23160APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pooled Identification
B"Bding Address:23160
PERMIT NO.
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nems one:-
APPLICIA TION A
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION /PERMIT
BUILDING -ELECTRICAL PLUMBING-MECFIANPCAL
I- (6'40jZ
C tadoi arae:1
A Ilea/Englrner. Uc. Na:
CATEGORY
CONTROL X
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
-
Addmcss:
❑ ❑ 1:1LICENSED
PERMIT ISSUANCE
CONTRACTOR'S DECLARATION
Ih:reby affirm that lam licensed under provisions o(Cha pter9 (commeac,
Ingwlth oflXvlelon3o(NeBuelanand l'rolesslonsCode, and my
license) B ddfect.
APPLIANCES -RESIDENTIAL
JOB DEECIUPTION
PANELS
Lice LIc.X
Dat Contractor
«
201-1000AMPS
HITECTS DECLARATION
I and tan myplansshallbeusedaspublicrecorelc
OVERIf100AMPS
SQ. FT. FLOOR AREA
E/SQ. FT.
SIGNSELECTRICAL
Limned Professional
SPECIALCIRCUIT/MISC
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contradorb License Law forth:
TEMP. MFOR POLE INST.
following renson,(Sedi.7011S,Bualnessand Professions Code: Anydtyor
rountywhi& requires a permit wmmtmd, alter,Improve, dennlleh, orrepalr
anystmmmprlorloibimance,alsorequlrestheappllantforsuchpmmitto
file a signed statement that he Is licensed pursuant to the provisions of the
POWER DEVICES
SWIMMING POOL ELECTW
Contractor's License I.A. (Chapter 9 (mnunencing with Section 7000) of Divi-
,on3 ofthe Bu elness and professions Code) orthat he le exempt therefromand
VALUATION
the basis for the alleged exemption. Any violation of Section 9031.5 by any
applicant fora permit subjects the applicant to Advil penalty M not .,other
OUfLETSSWITCHESFl
flue 1, as neroftheprdollars .
I, as owner of the property, or my employees with wages there sok
NEWRE51DENTIALELFIC SQFr.
STORIES
TYPECON5TRUCTION
compensation, will do r
and the stadureh not Intended or offered for
vie (Sec 7044, Business and Prv(easions Code: The Contractols Ucens: Law
Business And
does not apply to an owner of pmpery who Wilds or improves thereon, and
who does such work himself orthrough Msmen employees, provided that such
improvements are not lnorded oroffered forsale. IL however lhebuilding or
Improvement bsold within oneyearofcompl&bn, the owner-buRderwlll have
tl(S;Zurden of proving that he did not Wild or improve for purpose of sale.).
u Late owner of the property, am exclusively ountreding with Ilrensed
54,
contractors to construct the project (Sec. 90Business and Professions Cade:
AL:
QTY. PLUMBING PERMIT-'yFEE
OCC. GROUP
RES. UNITS
FLOOD ZONE
APN
PERMIT 1S5UANCE
The Contractor's License Paw don not apply to an owner of property who
Wilds or Improves thereon, and who contracts for such pi fens with a
t dar(s) licensed pursuant to the Contrador's License Law.
c LJ I am exempt under Sec. B & P C for this reason
,V.TFIZ-DRAIN &VENT- WATER (E,V
FEE SUMMARY
BACK FLOW PROTECTDEVICE
.
DRAINS FLOOR ROOF, AREA, GOND.
SANITARY Y N
RECEPr M
Avner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby of(= that I have a certificate of consent to self -Insure, or a
certificate ofWorken' Compensation lnsurancama certifkd copythereof(Sec,
3800, Lab C.)
FIXTURES- rFR TRAP
SCIdOOL TAX Y_ N_
RECEEPT «
GAS FA.SYSTEM-1 INCAOU1TLETS
PARKFRE Y N
RECEIPT
C. «
Cam any
GAS EA. SYSTEM -OVER 4MA)
BUILDING DIVISION FEES
ffc-difled copy Is hereby furnished.
L]Cerifled copy b filed with the city Inspection division.
GRLASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
COMPENSATION INSURANCE
(This section need net be completed If the permit 1s for one hundred dollars
Dale Recei t#
SEWER -SANITARY -STORM EA.2WFT.
WATER ITEATTR W/VENT/FLECTR
I,
ENERCYFEE Y N
(9100)arless.)
I certify that In the performance of the work for which this permit le issued,
WATER SYSTEM/TREATING
I shag not employ any person In any Wanner so as to become subject to the
Work:ri Compensation Laws of CalBornia. Date
PAID -
Applicant
NOTICE TO APPLICANT: U, making aking this Certificate of Exemption, you
Date Recei t#
NEW REnorxnwL PLMB. SQFr.
TOTAL:
should become subject to the Workers'Compensallon provisions of the Labor
Code, you =at forthwith comply with such provisions orthb permit shall be
deemed revoked.
BUILDING
-
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there b a construction lending agency for the Issued
and, of the work for which this permit is ued (Sec. 3097, CM C.)
Lenders Name
lender'.Addreca
1 red ify that I have read this application and nate that the above Information
laccumt. I agreeto comply with all city and county ordinances and nate lawsF9RMrr
TOTAL:
ELECTRIC FEB
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
a�
ISSUANCE
FEES PAID:
relatingtobulidingcua yahodze this mpme,.... esm
nstdlon,and herebm
city to enter upon the above-mentioned property for Wpection purposes.
(We) agree to save, indemnify an d keep harmless the City of Cupertino
A alnstliabillike, judgments, stsandexpe swhkh nuy In anywayaceme
LTFRORADDTOMECH.
Date Recei t#
AIR HANDLING UNIT CIO 10,000 CFM)
SUBTOTAL:
ago told CityIn conaequ M ng of this;:..
_
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
S azure of Applicant/Co r or Date ^
EXHAUST 11001) UC
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCI SURE
HEATING UNIT (TO 100,000 BTU)
Date RP.CfI l#
Will the appllant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.17, and the
hkallh and Safety Code Section 25537(a)I
RY. N No
HEATING UNIT (OVER 100,000 BTU)
TOTAL•
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
ill the applicant or future building occupant use equipment or devices
which emit hazardous air contaminants as defiad by the gay Area Air
Oualily Management District?
Yr No
�'
BOILER -COMP OHPOR 100,000 BTU)
BOILER-COMP(OVER 100,000 BTU)
have read the haza ous mstertab requirements under Chapter 6.95 of
the California Health & SafetyCode, Sections 25505, 75533 and 7:534. 1
understand that if the building does not currently have a tenant, that it is my
responsibility to notify the occupant of the requirements which must be met
prior to Issuance of a Ccrtifiate of Occupancy.
JAN Os 1992
NEW RESIDENTIAL MECH. - SQ.FL -
CIT -h 1(N�1
BY:
Owner or authorized agent DateISSUED
TOTAL -.;;
OFFICE COPY