23193APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification -
Building Address:
.�
PERMIT NO.
2 3 1 9 3
wmra one:
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING EaECTRICAIPLUMBINGMECIIANICAL.
p A A
�'L��
GU7'S�N S� (� N Uc'N.:
CATEGORY CONTROL #
Archltett/Engineer. Lk. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address: 6'5 / —/j _ 6x6 Uel— C )of S �
.
❑ ❑
PERMHISSUANCE
LICENSED ED CONTRACTOr pr DECLARATION
I heh Sectio irmrhatlaiv Heemsed under provisions ofC.i.ts .de,.menc
1 gwith Sedlon 7000) old effeon3ofthe9udlnessand ProfeaslomCode,orad my
erase la In foil m and effect 7 7
(cense Cl Lk.N
Yate / Contractor
DECLARATION
A. shall
Iundenbnd my plana shall be used upubecrewNs.
used
Limnsed l'rotensiwul
DECLARATION
OWI am exempt
I hereby affirm that I am 31.5, B s m the d Pmt Jo Lkenre Law for the
tollowtngichm uim ape? 1$Buein c and Pmfeaalonae=le h,ydtyor
rountywhkh rcqulrcsa pemdttoconatvM alter, Improve, demoWh, ormpalr
anystmu mpriortoltslaeuance,ahorequlmtheappltrantforsuchpermitto
file a signed statement that he b licensed pursuant to the provisions of the
Contractors License Low(Chapter9(mmnpndng with Section 7000) of Divi-
Stan of the Business and Pretensions Code) or that he h exempt therefromand
the bash for the alleged exemption. Any violation of Section 70315 by any
applicant tors permit subjecutthe applicant to a civil penalty of not more than
five hundreddollarsthep0).
I, as owner of the property, or my employees with wages r their wk
for
compensation, tion, will do the Business
vde: Th CoIntended o Untrue
dale (Sc.(gee 7004, to ainow and Protensity Code: The Contractors Lerner Law
pred the tensions
does whocloss pplysuch loan seofproperty who
nemorimprovesdhercoRand
whodsesants amrkhimself erthrough his owne. If,hoo,providedthatsu or
Improvementsarenet intended earofrod pletioe.t0however, deer ill have
implcrdernrbsoldwthat ithin oneyhe did et Wil Por onrhee,forprpose ofsahave
tt�ej 1, as wnir of the prod ,am eclorlmpmvefacing with Beans.
u I, as owner tr the property, am exclusively Business
ess andl^g with licensed
Code:
Business end of property
construct the w jectdoe (Sec. apply
TheconContractor's
The Ceor Improves
es then Lw don not applyic an owner I property who
builds or Improvise thereon, and who contnm me such w.ojesb with a
c ff,A{, 0daexempt under Secnt . the Contractor'•Licence Law.
u I am exempt under Sec. B & P C for this reason
APPLIANCES -RESIDENTIAL
JOB DPSCRB'ITON
J MWI
PANES
4VERIO PS
OVERt(100 AMI'
1
I tl,,�`,1�.•/—•J//
TE
SIGNS ELECTRICAL
SPECIAL CERCNT/M15C
�(p METER OR POLE INST.
POWER DEVICES
SWIMMNG POOL ELECTRIC
OUTLETSSWITCI{PSE%'TURFS
VALUAT DIJ5
G Q Q GJv
o
NEW RESIDENTIAL ELECTR SQFC.
STORIES
TYPECONSIRUCTION
,
T
QTY. PLUMBING' PERMIT FEE
OCC. GROUP
RES. UMTS
FLOOD ZONE
APN
PERMITISSUANCE
ALTER -DRAIN VENT- WATER ffNN
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
-OUTSIDE F�—Ls
DRAINS FLOOR ROOF, AREA, COND.
FIXNRES I'ER TRA('
SANITARY Y N_
RECE97 N
OwnerDate
WORKMAN COMPENSATION DECLARATION
❑t hereby affirm that I have a mrtiRcate of consent to self -insure, ora
00 ate OfWorkero CompevaHoniruurance oracertifletl mpythereof (Sec:
P.1i Lab .) t / 2 b 2
Poilgx C S�r�?fJ!
SCHOOL TAX Y N
RECEB'f N
CAS EA. SYSTE.1 INCA OUTLETS
PARK FIS Y N
ftFLIDrEM
GAS. EA. SYSTEM-OVER4(EA)
_
C�anY s
BUILDING DIVISION FEES
Certl ed ropy isbye
�ertlfied copy b Ned withth the city city inspection division.
CERTIFICATE OF E0OAPTION FROM WORKERS'
COMPENSATION INSURANCE
(TNssedion need net be completed lithe permit h toroce hundred dollars
(gt00)oifyth
rt
]ceify that In the performance ofthe work for which this permit bbsued,
I shalt Cot employ any person In any manner co as to become subbed to the
Workcrs'Compensatkm Lawsof Catlfernb. Date
ApplicantCENEW
Midis co esubject to AM:IL aftermakingfhb Certiflate o Exe=nL'you
Workers' Comprovisinpmvhis permit s Lab be
C dou=a forthwith comply
Code, you must forthwith comply with each pmedsloru orchis permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
�[heeehyaffirmthat there b a construction lendingagency forthe perform-
anRR of rhe work forwhkh thio permit Is issued (Sec. 3097, Civ, C.)
Lender. N.
Lender'. Addend
I certity that I have read this applicatio.. ed stare that the above Information
bcorrect. lagmtommplywiih.Bettyandcountyordlnanceeandoatelaws
relating to building conatrudion, and hereby authorise representatives of this
city to enter upon the above,mentioned property for inspection purposes.
(We) agree to save, indemnify an d keep hamelens the City of Cu pert Ino
against liabl@in, todgmenb, costa and expenses which may In any way accrue
against said City In consequence of the grant Ing of this permit.
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECKFEE /9win
LJ�
PAID I
Date Recei tilt
GREASE TRAP
SEWER-SANTfARY-STORM EA 4110P1'
WATER HEATER W/VENT/ELECIR
ENERGY FEE Y N
PAID
Date Rett'] of
WATER SYSTEM/TREATING
RESIDENTIAL PLMB._,SQF7.
TOTAL:
--1
BUILDING ITE �
SEISMIC FEE
TOTAL:
ELECTRIC FEE
-
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
Dale Recei tM
P
ALTERORADDTOMECH.
AIR HANDLING UNIT (TO 10,000 GEM)
SUBTOTAL'
AIR HANDLING UNIT (OVER 10,000CFMI
CONSTRUCTION TAX
Signatu no of Appllant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.14, and the
Flea lth and Safety Cod a oo 25534(a)?
F1 Yrs No
Will the applicant or future building occupant use equipment or devices
which emit haeardous air contaminants as defined by the Bay Area Air
Quality Management District?
Yea ��7NVo
have read the hazardous materials requirement under Chapter 6.95 of
the California Health & Safety Code, Sections 75505, 25533 and 21534. I
understand that iflhebuildingdon no cvrrentI ave a tenant, that it b my
I rheompant o(the rements which moat be met
Pdw t.'ssuarm of 1 teofOmpa //! Z
9
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
Date Recei k
HEATING UNIT (TOUA,ODO BTU)
HEATING UNIT (OVER I WOOD BTU)
TOT
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
PS
AN 16 1992 �.
City ui=Cur 4
ISSUED BY: Q. �u �
BOILER -COMP OTB' OR 100,000 BTL))
BOILER-COMP(OVER 100,000 BN)
NEW RESIDENTIAL MECH. SQ.FT
author a t Date
TOTAL:
OFFICE COPY