25315MY OF CUPERTINO APPLICATION/PERMI'P r%umam'r-n+H:cnnlvI
BUILDING DIVISION BUILDING PRO.IF:G'1IDEN'F11
11ILDING ADDRESS; �f\)
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QTY. ELECTRIC
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PERMITISSUANCEIlls
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LICENSED CONTRACTOR'S DECLARATION
Ihereby afMn that l sm licensed underprovisiom of Cbmpa9(commencing with
Section]a00)of Division J ol'Ibe Business and Professions Code, and my license is in
full e and effar.
forc
License Clan hie. #
APPLI C 1DHN1HA_
PAN E
-
T 00 AMPS
vFi<y
Dale Contractor
- ]"AMPS
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ARCHITF.CTSD. LARAI'ION
I understand my plans shall be used ss public recoNs.
OVER 1000 AM
SIGNS ELECTRI C
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RECEIPT#
Llcersa,] Pmfcssiond
OWNER -BUILDER DECLARATION
I harcby tat I am exempt from the Contractor'snsCo License Law for the
SPECIALCIRCU
TEMP. METER OR POLE INST.
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following reason. (Section 7031.5, Rosiness and Professions Code: Any city or county
d,effort,(Se
which requires a permit m construct, alter, improve, demolish, or mpan ery sesame
for,,, its issuance,aha requires theapplicant for such Permit n filen signed stamment
that he is Iicenxd pursuant to the provisions of the Corrommrs License Lew (Chapter
9(commencing with Semirn]001)af Division 3ofthe Business and Prnfionays Code)
POWER DEVICES
SWIMMING POOL ELECTRIC
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F•- 4
error he is exempt Unwhom and the basis for theellegcd exemption. Any violation of
ticdinn ]031.5 by any npPllcant fora pemtit subjects the applicant [n ecivil penalty of
{3TLET5- SWITCHES -FIXTURES '
cat,
x322
not mom than five hundred Dollars (5500).
❑ I, osownerofrhe Properly,ormyemployeeswithwagesmrheiraolecrmpcmatioq
will do the work, and the structure is not intended or offered farsole(Set.]fM4, Business
NEW RESIDENTIAL ELECTR_SQ. FT.
GRADING FEE
and Professions Cale: The Commmots License Law does not apply to an owner of
SOILS FEE
6 �^
property who builds rlmprnveethere a,mdwhndre ..chwnrkhouselfor through his
foe sole.
earrof
PAID
T
ampleered
however,rL
r improvement
however, the building or improvement is hath within one year or improve for the owner-
builder 'll hove the burden of proving that he did not build or improve for purpose of
QTY. PLUMBING PERMIT
R56i" #
I, aaownerofate propany,amexelasivelyeontracting with licensed contractors to
cans t the project (Sa. ]034, Business and Pmossiarm Code:) The Contractors
License Lawdoeanoutpplytoannwnunrproperty whnbaildsorint,ovesthanon,and
PERMIT ISSUANCE
BUILDINQiHa
who connotes such pmjects withaeonmaclogs)licensedpumumilothe Contractor's
Lice se Law.
nl
gL'1'Eft-DRAIN&VENT-WATER (EA)
❑ em exempt under Sec. B & P C for this rcasom
BACK FLOW PROTECT. DEVICE
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Owner Dote
DR N
°IFIXI'URESaPB
PL R AR I
P
WORKMAN COMPENSATION DECLARATION
m
l hereby affirthat l have a ecrifcme ofconsem tself-insure. oracertifica of
Worken'Compensetion lmorancea ecenifiedcopy thereof(Sa. Jg00, Lab CJw ch
rs tdl employee's under this permit. n
Policy a
( 6X. jJ E�• UH. -1 I C
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Company
GAS -TrM-0VE 4 P,A)
26
CI Carolled copy ishereby famished.
❑ Certified copy is filed wit the city inspection division.
L
EPI'O _
CERTIFICATE OF EXP.MPTION FROM WORKERS'
GREASETRAP
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 200FI'.
(This salionned not becompleted ifthe permit is forcnehoodred dollars($100)
art less.)
WATER I[RATER WENT/17LEMR771 1
I certify that in the performance afthe work for which this permit is issued. )shell
not employ any person in any mapper so v to become subjat to the Workers'
WXMRSYSTEMIGIMATING
O z
z
Compcmationlswsof California. Dan
Applicator
NOTICE TO APPLICANT: If. after making this Ceuifcme of Exemption, you should
NEW RESIDENT IAL PLMB. SQ. FT.
1
>
nsof dampate Cade,y. must
baomeh comply theimeh sCompensation rand
fnrhwit comply wont such provisions anhir permit shall be deemed revntrd.
Z
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Vshove
CONSTRUCTION LENDING AGENCY
1 herehy affirm that there is o construction lending agency for the performance of
the work for which this Permit is issued (Sec. 3097, Civ. C.)
T -
Lenders Name
Lenders Address
QTY. MECHANICAL PERMIT
1 certify that I have read this application said sate that the above information is
correct. I agree to comply with all city and county ordinances and state laws relining to
baildimgeorsmction, and hereby autmie repmsemmives rinds city menter upon the
-mentioned Property for inspection parponao.
PERMIT ISSUANCE
ALTF,RORADDTOMECH.
(We) agree to save, indemnify and keep hrumless rte City of Cupertino against
I iubil irim,judgments, costs and expenses which usyan any way accrue againstamd City
AIR HANDLING UNIT (TO 10,0(10 CFM)
in ennsequ ce of the granting nil' it.
W✓✓✓~
AIR HANDLING UNIT(OVER 10,M CPM)
Signal of ApplicwUComranor ate
EXHAUS'1'I{OOD(W/UUCO
HEATING UNIT (TO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant car future building ooupant spm or handle hsuudous material
as dented by the Cupertino Municipal Cade, Chapter 9.12, and the ]health and Safety
I HEATING UNIT (OVER I00,N00 BTU)
Coda, Section 25532(u)7
1:1 Yes ❑ No
VENTILATION PAN (SINGLE RESID)
BOILER- COMP DHP OR IW,W BTU)
Will tee licnntnrfmrre buildln Luse mnlevices wM1ich emit
pP eq
BOILER - COMP(OVER IB),WB BTU)
hawdrus air conmminame as dcfinul by the Bay Area Air Quality Manegcmenr
l by then Air
>inrirr]
❑ Yes ❑ No
NEW RESIDENTIAL MECIh. SQ. IT.
1 have read the hazardous materials requirements under Chapter 6.95 of the
Califomia Health & Safety Code, Scene. 25505, 25533 and 25534. 1 understand that
if the building does not curently have a mount, that It is n,00 uabiliry to notify the
occupant of the requirements which must be mer prior m issuance of a CerOfieate of
Occupancy.
Owner or authmiud agent Dam
FEE
25315
0i
NIC
E]ps
CONTROL# '
BUILDING PERMIT INFO
LOU
FACT PLUMB MMECH
V �-
SQ. FT. FLOOR AREA
�
VALUAT
I, /1
STORIES
OCC, GROUP
FEE FLOOD ZONE
l
FEE SUMMARY
71'SIU ELL.
SANITARY
YN
RECEIPTp
SCHOOL TAX
Y N
RECEIPT#
PARK FP.N
- Y N
RECEIPT#
BUILDING
DIVISION FP iS
PLANCHF.CK FEE
GRADING FEE
SOILS FEE
6 �^
ENERGY FFIE
PAID
Dam
R56i" #
TOTAI.:
BUILDINQiHa
FEE PL MBV FEE
MECHANICAL FI
CONSIRUCTION
PAID Dam Ra opt#
TOTAL:
ISSUANCE DATE
PAID
SEp %I 1993
.ary 4lk �:�Yt 11P4