work himself or through his own employees, provided that such
improvementsare not Intended oroffered for sale. If, however, thebuilding or
Improvement bsold witMnoneyearofcompldion, theowner-bultderwill have
0(gtittMen of proving that he did not bund or improve for purpose of wk.).
LJ L as owner of the property, am exclusively contracting with licensed
contractors to construct the pe jeot (Sec. 7044, Business and Professions Code:
The Contndor's License Law does nut apply to an owner of property who
Wilds or improves thereon, and who coned¢ for such projects with a
oqDt(+ctar(a) Rcenaed pormant to the Contractor'. License Law,
LJ I am exempt under Sec B & P C for this reason
APPLIANCFSRESIDENTIALJOB
DFSCR[PITON
gyp- /v^n �''", 1/�
1 /` z T
PANELS
TO 200 AMPS
701-1000 AMPS
OVERIODOAMPS
SQ. FT. FLOOR AREA S/SQ. Fr.
,11,`'
V A L E D
M P U T
I(
SIGNSELFCTRICAL -FIa
SPECIALCIRCUIT/MISC
TEMP. METER OR POLE INST.
POWER DEVICES DOTE!
SWIMMING POOL ELECTRICdon3
OUTLETSSWITCHESFIXTURES
�iVALUATION
¢% / O^
NEW RESIDENTIAL ELEGTR SQ.FL
STORIES
TYPECONSTRUCTION
TOTAL:
QTY. PLUMBING PERMIT FEE
OCC.GROIR'
RIS. UNITSwho
PERMIT ISSUANCE
ALTER -DRAIN& VENT. WATER (RA)
1'T.ODD ZDNE
APN
BACK FLAW PROTECT. DEVICE
FEE SUMMARY
DRAINS FLOOR ROOF, AREA, COND.
FIXTURF4I'ER TRM
SANITARY Y N_
RECEIPT #
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificate of consent to self -snare, ora
certificate ofWorkers Compensation Insurance or a camfled copy thereof(Sec.
3800,Lab C.)
Policy #
551001, TAX Y N
RFCEI NM
GAS EA.5YSI'FM-1 INCA OUTLETS
PARK FEE Y N
RECEIPT M
GAS EA. SYSTEM -OVER d (EA)
Com any
BUILDING DIVISION FEES
Certified copy's Bled hereby
the city
❑CertNad copy b (Ikd with the city inspection division.
CERTIFICATE OF IXEMPFION FROM WORKERS'
COMPENSATION INSURANCE
(Thio actlon need rad becomplded I(ihe permit b torose hundred dollen
(f100)orlensD
Irertlfy that In the performance o(the work forwMch this permit bissued,
I shall not employ any p nion N any manner n u to bject to the
Workers' C@9��eysa}lm 5wo o(,C�1lp�ka Da}e
Applicant FeDOt/r'I /(/1lA7eC a
GREASEANDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date Recei H{
GREASE TRAP
SEWER -SANITARY -STORM EA 70011.
WATER HEATE2W/VENT/ELECTR
ENERGY FEE Y N —
PAID
Date RCCCI Ill
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLM B.
NOTICE TO APPLICA :I, after making this Certificate of Exemption,you
should become subject to the Worken'Compevatlon pmvialons of the Labor
Code, you must forthwith comply with such provisions orthb permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hercbyaffirmthat them is a construction lending agency for the perform
ance of the work for which this permit b Issued (Sec 3097, Civ. C.7
Lender's Name
Lender'sAddress
1 mdifythati have read thbapphutbnand katethat theabove information
bcorrect. I agree to complywith all city and county ordinances and stale laws
relating to building construction, and hereby authorize representatives of this
city to enter upon the above-reardloned property for Inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino
against liabilities, pdgmants, costs nd expenses which may In anyway accrue
against said City in con oquenreaf the Ranting of this permit
TOTAL:
BUILDING
rix
TOTAL:
SEISMIC FEE
, 'b
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEB
PERMIT ISSUANCE
F•E$PAI
ALTERORADDTOMECH.
Date Recei HI
AIR HANDLING UNIT (TO 10,ODO CM)
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,010CFM)
CONSTRUCTION TAX
Signature of Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Wllltheapplln rat or future building occup.etstme or handle hazardous
material as defined by the Cupertino Me nidpal Code, Chapter 9.1 7, and the
Health and Safety Cade Section 75537(1)7
❑ Yes No
Will the applicant ar lure building occupant use equipment or devices
Mich coat haaaMous air contaminants as defined by the Bay Area Air
llty Ma nagemcnt Dist ries?
Yes J No
haverealthhe a ouyCode, la t1om2m05,25MerChapter. 1 of
the Californiatandt Heathe tih& Skiing oes not currently haven Sand, that 1
understand that ntify the occ,, ant not cemclutramanawlelc etttbmy
mxfi
rasp ability to notify lheom ani o(ifie requlrcmcnte whlc mu the met
prio 1 a if a f0ccepan
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
U
HEATING UNIT (TO 100,000 BM
Date RCCCI Ili
HEATING UNIT (OVER 100,00) BTU
TOTAL:
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
Wgy �4 1991
TTY Of GUNtRrINU
ISSUED
BOILER -COMP GHP OR 100,000 BTU
BOILER-COMP(OVFR 1110,000 BTU)
NEW RF5IDEMIAL MESi. •$Q.FT
Owner or authorized agent I Dire
TOTAL:
OFFICE COPY