20301APPLICANT TO Ft+ L IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Proles Identification
Bioi"oreoTR
PERMIT NO.
oaj Ave uulT sal Hl. l
20301
neva Name: C V.e one.
PWP&jPT-16-n
Contractor's Name: _ L
'q le. e:
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
BUR.DINT—ELECTRICALPLUMBINGKWHAMCAL
(5/1)9/90
CATEGORY
CONTROL if
Archiled/Engiaer. Lie. Nee .
QTY: ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address
�Y l� .� Fr
u LJ I_J
PERMITISSUANCE
LICENSED TR
Iam He under rDECLARATION
Ibereectionrm that lam Rcensedunderprovhloneof Cssions9(convnme-
IngwithSMlon7000)o(Dlvision3 ofthe Businessand Pa(easlonsCode,and my
Ilcenm le In full force and effect.
License Cuss LICY
APPLiANCESRESIDENI7AL
JOB DISCRETION
jjjjjC���R
S
PANELS
Date - Contndor
101 -IOW AMPS
ARCHITECPS DECLARATION
I undemmi d my plans shag be used as public records.
_
'
SQ. rattlIEN&VA f/SQ. FF.
OVER 1 ODD AMPS
SIGNS ELECTRICAL
Licensed Professional
1199U
SPECIALCItCN7/hQSC
OWNER -BUILDER DECLARATION
1 hereby affimnthat I am exempt from the Contractor's License law fwthe
MAY 1
�(p METER OR POLEINSf.
followi^'`'
..ty hiaho.(imap70HS, Busln®and Pmfemloe,Code: Mydtyor
caantywhich requlmapemnitbcoatrod, alteq Improve, demolth,arrepalr
�� •I
t>��/`vJY7v+{�aar 4
W1�1-'A+' nn /]afl��
anystm=mprlorbittsuame,aisorequlrestheappflmntfwsuchpermltto
file a signed statement that he is licensed pursuant to the provisions of the
LOWER DEVICES
SWIMMING POOL ELECTRIC
Contractors License Lsw(Chapter9(commencing with Section 7000) of Divi-
sbn3 ofthe Butlnnaand Profsmbm Code) orihat het emmptthemfmmand
VALUATION
the basis for the alleged exemption. Any violation of Section 703IS by any
fora permit subjects d the applicant to a civil penalty of caroom than
OUTLETSSWITCHESFIXTUIZES
60,311. ac—)
fivehundred dollars(5500).
a owner of the property, or my employees with wages as their sole
❑I,same
NEW RESIDENTIAL ELECTR_SQ.FC.
STORIES
TYPECONSIRUC'HON
compensation,w0ldolhe work and thestrudure isnot mandedor offered for
sale (Sec. 7044, Business and Professions Code: The Contractors License Law
� �
does not apply to an owner of property who builds or improves thereonand
who doessuch work himself or Nrough Msown employees, provided that such
OCC.GROUIx
RES. UNITS
m
improvement a. norinlended orofferod forsale. If, however, thebulldingor
Improvementtwidwlthlnowyearofew pletbgtheowner-buflderwilllove
TOTAL:
t1atIurden of proving that he did not build or improve for purpose ofsale.).
L j L as owner of the property, am exclusively contracting with licensed
contractor to co ontrod the project (See. 7044, Business and Pro(emions Cods:
QTY, ;, PLUMBINC PERMIT FEE
PERMIT ISSUANCE '
FLOOD ZOA
APN
The Contractor's License law dm net apply to an owner of property who
Wilds or Improves thereon, and who contracts for such p(ojeds with a
cgylador(s) licensed pursuant to the Contractor's Llanae Law.
LI I am exempt under Sec. B & P C for this aeon
--
ALTER -DRAIN &VENTWATER (FA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y_ N_
RECFLT' a '
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificate of consent to self -insure, or a
artificete ofWorkeri ns
Compeztloolmorance ora certified copythereof(See.
3800,, Lab CJ
Policy If -
FIXTURES. PER TRAP
SCHOOL TAX RECFL NN
CAS EA. SYSTEM -1 INGd OUTLETS
PARK FEE Y N
RECEIPT 0
-
VER 4 A)
CAS EA. SYSTEM -OVER (E
Com any
BUILDING DIVISION FEES
❑pC fied copy is hereby furnished.
ertlfled copy t filed with the city inspection division,
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECKFEE
GREASETRAP
CERTIFICATE OF EXEMPTION FROM WORK ERS'
PAID
SEWER -SANITARY -STORM EA.2WFf.
COMPENSATION INSURANCE
(Ehlssectlon need nor becompleted lithe permit t froom hundred dollars
Date Recei [#
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N
(E1 rfiem.)
mless.at he performance of lhewwkforwMch this permit is tinned,
Im
I shall not employ any person in any manner so an to become subject to the
Worken'Compensation Lawsuf Calfomt. Date
WATER SYSIFM/TREATING
PAID
ApplicaNUTICnt
k
NOTICEco MPLIct
Coon
Date Remi t#
NEW RESIDENTIAL PLMB. SQ.FT.
TOTAL:
orkem'fter
to ompeng
should become subject to the Workers' Compensation n provisions of the Labor
provisionsof the Labor
Coda You over (orthwlth comply wish such provtbns or this permit shall be
deemed revoked.
B
a
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
lhembyafflrm that then is a construction lending agency for the perform-
once of work for which this permit is issued (Sec. 3097, Civ. C.)
Iandee. Name
Lenders Address
I mrtify that l have read thtapplicationand Matethat (heaboveinformation
t correct. I agree to complywlth all city and countywdinances and state laws
TOTAL,
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMITISSUANCE
FEES PAID
,
relating tobuilding construction, and hereby authorise representatives oftht
city to enterupon the above-mentioned property for inspection purposes.
(We) agree to give, Indemnify an d keep harmless the City of Cupertino
against liabilities, judgment, costs and expenses which may In any wayacerue
ALTER OR ADD TO MECH.
Date ReCef t#
,Opti HANDLING UNIT ((O 10,000 CFM)
SUBTOTAL:
agalnstgild Cljoflhmpemnit.
�b
AIR HANDLING UNIT (OVER 1o,000CFM)
CONSTRUCTION TAX
Sig—nature of ApAppllcant/Contractor ate
EXHAUSTHOOD(W/DUC'D
CONSTRUCTION TAX PAID:
HAZARDOUS MATER DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Will the applicant or future building occupant store or hand le hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1Z and the
Health and Safety Coda Section 75531007
❑ Yn ,L+.�, No
Date Recei t#
HEATING UNIT (OVER I00,OOD BTU)
TOTAL:
VENTILATION FAN (SINGLE RF9D)
ISSUANCE DATE
Will theapplkint or future Wilding occupant use equipment ordevicos
which emit hazardous air contaMants as defined by the Bay Arca Air
Iity Management District?
L�� Yes ❑No
Ihave read the hazardous materials requirement under Chapter6.95 of
AI
PAID
/��/�
BOILER -COMP OHPOR 100,000 BTU)
BORER-COMP(OVER 100,000 BTU)
-
the California Health & Safety Code, Sections 15505,75533 and 15534. I
1. ;a1
NEW RESIDENTIAL MECH. SQ.Fr.
undentandthat Lithe building does not currently have a tenant, that it lsmy
responsibility to ndltythe occupant of the requirements which most be met
prior to Issuance of a Certificate ofOccepanry.
- City of I;IIDP.It1Uf1
ISSUEDBY: '�Vl—�` -
Owner or authorized agent Data
TOTAL:NJ
OFFICE COPY