22862APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Probst Identification I
Building Address: - 10
03-71 'Po2TaL AV 6-
PERMIT NO.
'1 /'g ^ 6 2
GG�}J( G
22862
mere amc: one:
�Ic IJ p-n.D GAP (L-1 o l,A l 3 8 YS (o
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
BULDIN6ELECTRICAL-PLUMBING-MECHAMCAL
A LDAIE
/0
f %
Cmdoubn"aN.7 ' c.N
pp Oa
CATEGORY
CONTROL M/�//
/� (p
Architect .nglnee Lie. No:
C,
QrY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
°G
1
Add.,: ?iZ.i 8 S. JT . 9'T 2.
PQihBTI55UANCEV
MECII
❑.
010N
LICF.NSF.D CONTRACTOR'S DECLARATION
Thereby aBiten that l am licensed under provisions of Chapter 9(commse
ingwith Sectlon7000)of Divisim3ofthe Businn,and ProfessimsCode, and my
license 1.
LlnChu"Ijc.#
Date ia l force and
Cormncio' ri4A .{
APPLIANCESRESIDENAAL
PANL
JOB DESCRIPTION
�O
201-1000 AMPS I
ARCHITECT'S DEC RATION
I understand my plan, shall be used as public records,
OVER lfflq
SQ. IT. FLOOR AREA
S/SQ. FT.
Licensed Professional
E C
/ L E D 114
OWNER -BUILDER DECLARATION
1 herebyafflrm tOWNER-BUILDER the DECLARATION
Llcenee lawfor e
lollowing reamn.(Sectlon 703t.5,Bminess and Profesebm Code: Any city
muntywhich requires a permittommtmci, alto, i.provq demolish, arrepair
LCIRCUI /
T E
'
P. METER OR LE INSf.
anystmcture pectin its iasuance,also resrylrestheappBcant forsuch permit to
file a signed statement that he b licensed pursuant to the provblaa of the
Contractor'.License Law (Chapter9(mmmenciagwith Section 7000) of Divl-
sbn 3 ofthe Buslnenand Professiom Code) orthat heb exempt Ihemfromand
the basis for the alleged exemption. Any violation of Section 70315 by any
applicant fora permit subjects the applicant to a civil penalty of not more than
flve hundred dollars ($5031.
], as owner of thero
property, or my employee, with ween as their sole
compensation, Busillldo the work and the sdere V not Intended o offered for
ssle(Sec 7044, nnsaM Professlom CC ode: The Contractors License law
POWER DEVICES
/
E
_..
SWIMMING POOL ELECTING
OIJTLElS5W17CFTF_SHXTURIS
VALUATION
% ,l
00 G/
/
NEW RESIDENTIAL ELECTS SQRT.
STOW
TYPECONSTRUCTION
don not apply to an owner of property who build, or Improves thereon, and
whodo s such work h0melforthrough his own employee,, provided that such
Improvements arc not Intended oraffercd for sale. If, however, the bulldinger
improvement bsold wlthlnoneyearofmmplellon, Iheowner-builderwill have
_
TOT
OCC.CROUI'
RFS. UNITS
tltliurden of proving that he did not build or Improve for purpose of sale.).
LJ I, a, owner of the property, am exclusively mntraoing with licensed
contractors to mmtruct the pmjeci (Sec. 7044, Business and Professions Code:
The Contmamm s Llceme law don no apply to an owner of property who
Wilds or improves thereon, and who contracts for such pippeta with a
cnactor(s) licensed pursuant to the Contractors License Law.
L..I I am exempt under Sec. B k P C for this reason
Cry. PLUMBING PERMIT FEE
PERMIT ISSUANCE rn�+
ALM -DRAIN A VENT WATER (EA)
FLOOD ZONE
APN
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
OUTSIDE FF.
DRAINS FLOOR ROOF, AREA, COND.
-
FD(TURFS.I'ER TRAP
SANITARY Y N
RECEIPT
Owner Drte
WORKMAN COMPENSATION DECLARATION
Ofhereby affirm that I have a mrUflcate to
SCIi00L FAX Y N
of consent self -Inure, or a
,ediflmte of Worken'Compeaadon Imumnm or a certified pec.
RECENT N
GAS EA. SYSTEM -1 WCAOUILEI'S
PARKFEE Y_ N
mpythereof
3800, Lab C.)
policy p
—
RECIBPT N
Com as Go
GAS P.A. SYSTEM-OVER4(EA)
B UILDING DMS ION FEES
ified copy V hereby te
Certified copy is filed withth thhcity e city Inspection division.
CREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Uhisaectlonneed not heompletedifthepermit isfororehuncireddollan
(5100)orlessJ
( certify that In the person In an the worrner so as to b co eermitsubj c Issued,
1 shall not employ any person In any manner so n to bttnma subject to the
W Applicant Compenudon Lawn of California. Date
NOTICE 70 APPLICANT: If, after making this CertificateNEW of Exemption, you
should becomesub)ect to the Worker,'Compematlon provisions of the Labor
Cade, you muss forthwith comply wRh such proalIona orthb permit ahall be
deemed revoked.
PAID '
Date Remi of
SEWER -SANITARY -STORM F.A. WIFE.
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N
pplp
Date Remi [fl
WATER SYSTEM/TREATING
NRESIDENTIAL PLMB. SQ.PT.
` `.
TOTAL:
BUILDING FEE
T07p:
SEISMIC FEE
ELECTRIC FEE
CONSTRUCTION LENDING AGENCY
Ihercbyafflrm that there b a mmtmction lending agency for the perform-
ance of the work for which this permit Is edged (Sec. 3097, Civ. C.)
lander,Namo
Lende/s Address
1 rertifythatl have read thisappliation and patethatthe above Information
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
FEE$PAID:
I,comed.I agree to comply with all cityand county ordinances and elate law,
PERMIT ISSUANCE
relating to building construction, and hereby authorlae representatives of this
city to enter upon the abovamentionsd property for inspection purpose,
Me) agree to save, Inde ify an d keep harmless the City of Cupertino
agalnstlla Idea, jadgme coslesnd expenses which orayln anyway, me
ag Wt t ItXin cone en f the granting of this permit.
-
ALTERORADDTOMECH.
Date Recei tN
AIR FIANDLINC UNIT (TO 10,000 CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,=CFM)
CONSTRUCTION TAX
S nabof Applicant/ r D e
EXHAUST HOOD (W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDO ATERIALSDISCLO URE
HEATING UNIT (TO 100,000 BTU)
Will the applicant or future Milding occupant store or handle haeaidou,
mrtcriala,deflned by the Cu dino Mu nicipal Code, Chapter 9.1 2, and the
Date Recei Ik
HFATING UNIT (OVER 100,00) BTU)
TOTA It
Heilthand SalotyCode Seatlon25532(a)7
M Y. I] No
VFNDIATION PAN(SINGLE RESIO)
ISSUANCE DATE
If p D
A p
OCTand 2� 1991
OC
Will the applicant or future building occupant use equipment or devices
which emit harardous air comamlmmsas defined by the Bay Area Air
Quality Management District?
4 Yes � No
have read the haat ous mnaterials requirements under Chapter 6.95 of
the California Health A Safety Code, Sect lora 25505, 25$33 and 25534. 1
BOILER -COMP QHP OR 100,0(D BTU)
BOILER-COMP(OVIR 100,000 BT U)
NEWRESIDENTIALMECH SQ.FT.
ersta ad that if the building doe, not currently have a tens est, that it h my
responsibility to not the occupant of the requirements whichmuatWttP
prior uaneeo rtlfiateof Qccopancy. Poo C4 rM l l j Q
�
CITY OF CUPEH7INU
l
ISSUED
e rauthoriad t Dat
TOTAL:
OFFICE COPY