23427APPLICANT TO FILL IN INFORMATION WITHIN RED LINE- USE BALL POINT PEN ONLY
BuildingProject Identification
Building Add ;zi �� Qom.
PFbLM TNO,
23427
"Pw a aces: one:
L- sal0 (e�3 v
CITY OF CUPERTINO-BUILDING
APPLICATION I PERMIT
BULDINGELE MCAL-PLUMBING- MGCtIAMCAt
2
centracmrJ.t'; me: YY a / Lk.,a
—LT�ZZ5
CATEGORY
CONTRA. S'
au
. rchited/Engineer. Llc. No:
ELECTRIC PERMIT - '" FEE
BUILDINGPERMIT INFO
,QTY
Address:
PERMITISSUANCE "'
LEI hHO
LICENSED CONTRl under SDE1maofCION
I hereby Sedi n7OOOallam Bcen3ofthe ur nnsandPm Chalxer odeand (comment,APPLIANCESRESIDENTIAL
Ingwlt I5I fol 7f100)olDiv Iact' a(Ihe Buslnuaand Pse(euloneCode,and my
iicenoe lsln full( anird le It
.N T2.4�Z2.3
License Clas .Cc
Date], Contractor 4
AAC hall be s DECLARATI
I understand my plans shag be used as pubic records.
Licensed Profeslaasl
]pgD RITION
QO /1 / ^'e_ a_
rT 6 JDF;=.�C
PANELS
UP TO 2DQ AMPS
AMPS
OVER00
OVER 1010 AMPS
Nom. FT. FLOOR AREA
5y/SQ.�Qj�
SIGNS ELECTRICALO
WNER-BUILDER DECLARATION
Iherebyaffirm thatI am exempt fromthe Contractor's License Law far the
I \ ��
SPGCIALCFRCUT/MIST
1 11-7
e ADO
(,.
ThMp,MEFER OR IOLE!NST.
following moon.(Sectlon7031S, Boodmesand Professions Cade:Anydnyor
countywhkh requires a permit m mmtmM alter, Impmve, de=lbh, or repair
l !r
,38
anystructum prlortoltalwaance,also requlrtuthe applicant for such parent to
ilk a signed statement that he he Beresed pursuant to the provisions of the
POWER DEVICES
MING POOL ELECTRIC
UTLPTSSWITCHIRSRXTURES
Contractor's License Law (Chapter 9 (commencing with Section 7000) of Dial-
sion3 ofthe Buslneasfes
and ProionsCodb e) orthat he exemptthercm
(roand
of nattySectiono 7031.5 by any
the basis for the alleged exemption. Anyviolationtola civil
applicanthred fora permssubjects the applicant toe cJvll penalty of not more ttun
�+ VALUATIONp 0
(•I1•�
�J 4
NEW RESIDENTIAL ELECTR SQIrL
five 1, as hepm
❑ I, as owner of the property, or my employee with wages r thele sole
d for
compensation, will do the Business.w I'mfesk. and thea Code:ure The
net Intended 's License
sac (Sec. Business. Code: The C Law
License Law
STORIES TYPECONSTRUCTION
I��1 �, D I
to f property
dons not apply loan owner of property who builds or Improves lhereory and
apply Improves
who does his own employees,
such
O OCC. �O •qFi.
' I o P
ments am nethimself edorofthrough
orhat
epr, the building
Improvementboold inlendneyearfcompfered reak.Iheh nv-buBderwilve
Improverrcnt .sold wilhlnoneycarofcompldlon,lheowner-bu0derw111 have
TO
1 V
21) as
tta.liurclanofproving that he did not build orimpreve for purposeofule.).
Lj L as owner of the property, am exclusively contracting with licensed
contmctors to construct the project (See 7014, Business and Profesions Code:
QTY. PLUMBING PERMIT E
DZONE
PERMITISSUANCE '
The Contractor. License law does not apply no an owner of property who
builds improves
or thereon, and who contrera for such pao)ects with a
cgat�ador(s) licensed pursuant to the Contrartars License Law.
LJ I am exempt under Sec. B k P C for thin reasonOUTSI
-
ALTER -DRAIN &VENTWATER (EA)
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
FFFQ
DRAINS FLOOR ROOF, AREA, COND.
F'C(TURFS PER TRAP
SANITARY Y N�
RECEIPT If
Owner Date
WORKMAN COMPENSATION DECLARATION
❑1 hereby affirm that I have a certificate of consent to self-inmm, or a
' certificate ofWorkers'Compeasation Insurance can mrtifd mpythemof(Eee.
3800, Lab C.)
Policy X
SCHOOL TAX Y_ N
RECEIPT N
GAS -EA. SYSTEM -1 INC.4OUTLETS
PARK FEE Y N
RECEIPT it '
GAS F.A. SYSTEM -OVER d (EA)
Com any
BUILDING (VISION FE ES
Gadded ropy b (lied with the dty, Inspection division.
JR Coddled copy is heed with teefty,
'CERTIFICATECREASE
MOF SATIPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thissedion need not be comploul If the perret b for one hundred dollars
($]I exemlash.)
so as to b comeesmlt is booed,
in oy he any arson i anye of hewmixmanner
Ill net thatemploy
I shag net employ any person In any manner at u to become subjM to the
Workers' CompenJuHon Lawn of UWomb. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the Workers'Compnuation provisions of the Labor
Cade, you moat forthwith comply with such provisions or thin permit hall be
deemed revoked.
GREASE/INDUSFRL WASTE INTERCEPTOR
PLANCFIEC�' (�a"2„ 33
2
as�..
P Date Ract tin $ W
TRAP
SEVER SANITARY STORM EA 100FT
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y
�/'-
1
PAID y
Date' f 1 t#
WATER SYSTEM/TRFNTING
NEW RESIDENTIAL PLMB. SQ.FT.
T T
ILD
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
Iherebysflrm that there b a construction lending agency for perform
Land of the work for which this person b heated (Sec. 3097, Civ.C.)
T
ELECTRIC
4ndefe Name
Lender's AddmJu
w appllrc tinnand ba "edihe above Information
I mrtt. I agree
recoingtobgreeta complywith and
gr I have complynanmsend stateIs.PERMIT
PLUM e—
-
QTY. MECHANICAL PERMIT ., FEE
M L E �—
ISSUANCE
_
FE SPA -
to building mnswrtion, and hereby
hereby auhortac
ori mpmenpurpos of thin
enter
cityrelat o e upon property in
cityWenteree to theabode-mention d pmpertyfor inspection purposes. Cups.
(We) agree to Jude, indemnify an d keep harsoes the City of Cupertino
ALTFX OR ADD 7DMFLH.
ate Recei tin
P
SUBTOTAL:
ant, ca
against liabilities, pdgmente, cosband expenses which may in any wayacerue
against said City in consequen of the granting of this permit.
asever
AIR HANDLING UNIT (TO 10,000 CFM)
AIR NIT 10,000CFM)
CONSTRUC NTAX
Sigasmrc of ApplHAI CoIO-19r Data
MIAUS HOOD
IX}IAUST HOOD(W/D[ICTI
((/DUCE)
CONSTRUCT! TAX PAID:
HA RDOUSM ERIALS DISCLOSURE
Will theapplicantby theuprtino buildingoccupantCode, hapten ie hazardous
Health a as dented by the Cupertino Municipal Coda, Chapter 9.12, and the
fieallhand5afdy Code Section 75532(x)7
❑Yes Cj No
Date ecei
RENTING UMT(TOIW,000 BTU)
-
HEATING UNIT (OVER 00,000111%)
0
VENTILATION FAN (SINGLE RESID)
ISSUANC DATE
Will the applicant orfutum building occupant use equipment or devices
which sent harardtus air contaminants as defined by the Bay Area Air
BOILER -COMP QHP OR 100,000 BTU)
Quality Management District?
ye, E No
4havcread the haz2usmaterialsrequirementsunderChapter6.95of
p�
B V
IOILERdAMP(OVU100,0WBTU)
the W llfernla Health k Safety Code, Sections 75505, 75533 and 25534. 1
-
NEW RESIDENTIAL MECH. 5QAT
understandthatif the building doesout .,unityhave atenant, that itIsmy
responsibility to notify the occupant of the requimments which must be met
V
jUN 16 1992
Inner to issuance of a Certificate of Occupancy.
City ur GUrcnun^
ISSUGD BY:_ / rr'I/
Owner or authorized agent Data
OFFICE COPY