23511APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building ProjectIdentification
Building.'Addme.s: �'� ✓ z1
6+�erB
PFR.WTNO.
- 23511
dme: One:
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CITY OF CUPERTINO6BUILDING DIVISION
APPLICATION / PERMIT
BUILDING -ELECTRICAL -MU INGMECHAtICAL
Cantactut.Name: Lie. No:
6nn(5_115
•rchited/Gglmer.
CATEGORY
CONTROLN
Lie. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:
❑ ❑ (A ❑
LTJ
PERMITISSUANCE
LICENSED hemsed CONTRACTOR'S
rpr DECLARATION
I hereby affirm that lam licensed under provisions of Chapter9 (comment.
In8w1thsMion7000)of Dlvlslon3ofthe Bustmssand Pmfe imsCode, and my
Ilceme le In fuB f and d(M. �q
Date CHITS ar L ��-
Date m Lk.M_iCbp�l7]� °[a i
ARCHITECPSDECLARATION
[ understand my pkv shell be used as public remrdw
Licensed Profealonsl - -
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
followingmmm.Occtfan7011S, Businessand Profession Code: Anydtyor
county which requlresa permit tommtmd, alter, improve, de=Ush,orrepalr
anystm mprlartotalsoame,alsorequrstheappHcantforauchpermitto
Ole a algned easement that he k licensed pumuant to the provisions of the
Contractor's License Law (Chapter 9(mmmencing with Section 7000) of Divi.
duel ofthe Business and Profenlons Code) orthat he k exempt therefromand
the bask for the alleged exempt Ion. Any violation of Section 701L5 by any
applicant fora permit subjeda the applicant to a civil penalty of nat more than
flue hundred
m, dollars (SSM. W).
❑ e as owmr of the property, or my employees is with wages r offered
mm(5eR,7 Kw01Bothe work, and Ne,Codereh not Intended or o!.L(or
edoes ase (Sec, apply to -trandan ow er f pmpeImfiessty Cuda: The C impeovra Limen Law
apply torn unser ofprough hison ilds empoyes,proided thtand such
who does
whodoes ntsaornhi tededoroffahlsowna.1f,h es,providedildingor
ImprovementiYsold intended oro.f,o pletk .IL howevenlflderwdingor
Improvement iseold withinoneycno(compleibrytheowneo-W Hderwill have
tli,"urden of proving that he did net build or impmvo for purpose ofsakJ.
u L as owner of the property, am exclusively =trading with licensed
camnx n to construct the proper (Sec. 70K Business and Professions Code:
The Contndorf License Law does not apply to an owner of property who
Wilds or Improves thereon, and who centrads for such pRojem with a
e75Ydor(s)licensed pursuant to the Contractor's LI... Law.
ec.
L� I am exempt under SB & P C for this mason
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
"
PAN12.S
UP TO 200 AMPS
"' 00 AMP
OVER
OVER 1000 AMPS
SQ. FT. FLOOR AREA
I T
f/SQ. FT.
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC
TEMP. METER OR POLE INST.
pOWp((DEV[CES r
57yQ,(MING,: L, C
OUTLETSSWITCHESFI
VALUATION
TYPECONSIRUCTION
NEW RESIDENTIAL ELECTR FT.
TOTAL:
QTy.PLUMBING PERMIT FEE
PERMIT ISSUANCE
OCC.GROUP
RFS UNITS
FLOOD ZONE
APN
,
ALTER -DRAIN &VENT -WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
FIXTlIRFS PER TRAP
SANITARY Y_ N_
RECEEPT N
Owner Date
WORIONANCOMPENSATIONDECLARATION
❑I hereby affirm that 1 have a certificate of consent to self -insure, ora
3800,Labcertificate C. Worken'Compensatlonlnsurance oracertlfled copy thereof (Sec.
3800, Lab C.)
policy p
SCI;OOL TAX Y_ N
AECITT'T N
GAS EA. SYSTEM.I INCA OUTLETS �"
PARK FEE Y N
RECEPT
CAS FA. SYSTEM -OVER 7 (EA)
Com any
BUILDING DIVISI ON FE ES
Certified copy 0 hereby filed
Certified copy is filed wllh the city Inspection divides.
the city
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thlssedlon need not be completed lithe permit is for om hundred dollars
(8100)arlea.)
(certify that In Chep ormance o(the work ion ch ehla pemmlt is butted,
I.haH not employ an non i ny manner. o bepome eub{ect to the
Worken'Compem law GHforYt at 2
Applicant
GREASEANDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date Recel IM
GRE'A'SE TRAP
SEWER -SANITARY -STORM FA.700Pf.
WATER HEATER W/VENT./C.ECTR
ENERGY FEE Y N
PAID
Date Remi tN
WATERSYS17EM/TRFA.DNG
NEW RESIDENTIAL PLMB. SOFT.
Exemption, you
TICE TO :.W.dmakin t provisions
ahwld becomes caths Worken'Co on provisions olths Labor
Code, you must forthwith comply with su peuvisiomuorthkpermlbhallbe
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hembyaf1.thatthere Baconstmdion landing agYntgfarthepednte,
anm of the work for which this permit is blued &R. 3097, Clv. CJ
Lander'. Name
LandereAddrea.
rtlfylhat l have read this applleationand dalethat theabove information
I mma
is correct l agreeto comply with all city and countyordlnances and date laws
relating to building construction, and hereby authoda repre.natives, .(this
city to enter upon the above-mentiodd property for bupedfon purposes.
(We) agree to save, indemnlly an d keep harmless the City of Cu pemtim
again if. m,jud nts,.O.a.dem enseswhich.yi.anyway.c a
againsts ityln sequenceo(th ra nti20f this permit.
Sig of plicant/Contr Date
HAlARD US TERIALS DISCLOSURE
oa..Bunt or future wilding. pant atom or handle hanardou.
material as deflmd by the Cupertino MuNdpal Cade, Chapter 9.17, and the
I;ealth and Safety Cade Sedlon 2M32(a)?
❑ Yes r] Na
Will the applicant orfumre bullding omvpart an equipment or device.
which emit h..rdous air contamlana a, defined by the Bay Area Air
Quality Management District?
4Ye8 4"°
have mad the haza sue materials requlremenbunder Chapter G95 of
the C.lifomla Health & Safety Cade, Sections 25505, 25533 and 25537. I
undentand that lithe the douches not a 1q.lyhavea tenant, that It Remy
and llbldthatndleb.MingdoesnetWnequlremcntswhichmuatbemet
Prior to Eauance of a Certificate of Occupancy.
-
TOTAL:
BUILDING FEE
�•
TOIN
SEISMIC FEE
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PERMIT ISSUANCE
PLUMBING FEE
�—
MECHANICAL FEE
FEES PAID:
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (T010,000 CFM)
Date Recei elf
SUBTOTAL:
AIR HANDLING UNIT(OVER 101000CIM)
CONSTRUCTION TAX
EXHAUSTHOOD (W/DICT)
CONSTRUCTION TAX PAID:
HEATING UMT(TO 100,000 BTS))
Date ReCei tis
HEATING UNIT (OVER 100,000 BWTOTA
�.
VENTILATION FAN (SINGLE RESID)
P)SgUAIRE DATE
APR 1 U 1992
CITY urGu YGF11111V "1
ISSUEDBY, 1
BOILFR-COMP OEIP OR 100,000 BTU)
ROLLER-GGMP(DVQt 100,000 BTL?)
NEW RESIDENTIAL MIiCH. SQ.FT
Owner or aulhorlud agent Data
TOTAL:
OFFICE COPY