22796APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
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BuildingProjectMI
Project Identification
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PLRT NO.
.. 22796
nese arse: cane.01I
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
BUILDINGELECnUCAL-MUMBINGMECHANTCl�CATEGORY
APPUCAi
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BUILDING PERMIT INFO
Arch tett/Engineer. Lic. No:
X./19 G
QTY ELECTRIC PERMIT FEE
-
Add. 'Z . d
,
\.i ❑
PERMITISSUANCE ��1
LICENSEDCON ACTOR'S DECLARATIO
I hereby affirm that l am licensed under provWons of Chapter 9 (mmmc
Section 7000)of DAsion3ofthe Busies sandl'rofemrom Code, and my
limrue is in till dd(eat I'I 5%,�7¢�/:7(/v� (f�%�
e Contiact.r
E7tP ARCHITECT' DECLARATION
I understand myplaa shag be used upublicrerords
Licensed Professional
OWNER -BUILDER DECLARATION
Ihereby aRirmthatI x7exempt from the Contractor's Llrenx Law fort he
fo0.wingich reg(Sectlonrmt tocom ass and Professions Code: Mycity or
countywhkh requlre.a permit roconstaci, ilteq Improve, demolish,.rrepair
any structure prior to its Issuance, also requires the applicant f.rsuch permit to
file a signed statement that he is licensed pursuant to the provisions of the
Contractors License Law (Chapter 9(o.mmencing with Session 7000).( Divi-
sins 3 ofthe Business and Profe dons Code) orthat he is exempt therefromand
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant for a panNtaubjectathe applicant to a civil penalty of not more than
five hundred dollars ($500).
Fit, as owner.( IM property, or my employees with wages as their sole
compensation, will d° the work and the structure Is not Intended or offered for
sale (Sec. 7614, Business and Professions Code: The Contractors Lirnas Law
does not apply to an owner of property who builds or improves thereon, and
who doessuchwork himseiforthrough lisovAemployea, provided that such
ImprovementsarenotintendWorofferedforwh.ILhowevepthe WRdingor
Improvement lseoldwithlnoneyearofcompleti.n,the ownerbulMerwlil have
t rden of proving that he did not build or improve for purpose of sale.).
4 as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7036, Business and Professions Code:
The Coram ore License Law does nor apply to an owner of property who
Wilds or improves thereon, and who contracts for such projects with a
ctactor(•) licensed pursuant to the Contractors License Law.
LJ I am exempt under Sec B & P C for this reason
APPLIANCES D
]00 DESCRIPTIONingwith
\�
�-
P
OVER 0000
OVER 1000
SQ �
FT. FLOOR AREA .w`
L4`001:11
V
$/SQ.FT. .
1 M
"'
d
SIGNSELECTRICAL
IrECIALCIRCUIT/ML9C
U1MP. METER OR POLE INST.
ROWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
VALUATION
`-
NEW RESIDENTIAL ELECTR SQ -FL
STORIES TYPE CONSTRUCTION
C'GRO''\v/fra Oa � T
TOT
QTY. PLUMBING PERMIT FEE
I PERMRISSUANCE
ALTER -DRAIN &VENT -WATER (EA) .�+
^wF]�DZANE P
FEE$UMMARY
BACK FLOW PROTECT. DEVICE
FEES
DRAINS FLOOR ROOF, AREA, COND.
PLYIURES-PER TRAP
SANITARY Y N_
RE-CEPr N
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificate of consent to self -Insure, or a
certificate.(Workesi Compensation lnsurm.1. certified copy thereof(Sec.GAS
380O,lab C.)
Policy X
SCHOOL TAX Y_ N
RECEIPT N '
F.A.SYSTEM-I INCA OUTLETS �•
PARK FTE Y_ N_
RECEIPT X
GAS LA. SYSI73M-0VER 4 (EA)
Com any
BU IL DING DI VI SION FEES
MCcAtcrifed copy ls hercbytumls ed
city
❑Certified copy ls filed with the city Inspection division.
CERTIRCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thissectlon need not be completed if the permit bfor one hundred dollar
($1I cattyth Nperformance
Irn.rl..at the perfonnof the work (orwhkh
hthls permitlssued,
I shall not employ any Foram in any manner so as to become subject to the
Workers' Compensation Gw. of Callfomia. Date
AppliNOTICE
NOTICE TO APPLICANT: If, after making pe Certificate of Exemption,aLabor
should become subject to the Workers' Compensmlon provisions Nof the Labor
Code, you cawed krthwllh comply with such provisions or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
Iherebyaffirm that there h a coatmetion lendingagency for the perform
nee of the work (or which this permit b Issued (Sec. 3097, Civ. C.)
lender'. Names
lenders Address
I oemitythat I have read thhapplloRonand Eatethatthe above information
Is correct. i agree to comply with all city and county ordinances and nate laws
relating to building constroction, and hereby authome, representatives.( this
city to enter upon the above-mentioned property for inspection purposes.
(We) agree to save, indemnify an d keep harmless the City of Cupertino
aga Inst lhbiEties, pdgners,costsand wlikhmayinarywayaccrue
against said City In cons erreting le permit
/
CREASE/INDUSI'RL WASTE INTERCEPTOR
PLANCIiEC FEE
l.�
` 'Ian
D f CCeI IN
GREASE TRAPPAID
SEWER-SANITARYSTORM EA 200FT
HEATER W/ [C
EN G Y N
— Q��/q
PA
WATER SYSTEM/TREATING1
NEW RESIDENTIAL PLMB. SQ.FE
Date Rem t _
TOTAL:
BUILDING FTE
SEISMIC FEE X
TaTA
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEEMECHANICAL
PLUMBING PEE
FEE
PERMrFM5UANCE
FEES PAID:
Date Receipt#
ALTER OR ADDTO MKI-L
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
gnature.f Appli .' r t
DOUS ERIALS DISCLOSURE
Will the a pl,119511011irfuture building onvpant store or handle hazardous
material as defies by the Cupertino Municipal Code, Chapter 9.17, and the
Tiealthand yC.d a�z. -S�ectlon25537(a)7
E-1Y.u No
Will the applicant or future building occupant use equipment or devices
which emlt hazardous air contaminants as defined by the Bay Area Air
a111y Management Dktrict7
Yes No
love read the hazardous materials requirements under Chapter 6.95 of
the California Health & Safety Cade, Sections 75505, 25533 and 75536. 1
understand that if the building does not currently have a tenant, that It is my
nspmulbility to notify the occupant of the requirements which must he met
Prior in I%.... of a Certificate of Occupancy.
EXHAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
Date Remi
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER 100,000 BTU)
TO
VENTILATION FAN( SINGLE RFSID)
ISSUANCE DATE
PAID
7(1(]J
NOV 12 1991
CITY OF CUPEH j INN
ISSUED
IOY:
BOILER-COMPDHPOR100,OIOBTU)
BOILFR-COMP(OVER 100,000 BTU)
NEW RESIDENTIAL MECFL SQ.PI'.
Owner or authorized agent Data
TOTAL:
OFFICE COPY
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ALTER -DRAIN & VENT -WATER (EA.1
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ADDITIONAL PERMIT
FEES
BUILDING PROJECT IDENTIFICATION
VALUATION
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FEE SUMMARY
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PLAN CHECK
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FEE
PHONE
SEISMIC FEE
OTY. ELECTRIC PERMIT FEE
OUTLETS SWITCHES -RECEP
ELECTRIC
.,
LIGHTING FIXTURES
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PLUMBING
- -
PPLIANCES-RESIDENTIAL.
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SIGNS TRANS.
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