23557APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification -
Ruild!nSAedmss_ Cv �',�
PERMITNO.
.23557
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING-ELLCTAICAUPLUMBINGMECIIAMCAL
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Contranor's Name: Lte. No:
V ��
CATEGORY
-
CONTROL. N
Arch ten/Engineer: Lic. N.
QTY ELECTRIC PERMIT. FEE
BUILDING PERMIT INFO
Address: WS"D
I>[RA9r1S5UANCE
_ ❑ 1-1 j -Q ❑
I/O
LICENSED CONTRunder SDBoes ofCION '.
I hereby licensed Cssions ode,anrnc-
fn ease I Senora foW)af Division 3olthe Bualnneand ProlnslonsCnde,and my
Ltom Islns force and df. If
Dute Clam LIC.#
Date Contanor
ARCHITECTS DECLARATION ..
I understand my plans shall be used as public records
Licensed Profemlarul
OWNER -BUILDER DECLARATION
I hembyafflrm that I am exempt from the Contractor'sLicenseCaw for the
following reason. (Section 7031.5, Business and Professions Code: Any city or
county which requiresa permit mamatrucl, alter, Improve, demolbh,orrepair
any strucrom prior to Its issuance, a iso rtyume; the applicant for such permit to
file a signed statement that he is licensed pursuant to the provisions of the
Contractors License raw (Chapter 9 (mmmencing with Session 7000) of Owl-
.ion 3 ofthe Rude ssand Profemlom Code) orthat he is exempttherefromarm
the basis for the alleged exemption. Any violation of Session 7091.5 by any
applicant fora permit subjects the applicant to a civil penalty of net morethan
f e ndmddollars(.SM,
I, as owner of the roe
property, ray,orhe employees as their
not Intended or offered L for
peneatlon, Buswill iness
work end ionsiCode: The
Bale (Sec. 704q Bminess and Professions Code: The Contranoie Llce.e Law
doesnot apply to an owner of pmperty who Wilds or improves thereon, and
who doeswch work himselforlhrough hlsownemployees, provided that such
Improvements are not Intended oroffered faradic. I( however,thebuilding or
improvement issold withino.yearofcompleion,the owner-bullderwill have
tLIpeden of proving that he did not build or improve for purpose of ads.).
LJ L as owner of the property, am exclusively contracting with Ilmmed
to mnstrun the project (See. 7044, Business and Profeemons Code:
The Contractor'sLimnse law don not apply to an owner of property who
or I.p.thereon, and who contract for midi puojecst with a
m,E(Tanor(e) Bmnsed pursuant to the Correctors Llmnse Law.
LI f am exempt under Sec. B k P fee th� reason
APPLIANCES -RESIDENTIAL
JOB DPSCRIPI'fON
e o •�
J/� /
PANELS
— UP TO 200AhTS
201-1000 AMPS
OVERIODOAMPS
SQ. Pr. FLOOR AREA
8/SQ.FT.
SIGNSELECTRICAL
SPFF,MALCIiCIRT/MLSC
TEMP. MEYER OR POLE [NST.
)OWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
OUTLETSSWITCHFSFLYTURES
N'EW RESIDENTIAL ELECTTt SQ.FT.
STORIES
TYPE CONSTRUCTION
TOTAL:
QTY. PLUMBING PERMITt FEE
pp 4,p ISSUANCE
ALTER -DRAIN k VENT- WATER (EA)Wild.
OCC.GROUP
RFS. UNITS
FLOP zDNNE
APN
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
DRAINS FLOOR ROOF, AREA, GOND.
SANITARY Y N
RECEIPT#
Date7—
WORKM COMPENSATION DECLARATION(
❑I hereby affirm that 1 have a mrtificate of consent to self-Inem, or a
certificate of Workers' Compensation l.umom ne a mnl(led copy thereof (Sec.
3800, Lab
Policy N
FIXTURE^, PER TRAP
OOLTAX Y N
RE= N
CAS EA. SYSTEM -]INCA OUTLETS
PARK FEE Y— N_
RECEIPT #
GAS PA.SYSCE.MAVERd(EA)
Com an Y
BUILDING DIVISION FEES
Cenlfied copy b hercbyth the cid.
�Cenified copy V filed with the tlly Inspection division.
CERTIFICATEOF EXEMI`TION FROM WORKERS'
COMPENSATION INSURANCE
(TMs senlon need not be complded [(the permit b foram hundred dollars
($1I(mAlless.)
Icenify that Nthe pedormanmofthe work for which this permit is lsua d,
I shall not employ any person N any nanner n n to become wbjen m the
Workers Compensation Lim of California. Date
Applicant
NOTICE TO APPLICANT: IL akar mating thio Certificate of Exemption, you
should become subjen to the Worksn' Compensation pmvbiom of the Labor
Code, you resat fon hwlth comply with such provisions or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lendingegency, forlhe perform-
sore ec of the work for which this permit is Issued (S 3097, Civ. CJ
Lender'.Nerre
Lender. address
I rnrtilythatl have read this appliationand state thattheabove Information
Is coma.I agree to comply with all city and county ordinances and agate laws
relating to building construction, and hereby authorize rcpresentativea of thio
city to enter upon the above-mentioned property for Inspection purpoen.
(We) agree to save, Ind connify an d keep tere. the City of Cu penlno
against llabilitlm,judgments, costs and expenses which may In any way accrue
againd said City in consequence of the granting of this permit.
CREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECKFEE
PAID
Date Recei t#
GREASE TRAP
SEWER -SANITARY -STORM EA. 200FT.
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y N —
PAID
Date Recet t#
Ina) STEM/TREATTNC
NEW RESIDENTIAL PLMB. SQ.IT.
TOTAL:
BUILDING FEE
SEISMIC FEE
TOTAL:
ELECTRIC FEE
-
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
ALTFRORADDTOMECH.
Dale R0Ce1 t#
P
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL-
AIR ITA NDLING I1NTr (OVER IO,000CFM)
CONSTRUCTION TAX
Signature of Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicant or future building mxupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.17, and the
25532(a)7
Health and Safety Code Section No
❑ Ye. o
Will the applicant Mee building occupant use equipment or d^vices
which emit ha,mrdoud air mnlamimnts a. defined by the Bay Area Air
�uality Management District
4. Yes gNo
have re ad the hazy ons materials requirements underChapler 6.95 of
the California Health & Safety Code, Sento. 25505,75533 and 25534.]
understa cid that if the building does not m b rrenlly have a tenant, that it my
responsibllity to notify the ocevpa cit of the requirements which must be, mat
prior to issuance M a Certificate of Occupancy.
EXHAUSTHOOD(W/DUCD
CONSTRUCTION TAX PAID:
BEATING UNIT (T0100,000 BN)
Date Recei l#
HEATING UNIT (OVER 100,000 BTU[)
-41
TOTAL:
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
p
P -A I D
22 1992
Cl I OF cupf:n 1 IWu
ISSUED BY:.�l� (.� �•
BORER -COMP OFIm OR 100,000 BTU)
BOILER -COMP (OVER 100,000 BTU)
-
NEWRFSIMNTIALMECH. SQ.FT -APR
Owner or authoriad agent Date
TOTAL:
z � a
OFFICE COPY