23490APPLICANT TO FILL IN INFORMATION.WITHIN REDLINES — USE BALLPOINT PEN ONLY
Building Protect Identification - -
Building Address: - - : syr N-
- PERMIT NO, -
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A
G34�yi 0
nares one:
- A
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
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Contractor's Name: Lm. No:
y
LDI IrNLtTMBINCM.ECHANICAL
B-
CATEGORY
CONI%p
!.E,LECTRIC'PEMI
`Arc- - I A70 <. ;t -
Qn )U�, SGi-FlPiCnUCAL,P-
BUILDING PERMIT INFO.Q
.. ..• .
Add.
.
PER
PERhtITISSUANCE r
A
LICENSED CONTRACTOR'S DECLARATION
Iherebyaff)rm that l am licensed under provisions of Chapter 9(rommmc
ingwith5dion7000)ofDi"sion3ofthe Businessand PmfmalonsCode, and my
license lain lull !juice and effea.'u95� / t
I C ss ;f Lke T
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
cur\ �, CCLL
l
P
at / - Contractor 4 37,w rS "
ARCHITECTS DECLARATION21!11.WTAMPS'
I understand my plamshall he used as public records.
Licensed Professional
•-•(/_
O PS
SQ.. FT. FLOOR AREA �'1{S/SQ.
/ p Y0
FT.
E _ A
YVALCIR M75C
- OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contract.r'a Licenses law (or the
ETER ORPOLEINST..
following .... (Setl.a 7031.5, Business and Professeooe Code: Any city or
cauntywhichrequ a apert ttororutr Maller,lmpmve,de=lbh,ormpair,
,
anystructure pi -form its Issuance, also requires the applicant forsuch permit to
file a signed statement that he b licensed pursuant to the provisions of the
POWER DEVICES
`
QVIMMI NG POOL FI.ECTRIC
_
EISSWITCHPSFIXTURES-"Z
Contractor's License Law (Chapter 9 (commencing with Section 7000) of Dise
sion3 of the Buslnessand Professluru Cade) or that he b exempt therefromand
the beisfor the alleged exemption. Any violation of Section 7631.5 by any
appllont fora permit subjects the applicant to a civil penalty da room than
VALUATION G Q
Eve hundred dollar 0$500.
❑ I, as owner of the property, my employees with wages thele sole
NEW RESIDENTIAL ELECTRSQ.FT,
STORIES
- TYPE CONSTRICTION
d
andthe, r offend for
compensation, a4Wdess
lntendr's
_
and Pr
sale (Sec appy Business and Code:
Code The ctbls L law
f property or Imp
dsoympmovidedthatand
ves hereon
does notapplysuch ork owner ofpropertywho iown employees,
or
who does ents
providdilding
OCC.GROUP
RIS. UNITS
am ntintelf
dedoroffe dow le. If, owe r
however,
-
improvementsarcnMintendedoront issold 6fcmpleiont have
tFiLkordenof wnerongthathedidnat forpurpose ofune
jJ I, as owner tr the property, am a 0,14 iB si mNrading with licensed
contractors to roevlrud the project (Sec, 704y Business and Pro(eeslona Code:
QTY, ,;rtJ„pi c, PLUMBING PERMIT ;t t' '.'FEE�'�
FLOOD ZONE
-
APN
PERMITISSUANCE
The Contractor's License Law does not apply to an owner of property who
Wilds or Improve thereon, and who contracts for such p(ujeds with a
ador(s)Bcensed pursuantmtheContndor'e Llrense Law.•
IJ I am exempt under See . B k P C for this reason
ALTER -DRAIN & VENT- WATER (EA)
-
�,�' „ta;• FEESUMMARY'
BACK FLOW PROTECT. DEVICE
. DRAINS FLOOR ROOF, AREA, COND.
'FTXTUREq PER TRAP
SANITARY' Y_ N
.RECEI T p
Owner Date
COMPENSATION DECLARATION
WORKMAN I have
❑I hereby alflnn that l have a rerHRate of consent m wlf-Insure, ora
mrtifrate ofWorkere Compensation Insurance ora certified copy thereof(Sec.
3800,Lab Cd
Policy If
SCHOOLT Y_N_
RELENT M
P 1 1-y N
' RECPR'r M
GAS. EA. SYSTEM -1 INC.40UTLETS
GAS. EA, SY-OVER
Co
BUE, DING DI VIS I ON FE RS
!any
Certified copy Is hereby furnishd.
❑ CeniRd copy b fi4d with the city Wpection division.
"GRGSE/INRL I TO
G"IEC FEE
CREASE TRAP
e
. CERTIFICATE OF EXEMPTION FROM WORKERS' `
-
COMPENSATION INSURANCE
(Thlssecti.n need nut be completed if the permit ls for one hundred dollars
SEWER SANITARY SIO 200F1'
DBIC RCCCI tH
WATER HEATER W/VENT/
ENERGY FEE Y N
PAID
-
($100) or IessJ -
Icertily that in the performance .(the work for wMchtMspesnitbbsud,
I shall not employ any person N any runner n e to bemme subject to the
Wurkers' Compensation laws of California. Date
WATIR SYST[M/TR NG
NOTICE TO APPLICANT:
NOTAppICE IL after making this Certificate of Exemption, you
should become subject to the Worksm'Comperoation provisions of the Labor
NEWRESIDENTIALPLMB. SQJ,7'
Date Recei t#
TOTAL:'
3 e 0
Code, you must lost hwith comply with such pmvlslonv or this permit shall be
deemed revokd.
- CONSTRUCTION LENDING AGENCY ' '
BUILDING •
.00
- -
$EISM IC FEE
%
Ihercbyafflrmthat therebaromtroctlon kndingagenry forthe perform-
once of the work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name .. -
tender'. Address -
I certlly that have read this ap Fixations Ad state that theabove Information
iscomed. Iagreet.complywithalldtyandrountyordlnanresandrtatelaws
ELECTRIC FEE -
',-,
QTY. ', �. 111ECHANICAL'PERMIT ,'' '`'FEE"
PERMIT ISSUANCE IS
PLUMBING FEE
MECHANICAL FEB
FEES PAID:,
relating to building construction, and hereby authorlae representative of this
city to enter upon the above-mentloned property for inspection purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cu pertino
against liabilities, judgment, costs and expenses which may litany way accrue
against said City incon,°{� ee.m.fth ant ing of this
l ALTQt ORADDTOMECH.
Date - ReceiptN
AIR UNIT (TO 10,000 CFM)
SUBTOTAL:
AIR ]CANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTIONTAX .
"j
Signature.!ApplHAl?! CDOUSor Date
IXFL3UST HOOD
CONSTRUCTION TAX PAID:
'
HAZARDOUS MATERIALS DISCLOSURE
store de,Chater 9. hazardous
Will ia the applicant orehitu re Cupertino Municipal
material and defend by ode Cupertino Municipal Code,Chapter 9.1 2, and the
IlralthandSafety Code Section 25532(.)7HEATING
M Y. . �] No
'
-
HEATING UNIT (TO 100,000 BTU)
Date Recel
• TO
UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
Will the applicant or future building occupant use equipment or devices
which emit havrdous air contaminants as defined by the Bay Arca Air
yl,s
I)�lity Management District?
havc rcidtheh.ardo somaterlahmquimm nbunder Chapter6.95of
G ® '
'Is9
BOILER -COMP OLTP OR 100,000 BTU
BOILER-COMP(OVIR100,000 BTU)
the California Health A Safety Code, Sections 25505,25533 and 255M.]
u aderstand that if the building does not currently have a tenant, that it ls my
IIfI,
MAY 18 1992
NEW REST DDHIAL MECH. SQ.FT.
resporsibility, to not ify the occupant of the requirements which must be met
prior to issuance of a Certllicate of Occtipanry.
' •
GUY ur t Ur<<III`�
Y
ISSUED B�
Owner or aolhorirrd agent ' Date,
TOT I
OFFICE COPY