23016APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project ldemlrlotlon
Building Aaarea,: sifts- J si
1 oldts, _ , rtolzA-0s
PERMIT NO.
n � O � C
G U
s ams: - one.
CITYOFCUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDINC-ELECTWCA4PLUMBING-MECI{AMCAL
cont, tnl.N""' Le. No:
E OPV�2Z366g
CATEGORY
CO
Archil /Enginser. Lk. No:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address:
PERM TISSUANCE
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby afftrmthat l am licensed under provisions of Chapter 9(ocmeamc
Ingwltn Sedlon7000)of Divi.1=3ofthe Businesand PmfesslonsCode,andmy
license is In full force and died.
APPUANCESSRESIDENTIAL
JOB DESCRIPTION
-
��
PANELS
LlcenseChs Lic.N
Data q-R2�- T -Contractor
ARCHITEC171 DECLARATF N
I understand my plana.hall be used n public records.
201-1(00AMPS
OVERIODOAMPS
SQ. Fr. FLOOR AREA
S/SQ. FT.
SIGNSELFGTRICAL
Licensed Professional
as
SPECIALCIRCRIT/MISC s
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor'. License Law forthe
TEMP. METER OR POLE INS,.
following reason. (Section 7031.5, Business and Professions Code: Any city or
cmntywhichmqubnapem ttocomimMalter,Improve,de=4sh,ormpair
anystmmmpdortolmiswance,alsorequimtheappRcanlforsuchperMtto
file a signed statement that he is licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9(commencing with Section 7000) of Divi-
rro(embn. Any donationhat f exempt therefrom and
the buds
the baan. for the alleged exemption. My violation cine tion nor 1.5 by any
applicant for a permit subjects theapplkmt to a dull penalty of rat more than
POWER DEVICES
SW%MNG POOL ELECfRI
OU77.E
VALUATION
WITt R
flue hundred dollars (5500).
❑ I, as owner of the property, or my employees with wages as their sok
RIES
TYPE CONSTRUCTION
compensation, will do the work and the structure V not intended or offered for
.1.&c.7044, Buslnn. and Professions Code: The Contractors License Law
does not apply to an owner of property who builds or improves thereon, and
whodoessuchworkhimselforthrough hisownemployees, provided that such
DATE
OCG GROIIIs
RES, UNITS
improvements are not intended muttered for sale. If, however, the building or
TOTAL:
Improvement bsold withinomyearofcompIdioNtheowner-bullderwill have
t"Men of proving that he did am build or improve for purpose ofsals.).
L1 L as owner of the property, am exclusively =trading with licensed
contractors to mru4ud the project (Sm. 7066, Bushes and Profenlow Code:
QTY. PLUMBING PERMIT FEE
FT -ODD ZONE
APN
O PERMIT ISSUANCE
The Contractors License Law don nal apply to an owner of property who
Wilds or Improves thereon, and who contracts for such pbojects with a
cg01(ador(s)Brengel pursuant to the ContradoYS License Law.
LI I am exempt under See. B & P C for this reason
ALTER -DRAIN & VENT- WATER (EA)
FEE SUMMARY
BAIX FLOW PROTECT. DEVICE
OUTSIDE FEES
DRAINS FLOOR, ROOF, AREA, COND.
SANITARY Y N
RECE97 s
Owner Date
WOR KHAN COMPENSATION DECLARATION
❑I hereby affirm that 1 have a certificate of consent to self -Insure, or
certlBeateof Workers'Compersolm, lruunncemacertlfled copy tbemcf(Sec'
polis Lab C.)
Policy p
FIXTURES PER TRAP
SCHOOLTAX Y N
RECEIPT M
GAS EA.SYSTEM-1 INCA OUTLETS
PARK FEE Y N
RECEIPT M
GAS. EA. SYS -EM -OVER d (EA)
Com ray
BUILDING DTVI TS
�CertBled copy b herebyfamished.the city
❑certlnea ropy b filed with me city inspection amwms.
CREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
nv
GRPASETRM
CERTIFICATE OF EXIMPTION FROM WORKERS'
PA
��,
COMPENSATION INSURANCE
(Thlssetion need net be completed tithe permit h forone hundred dollars
R CCI t#
SEWER -SANITARY STORM EA iWFI'
WATER I-IEATFR W/VIM/ELECTR
EN Y E Y I
($100).Hos.)
I certifythat in the performance of the work forwhich this permit is issued,
WATER SYSTEM/TREATIM,
I shall not employ any person In any manner in as to become wbjed to the
Workers' Compensation Laws of California. Date
PAID
NEW RESIDENTIAL PLMB. SQ.Fr.
Applicant
Date Reoei t#
NOTICE TO APPLICANT: If, site, making this Certificate of Exemption, you
should become subject to the Workers' Compewtlon provisions of the Labor
TOT
Code, Jou crust forthwith comply with such provlsloa or this pemNt shall be
13UILDING FEE
deemed revoked.
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby atfirmthat there is a coawction lending agency(cribs perform
ance of the work for which this permit V Issued (Sec. 31197, Civ. CJ
L.ender'.N.me
Lender. Add..
I certify that I have read this appileathm an, atate that the above information
Lscorrod. l agree to complywith all city and county ordinance and state laws
TOTAL:
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMITISSUANCE
FEES PAID:
relating to building coatmdrren and hereby authorise cep tioenpurpos o(th
city Wenter purpose.
propertyfeeharming
eeupon to ave,he indemnify and City
the City of Cupertino
(We) agree to judgments,
indemnify and keep es which
against expenses which nuyln any wayacc,ue
nco..nb,co
Date Reeipflt
O ALT[R OA ADD TO MECH.
.� AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
sabllitln,
against said Clty In coneryuence o! the granting of this permit.
of the
AIR HANDLING UNIT (OVFx 1B,EBBCFM)
CONSTRUCTION TAX'
Slgruwre of Applicant /Contractor Date
_ EmAUST HOOD (W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
-
Will the applicant or future building occupant store or hand le hanrdous
material as defined by the Cupertino Municipal Code, Chapter 9.1$ and the
I{calth and Safety Code Section 25532(a)?
❑ Yes_ No
Date RCeel t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
Wllltheappliant or ture building occupant use equiprrent or devices
which emit hazardous air contamW rats as defined by the Bay Area Air
Quality Management District?
Yrs No
have read the ha. ous materials requirements u oder Chapter 6.95 of
PAID
BOILER -COMP OFIP OR 100,000 BTU)
BOILER-COMP(OVER 100,000 BTU)
the Cailfornla I Inalth & Safety Code, Sections 25505,25533 and 25534. I
understand that lithe building does not currently have a tenant, that it b my
DEC 23 1991
NEW RESIDENTIAL MECH. SQ.Fr.
.possibility to ratify the odvpant of the requirements which it be mot
prior to lssuanm of a Certificate of Occupancy.
CI I r ser Cdt'en I uvv R
f'
ISSUEDBY: I ULL'
—
Owner or authorised agent Date
TOTAL:
OFFICE COPY