19684APPLICANT TO FILL IN INFORMATION WITHIN RED LINES---: USE BALL POINT PEN ONLY
Building Pro�eet Identification
Building Address'
v Z�2
O.
PERMIT N19684
. 1 9 6 8 4
ween a Phone.
CITYOFCUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
p
ZOO / O
C: •a Lie, No:
Architect/En neer, LIc. Na:
' BUILDING-ELECTIUCALPLUMBINGMECHAMCAL
CATTGORY
CONTROL M
ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:
PERMITISSUANCE
El E- 0
LICENSED CONTRACTOR'S DECLARATION
1hembyafflren that l am Ieseaed under provisions ofChapter9(comenese
ing Mth Sedion7OOO)ofDivlslon3ofthe Buknemand PrefemlorsCcode, and my
licensele in pie effect.
Class
Dal ContractordoGn"
APPLIANCES -RESIDENTIAL
JOB DFSCRE'HON
_
-
PANELS
UP TO 200 AMPS
201-1000 AMT'S
Alt C H I TE crT DECLARATION
I understand my plans shall be used u public records.
OVER1000AMPSQ.
FT. AREA
S/SQ. FT,
Licensed Professional
SIGNS ELECTRICAL
OWNER -BUILDER DECLARATION
Thereby affirm lhatIamexemptfromlhe Contractoh Licenm Law for the
SPECIALCIRCUIT/MISC
s
` " Q
j
TEMP.METERORPOLE INST.
following mason.(Sectlon9Ri1.5, Buainemand Profemlona Code: Anydtyor
mentywhich requires a permit tomestruct, alteq mo
Improve, delbh,or repair
J
anystructure prlorto Its issuance, also regWreethe applicant for such permit to
Ole a signed statement that he b licensed pursuant to the provisions of the
POWER DEVICES
I
SWIMMING POOL ELECTRIC
Contractor'sLiccom saw(Cha pter9(comerencing with Section 7000) of Divi-
ivi-
don
don3 ofthe Buslnemand Profemlons Code) orthet he b exemptthemfromand
.../'
VALUATION .11
the bas's for the alleged subjects applicant Any violation of Section ect ro by any
applicant for apermRed exe ption.Anyvioation f naltySects effn703 more than
OUILETSSWITCHISI-FTXTURFS
/
sV-
NEW RESIDENTIAL ELECTR SQ.FT.
(IFe 1, asreddollars ofthe p(n.
❑ I, as owner of the property, or my employees with wages thele sole
STORIES
ECONSTRUCTION
compensation, wilBuldothework,andthe r
net Intended oroffendfor
Co
lues, Code: The Lienors Law
Businea and Predmaof
Wild&Contractors
docs net apply loan owner ofp rough whonempoyImproves
doe net apply property
who does or ovided thatsud
OCC.GROUP
RES. UNITS
mentsa nhim�lf
edoroffehlsowne. If, however,thebthatng or
improvements ithindneyear fcompemd rsale,th owerep deer ldingoe
Improvementbaold within oneycarofcomplellon,the ownervbullderwlll have
TOTAL:
'
tj,9�Lden of proving that he did not build or improve for purpose of sale.).
LJ [. as owner of the property, am exclusively contracting with licensed
contactors to construct the project (Sec. 9016, Business and Professions, Code:
QTY; PLUMBING PERMIT FEE
PERMIT ISSUANCE
nDOD ZONE
APN
The Contractor's License Law does not apply to an owner of property who
builds or Improve themon, and who contracts for such Mjects with a
, t ctor(s)if...d pursuant to the Contractor's License Law,
I am exempt under Sec. B & P C for this reason
ALTER -DRAM & VENT - WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICELl
OUTSIDE FEES
DRAINS FLOOR ROOF, AREA, COND.
FIXTURES PER TRAIT
SANITARY Y N
RECEIPT p
Owner Data
WORKMAN COMPENSATION DECLARATION
❑[ hereby affirm that I have o nasus to o consent to self4exure, ora
certJiate of Worken'Compens,atlonlnsuranceora certiflM ropythearof(Eec.
3900. Lab )
Poilryp
Com
MCertlfled copy's e d with the city
❑Cedifled copy b filed with the city inspection division.
SCHOOL TAX Y N
RECEOT Is
GAS EA. SYSTEM -1 INCA OUTLETS
PARK FEE Y N
RECEIPT
GAS E3. SYSTEM -OVER
BUILDING DIVISION PRIiS
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASETRAP
CERTIFICATE OF EXLMPTION FROM WOR KERS'
PAID
SEWER.SANITARY-STORMRA.200F1'.
COMPENSATION INSURANCE
(This section need no be completed lithe permit bdr
foronshuneddollam
Date Remi it
WATER HEATER W/VENT/ELECTR'-
ENERGYFEE Y N
PAID
(s100)or lem3
[certify thatlnthe person In an lhework so as to become
I shall not employ any person In any manner m u to become subject to the
Workers'CompensationLaws of California. Date
WATER SYSTEM/TREATING
ApplicaNOTICE
NOTICEco e..bjeAM:If,e after making this Certlflp of Exemption, you
n the Labor
shads, become object to the Warkait Cuch
Date Recei I#
NEW RESIDENTIAL PLMB. SQRT.
TOTAL:
Codayou s orchis permit
provisions
revoke forthwith comply with auchproWlons orthb pemdt shall be
deemed revoked.
ING
% p
SEISMIC FEE
50
CONSTRUCTION LENDING AGENCY
Iherebyaf0rm thatthere bamestruction lendlegagenry, forthe perform
anre of the work for whkh this permit b bossed (Sec. 3099, Civ. C.)
Lender. Name
TOTAL:
FEE
PLUMBING FEE
Lenders Addrem
I certifythat l haveread thbappllation and state that theabove information
Is correct. I agree to comply with all city and rountyordleanms and nate laws
QTY, MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relating to building construction, and hereby authorize representatives ofthls
city to enter upon the above-mentioned property for inspection purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cu pen Ino
Dafe Reeeipt#
ALTER OR ADD TO MECH.
SUBTOTAL:
against liabilities, pdgemets, mks and expenses whish nuy In any wayaccrue
.gal ,City i' consequence gra Ing of (I permit.
Ae
ATR HANDLING UNIT DO 10,000 CFM)
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
Sig( of Appllcanl/ ontracto Date
EXHAUST HOOD(W/DUCT) -
CONSTRUCTION TAX PAID:
HAZARDOU ATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Will the applicant or future Ilding ocmpantstom or handle hazardous
material as defined by the Cu pe Mu nicipaI Code, Chapter 9.1 2, and the
IO Mand Safety Code o .255324)?
Date Receipt
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENDLATION PAN(SINGLE RESID)
ISSUIM
Will the applicant or future building occupant use equipment or devices
which emit haza=9Dsecoeta rants as defined by the Ray Area Air
Quality Management Dls ,
F�
BOILER -COMP GHP OR 100,000 RTU)
4 Yea o
have rcadthehazar ouanutcrialsrequime nbunderChapter6.95of
l e, set Yi U IygU
BOMER-COMP(OVER 100,000 BTU)
the California Health &SafetyCod, Sect1om 25505,25533 and 25539. I
NEW RESIDENTIAL MECH. EQ.FT.
understand that if the building does not currently have a tenant, that It is my
responsibility to notify the occupant of the requirements which =at be rest
prior to issuance of a Certificate of Occupancy.ws
ISSUED BY:
Owner or authoremd agent Data
TOTAL:
OFFICE COPY