23124APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Heading Protect Identification
Building Address:
PERMITNO.
23124
ams: one:
S—T—CL.CITY
C I d ' Nam I T La. N.:
OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDINGELECTRICAL-PLUMBING-MECHANICAL
Z.:
CATEGORY
CONTROL#
Archited/Engineer. Lic. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Adtlreae:
❑
❑ ❑
PERMITISSUANCE ,rQ%
LICENSED CONTRACTOR'S DECLARATION
thereby
sfflmnthatlamlicensed lunder p onsoC9(m,mmmc-
i70alo3oftheguMnand ProfessionsCodeandmy
I...isl.fu rcearnd
loan On ic,#
are Contractor I
ARCHITECTS DECLARATI �N/
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION N
����
PANELS
x e
2014000AMPS
OVER1000AMP5
Q,Q7�tEA'
{{E_� D
I,,/[
# V p
/
G�
00. FT.
I understand my plana shall be used as public records.
Limned Prolemloml
mhatOWNER-HOLDER DECLARATION
Thereby af0rtmexempt from the Contractor's License Law for the
following mases.(Section7031S, Businessand Professions Code: My city or
countywhich requires a permittoconstru, alter, Improve, derrnkh
ci i, orrepair
any structure prior to Its Issuance, also requires the applicant forsuch permit to
file a signed statement that he Is licensed pursuant to the provisions of the
SIGNS ELECTRICAL
SPECIALCIRCUIT/MISC
.
?EMPMETER OR POLE INST.
POWER DEVICES DAT
SWIMMING POOL ELECTRIC
Contractor's License Law (Chapter 9 (commencing with Section 7000) of Dlvi-
slon3 ofthe Buslnessand ProfsssloneCode)mthat he is exempt therefromand
VALUATION
the bask for the alleged exemption. Any violation of Section 70115 by any
applicant for a permit subjects the applicant to a civil penalty of not more /ha
OUILETSSWITCHES-FIXTURFS
five hundred dollars ($.SOB).
M 1, as owner of the property, or my employees with wages as their sok
NEW RESIDENTIAL ELECTR SQ'FT'
STORIES
TYPE CONSTRUCTION
compensatloN will do the work and the structure is not Intended or offered for
sale (Sec. 7044 Business and Prof.lons Code: The Contractor. License Law
-
TOTAL: e
doesnetapplytoan owner of property who Wilde or Improves thereon, and
who domsuch work himself oethrough his own employees, provided that such
Improvements are not intended oroffered for sale. If, however, the buildings
OCC. GROUP
RES UNITS
improvement ksold within oneyearofcompletion,the owner -builder will have
(burden of proving that hedld net Wild or improve for purpose of sale.).
LJ I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec 7014 Business and Profession. Code:
QTY. PLUMBING PERMIT FEE
FLOOD ZONE
APN
PERMIT ISSUANCE
The Contractor's License Law dce. net apply to an owner of property who
Wilda or improves thereon, and who contracts for such Ink ject. with a
gt�[actor(a) licensed Pursuant to the Contrus.e. License Law.
LII am exempt under Sec. B & P C for this reasonOUTSIDE
ALTER -DRAIN & VEM-WATER (EA)
FEF. SUMMARY
BACK FLOW PROTECT. DEVICE
FEES
DRAINS FLOOR RODE, AREA, COND.
SANITARY Y— N—
RECEIPT #
Owner_ Data
WORKMAN COMPENSATION DECLARATION
1 hereby affirm that I have • certificate of consent to self -Insure, or a
certificate ofWorkers' Compensation Insurance or a certified copy thereof (Sec.
38W lab C/)��
!BO Q s/�!/!.
FIXTURES, PER TRAP
SCliCOL TAX Y— N-
RECEIPT p
GAS EA. SYSTEM4 INCA OUTLETS
PARKFEE Y N —
RECEIPT #
P.I;y p_&VC ^113
Cam ansa C/i. leALT�
GAS EA. SYSTEM-OVER4(EA)
BUILDING DIVISION FE ES
�C d copy Is hereby furnished.
erti(led copy is filed with the city Inspection division.
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
CREASE TRAP
CERTIFICATE OF EREMPFION FROM WOR K ERS'
PAID
SEWER-gAMT,U2Y-MRM pA.71bF1'
COMPENSATION INSURANCE
(Thisseuian need not be completed If the permB tsforona hundred dollars
Date Recef [#
WATER HFATERW/VENT/ELECTR
ENERGY FEE Y_ N—
($100) or
I certifylfythat in the performance o(Ihework (orwMch this permit is Wued,
WATER SYSTEM/TREATING
I shall not employ say person In any manner m as to become subject to the
Workers'Compensation Laws of California. Date
PAID
NEW RESIDENTIAL PLMB._SQFT.
Applicant
Applicant
NOTICE TO MPLIGNT:If,cher making this Certificate o(Eaemptlon, you
should become subject to the Workers' Compamatlon provisions of the LaWr
Date Recei t#
TOTAL:
BUILDING FEE
Code, you mu at forthwith comply with such provisions., thin pemmishall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I hereby afflmnth.t there Is a construction lending agency forthe perform-
ance of the work for which this permit is Issued (Sec. 3097, Civ. C.)
Tender. N.
Lender.Address
I cedifythatl have read thkapplkattonand slatethattheaWve Infomutlon
Is cormct l agree to complywith all cityand county ordinances and nate law.
TOTAL:
ELEC'T'RIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAIL-.
relating to building construdion, and hereby authorize representatives of this
city to enter upon the above-mentionad property for Inspection purposes.
(We) agree to save, Indemnify and keep harmless the City of Cupertino
againrtllabiRtiegjd gments'ecau-ndex eraseswhl maylnanyway...
ALTFRORADD'IUMECH.
Date Receipt#
AIR HANDLING UNIT (TO 10,=CFM)
SUBTOTAL:
IW
against city, con.equen oflhe ydm sPermit'
B
AIR HANDLING [IMT (OVER 10,000CFM)
CONSTRUCTION TAX
Ignsere of Applimst/ra6mictor ate
IXTtAUSTflOOD(W/DICT)
CONSTRUCTION TAX PAID:
HAZKRDOUS MATERIALS DISCLOSURE
Will the applicant orfuNre building occupantstore or handle havardous
HEATING UNIT (TO 100,000 BTU)
Date Recei t#
material as defined by the Cupertino Municipal Cade, Chapter 9.17, and the
fk.Ithand Safety Code Sectm.255320)7
Fly. No
Will the applicant ar lure building occupant use equipment or devices
}SEATING UNIT (OVER 100,000 BTU)
TOTAL:
f
VENTILATION FAN(SINGLE READ)
ISPJ N�f:,pATE
which emit havardous air contaminants as defined by the Bay Area Air
Quality Management District?
No
�.l (J
BOILER -COMP OFIPOR 100,000 BTU)
BOILER -COMP (OVER 100,000 BTU)
4Yea❑❑
have read the beaardous materials requirements underChapter 6.95 of
the Califomla Health & Safety Code, Sections 25505, 75533 and 25534. 1
understand that if the building does not currently have a tenant, that it is my
DEC 18 1991
NEW RESIDENTIAL MECH. SQFT
responsibility to sully the occupant of the requirements which mu at be met
prior to issuance of a Certificate of Omrpanry.
'CiIY uF'CUPEH I INU
ISSUED VVV--- BYI` VC r
-
Owner or authorlmd agent Data
OFFICE COPY