22938APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
Building Project IdentificationPERMITNO.
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22938
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CITY OF CUPERTINO-BUILDINGDIVISION
APPLICATION I PERMIT
BUILDINC MMTRICALPLUMBING•MECHAMCAL
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C attn ga^� '! Nm
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CAI RY
CONTROL N
Lie. No:
Archlt /Fygineer. �� I ��
QTY ELECTRIC PERMIT PEE
BUILDING PERMIT INFO
Address: Vm pg$OM
S 2,
❑ 1:1 11
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affim, that exii..7000M iv lkmeedunder provisions o(Chapter9de,and
ingwithHarriet fonforcea deffoon7 ofthe BuYnemand ProfessionaCode,anti my
Harriet in fuB force and cited.
Llcenm Class Lk.X.
Date Contractor
ARCHITECTS DECLARATION
I understand my phos.hall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt f centhe Contractor'sLicense law for the
following reason. (Section 70315, Business; and Profession. Code: Any city or
county which mrylrma permit tororetruct, alter, Improve, demoWh,or repair
any structure prior to Its Issuance, also requires the applicant forsuch perrtdito
file a signed statement that he Is licensed pursuant to the proWbns of the
Contraclo/s License Law (Chapter 9 (commencing with Section 7000) of vl-
alon3 of the Buainroa.nd Profemlons Code) orthat he Is exempt therofroma
the W96for the alleged exemption. Any violation of Section 7MIS by any
appilcant(nraper tB bj [ theappllcanitoadvllpemltyofnm=mtWn
rive hundred dollars($SM.
r-1 1, 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. 704q Buslnem and Pnofesslom Code: The Commodes License Law
does not apply to an owner of property who Wilda or improves t hereon,and
who doessuch work himself ortheaugh his own employees, provided that such
improvements am not Intended oroffrmd for.ale. If, however, the bulldingor
Improvement 1,sold within one year ofcompldlon, the owner-builderwill have
l"rden of proving that he did net build or improve for purpose o(sakJ.
u L as owner of the Property, am exclusively contracting with licensed
centrations to construct the project (Sec 7044, Business and Professions Code:
The Contractor. License Law dm not apply to an owner of property who
builds or improves thereon, and who contracts for such ptojects with a
cq)g(aetor(s) licensed pursuant to the Contractor's License Law.
IJ I am exempt under Sec. B k P C (or this remora
APPLIANCE -REBID
JOB DFSCRE'IION
l V
PANELS
701-IODO AMPS
OVER 1 W0
SQ. Fr. FLOOR AREA
S/SQ. Fr.
SIGNS EL CAL
L C[BT/M
Lrrp-g OR POL I
UEVICE
SWIMMING POOL FI.ECTTIIC
UILETSSWITCHESPIXTURE
VALUATIO
d
NEW RESIDENTIAL ELFCTR Ff.
STORIES
TYPE CONSTRUCTION
TOTAL:
QTY. PLUMBING PERMIT FEEFLOOD7DNE
OCC.GROIR'
RES. UNITS
PERMIT ISSUANCE
ALTER -DRAIN &VENT - WATER (EA)
APN
FEE SUMMARY
BACK FLAW PROTECT. DEVICE
DRAINS R FLOOROOF, AREA, COND.
FIXTURES, PER •CRAP
SANITARY Y_ N_
RECE'T N
Owner Date
WORKMAN COMPENSATION DECLARATION
of convent to opytheuro, ora
❑I hereby affirm that I have o Insurance
cert,lAbCicate fWorkem'Compensatlenlmurance ora certl(kd ropythereo(lScc.
Pollry N
SCI TAX Y - N_
RECEIPT X
GAS EA.SYSTEM-11NCAOUTLEIS
PARK FEE Y N
p
RECEDING
GAS EA. SYSTEM-0VER 4 (FA)
Com any
GO
DI
BUILDING DIVISION Fr: F.S
copy Is herebyfurnished.the city
CenlRed copy 4 flied with the city Inspettlon division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thin action need not W complMed lithe permit Is forarre hundred dollars
(St00)otifyth
lunot thatlnthey.dormaInanynce manner
so an to bewhIch come
I .hail not employ any person In any manner n an to become eubjett to the
W 'CompeneatlonlawsofCallfomk. Date
Applicant
NOUCETO APPLICANT: a after making this at ion prin of Ext of the
should become forth to the Workers' CompmuYlans or this p ofthe Labor
Labor
deemedyou must ked. forthwith comply with such provisions or this permit shall
deemed revoked.
CONSTRUCTION LENDING AGENCY
I herebyaffirm that there Is a construction lerAingagenry, for the perform
ante of the work for which this permit is Issued tSec. 3097, Civ. C.)
]ender. Name
Lends. Address
I mdlfythatl have read this application and statethatthe above information
ummed.I agree to complywith all city and county ordinances and Yate laws
relating to building construction, and hereby authorlu representatives ofthis
city to enterupentmabove- rationed property for inspectionpurposes,
(We) agree to save, Ind ify an d keep harmless the City of Cupertino
against liabilities, j dgnre .Yacode nm whiehmaym.nywayacxoue
against sold City in re erre of t gr ng of thiypenNt.
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECK PEE
PAID
Date Recef t#
GREASE TRAP
SEWER-SANDARY-STORM seam•
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N
PAID
Date Re,Xi t#
WATER SYSTEM/.]TREATING
NEW RESIDENTIAL PLMB. SQ.FT.
TOTAL:
BUILDING
SEISMIC FEE
TOTAL:
ELECTRIC FEE
QTY. MECHANICAL PERMIT F
PERMIT ISSUANCE
PLUMBING FEE
MECHANICAL FEE
FEES PAID:
ALTER OR ADDTD MFAH,
Date Reeei (#
AIR HANDLING UNIT (TO I[L"CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER IO,000C17u)
CONSTRUCTION TAX
SlgnatumofA cant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or(uture building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.17, and the
]❑alt .rad SafetyCoa1Sectiion 25537(.)7
yes No
Wllltheappllca in or❑future building occupant use equipment or devices
which emit hazardous air contaminants as defined by the Bay Area Air
Quallty Management District?
Yea N
have read the h.9"omatedale requirements underChapter 6.95 of
the Callfomla Health A Safely Code, Sedfons 75505, 75533 and 75534. I
understand that if the building does not mriently have a tenant, that It 1. my
responsibility to notify the occupant of the requirements which must be met
prior to Issuance of a CertlBmte of Ompanry.
EXHAUSTIIOOD(W/DICT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,DDD BTU)
Date Recei t#
UNIT I00 BTLD
HEATING UMW,0
TOTAL:
VENILATION FAN (SINGLE REBID)
p jSSIIALICE DATE
V" L� r 1./
,
NOV -5 1991
C1IY UI- CUPEHIINU
V
v
1,
ISSUEDBY: L)C-
BOILER -COMP DFB'OR 100,000 BTU)
BOILER-COMP(OVER 100,000 BTU)
NEWRESIDENIALMECH. SQ.W.
Owner or authorised agent Data
TOTAI.:
OFFICE COPY