24140APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Ym'ed Identification
Building Address:
Q 6�to S.Cat Q
PERMIT NQ, 414 0
cm_e: one:
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�.-Coot: L) 8w
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUfLDINGELECnUCALPLUMBINGME MEAL
�/
Conte o' ) LIcNo:
_
CATEGORYCONTR 6C
rch ed/Engineer: Lk No:
QTY ELECTRICPE FEE
BUILDING PERMIT INFO
Address
It Xi
PERMITISSUANCE aaW
LICENSED CONTRACTOR'S DECLARATION
I MrebyafBrm that[ amtvamsed heunder Busl ossand sol Gapter9(mmmme
ingwithficon.I SI full 7000)ofdoffeon3 ofthe BuNnmsandl'rofesdonsCode,and my
license is ln'(uB( and effect
an"I" Lk.I
DateContrador S.
ARCHITECT'SDECLARATION
APPLIANCESRESI E L
JOB DGSCRRs'ITON
�4. Je
PA
"l
O AMPS
SQ, ET. FLOOR AREA
` OO DD
5/SQ. FT.
&—
I understand my platy slug be used as public records.
Licensed Professional
SIC EL Al
OWNER -BUILDER DECLARATION
I herebyafOrm that I am exempt from the Contractors License law for the
SI'-CIALC UI EC
gpTppM POL ST.
following reasons. (Section 7611.5, Business and Prefesslow Code: Any eity or
county which requiresa pernmertmestrac alter, Improve, demolish, ormpalr
anystmctum priorto ltslamance, also requirestheappRcent forsuch permit to
file a signed statement that he ls licensed pursuant to the provisions of the
Contractors License law(Chapler 9(commencing with SeR1on 7000) of Divi-
sion3ofthe Buslnessand Limitations Code) or that he is exempt therefromanci
the basis for the alleged exemption. Any violation of Section 7031.5 by an
applicant for a permit subjects the applicant to a dvll peralty ofmt more than
five 1, as ed owner of
I, as owner of the property, or my employees with wages their dole
POWER DEVICTS
SWIMMBNC LELECTRIC
ETSSWITCHES-FIXTURRS l �^
41
VALUATION /eyq
�i /� �tl� O AyjeY[
iw� y
NBWRFSIDENTIALELECTR SQ.FT,
STOWFS
TYPO CONSTRUCTION
mmpewation,will Bothe work and thestmcture ls not Intended or altered for
r
sale (Sec 7044, Business and Professions Code: The Contractors License law
_
does not apply to an owner of properly who builds or Improves Thereon, and
who doessuchworkhimselforthrough hieownemployen,provided thatsuor
Improvements are not Intended oroffered forsole. If, however,thebullding d
CRIW�_
a
improvement V sold within one yea mlcompietlory the owner -buts erwill have
t L as o neerproingof t e pro erty,did a build orimprovepurpose ficurn .
contracting
LJ 4 as toner of the property, Se exclusively Booty mntradprowith Ilcen¢d
ro construct the project (Sec. 8usinen and Limitations Code:
QTY, PLUMBING PERMIT E
PERMIT ISSUANCE r
T FLOOD TpNg�
/
p 3j
% s--/
e Contract
The Contactors Lices.thee Lw docs cad apply tct, f owner of property who
app[
Wild. Or Improves thermry and who taint !t such p(ojecb with a
theContractt's License PLaw.
C'nad am under outt Sm
LJ I am tempt under Sec B k P C for this reason
ALTER -DRAIN h VENT- WATER (EA)
FEESUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
FIXNRFS PER TAM
SANITARY Y N�
RECH rr p
Owner Date
WORKMAN COMPENSATION DECLARATION
❑1 hereby affirm that I have a certificate of consent to selfdnsore, or a
mrtlflmteofWorken'Compensatimlw mnmoramrtifledmpythereof(Sec,
3800, Lab C.)
SCHOOL TAX Y N_
RECFdPT M
GAS EA.SYSTEM-1 INCA OUTLETS
PARK FEE Y N
policy p
RECEIET X
GAS EA. SYSTEM -OVER 4 (EA)
m any
BUILDINGDIVIS NFEES
rtNed copy I henbylurnlahed.
Certifi i_pyls'tied withthe dtyinspectiendlvleion.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thio need not he compldedI(the permit V(Drone hundred dollars
CREASE/WDUS[RL WASTE INTERCEPTOR
PLANGI-IECK FE - Al"
PAID
t'
a Recei t#
GREASETRAP
SEWER-SANITARY-STORM EA. WET.
(SI
(5100)orleatIn..) J
I certify Thato (he performance of the work for which this permit ctlsmed,
empty any person In any manner so u to become subject to the
I shall Workers
W laws of California. Date
WATER FIEATERW/VENT/ELECTR
ENER FEE —
PAID
WATER SYSTEM/TREATING
plica'Compensaticn
NOTICE
NODCETO a sub)e t to the after nuking this Ction pr a is Exemption, you
Code, become subjectto the Workers Cuch pruasonprovisionsofthe Labor
Code, you must (orthwl[h comply with such previsions or this permit shall be
deemed revoked.
Date Recti t!)
NEW RESIDENTIAL PLMB. SQFT.
TOTAL:
-BUILDING FEE t
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
IherebyafRrm that there 6 a mwtmction lendingagency for the perform
ance of the work for which this permit Is Issued (Sec. 30W, Cir. G
T
ELECTRIC FEE ^,t
Lenders Name
Lenders Addrew
I certlfythatl have readthlseppllallonond atarelhatthe above In(ormatlon
Is correct. 7 agree to comply with all city and county ordinances and state laws
- -
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICALFEE
PERMITISSUANCE
FEES PAID:
relating to building construction, and hereby authorize representatives olthls
city to enter upon the above-mentioned property for hafmcdon purposes.
(We) agree to save, ind emnlly an d keep harmless the City of Coped Ina
ALTD40RADD TO
Date RLYCI til
SUBTOTAL'
against liabilities, judgments s and expenses which may In anyway acme
against sa y n of the graining of this permit.
AIR HANDLING UNIT (T010,000 CIM)
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
Igtutureof AppricsftIrContranorIto
HAZARDOUS MATERIALS DISCL URE
IXHAUS"THODD (W/DIKT)
CONSTRUCTION TAX PAID:
HFATINGUMT(TOIOO,000BTU)
Will the applicant orlunre building occupant store or handle hazardous
as defined by the Cupertino Municipal Code, Chapter 9.1 2, and the
Date RCC 1 #material
HEATING UNIT (OVER 100,000 BTU)
T O
Health and Safety Cod_SSeyyetr2:532(a)7
Yee
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
ffrry� p
It" Oak D
Ill the a pplim nt or future bu llding occupant use equipment or devices
which emit hazardous air contaminants as defined by the Bay Area Air
a lily Management Dkhict7
BOILER -COMP DHPOR 100,0(X1 BTU)
Yes p' o-
BOILER.COMP(OVER 100,000BTU)
ho"madthehazambuematerialsreqummentsunderChapter6.95of
the California Health k Safety Code, Sed Ions 25505, 25533 and 25534. I
OCT 8 1992
NEW RESIDENTIAL MECH. SQ.FT.
undmia ti( the building does not mrmntly have a tenant, that it is my
repo ilii to nqH the oceip!ld#the requirements which moat be met
prior Diss nrebf CertIy9ahl9lvocupancy.
LL3 -9�
'
CI I Y Ur QuIl"I
ISSUEDe
roc tori g¢ Date
OFFICE COPY