21103APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY I „Y -?
BuildingProject Identification L,
Building Addrem: I " e
'�.o `Fa,r Vo /awTe ice- V
PERMIT NO. 10
21103
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mAa-mf -31
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
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BUfLDINGELECTRICAIPLUMBING-MFLHAMCAL
CATDGORY
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CORM OL#
Anpeen -Lk. yorc :
QTy ELECTRICPERMIT FEE
PERMITBUILDING INFO
Addm
uJ
PERMITISSUANCE
LICF.NS F,D CONTRACTOR'S DECLARATION
Thereby affirmthat l am licensed under provisions of Chapter9(commeno-
i.gwlthSedlon7000)of Dlvislon3oftheO..i.,a PrcfesslonsCode, and my
Iimnse l-.(ul- .odLdfeR---J�;
I.Icen V LIc.M
APPIJANCESRF.SIDENI7AL
JOB DFSCRIP170N
T-f� 1
�r'V Ii.I`
PANES
Date ..tractor_
201-1000 AMPS
ARCHITECT'S DECLARATION
I understand my pla..hall be used an public records.
OVER IOW AMPS
SQ. FT. FEDOR AREA
S/SQ. FT.
Licensed Professional
a�#
VV
SIGNS ELECTRICALq-6183
SPECLILCIRCUIT/MISC'
OWNEReBUILDER DECLARATION
that Is. n7exemptfrom the Contractors LicenCodese Law fort he
1wing reason.
follow).greman.(Sedip"ttomm031.5, tmmand Pimp e, e=ltshnycity or
countywhkh requlresa periNt tocomtmct, altep Improve, demolish, .,repair
mpair
b
TEMP. ME= OR POLE INST.
anystrudure prlorlo Its Issuance, also requlrestheappliant forsuch permit to
file a signed statement that he is hurled pursuant to the provisions of the
Contractor's License Gw(Chapter 9(commeacing with Section 7000) of Dlvl-
don3 ofthe Buslar mond profemloru Code).,that he is exempt therem
froand
POWER DEVICES
SWIMMING POOL ELECTRIC
LU
the basis for the alleged exemption. Any violation .f Sectio. 7031.5 by any
appgont fora permit mbjeds the applicant to a dull penalty of nat nitre than
Ove hundred dollars (5040).
MI, as owner of the property, or my employees with wages as their sole
OUTLETSSWITCIIESFIXTURE4
♦.+ib'y"'r3
NEW RESIDENTIAL ELECTR SQ.FT.
STORIES
TYPE CONSTRUCTION
compensation, will d o the work, and the structure is not Intended or offered for
m1. (Sec. 7044, Rudnem end Professions Code: The Contractors Liceme Law
F
does not apply to an owner a property who Wilda or Improves thereon.and
does such work hlmew
elforthrgh his own employees, provided that such
OCC, GROIN
Rh5. UNITS
Improvements are not Intended oraffered for sale. If, however, the building or
imro
pvement iseoW wilhln.ne)carafcompldlory theawner-WRderwill have
th5kurden of proving that hedid notbuildorimproveforpurpoaeofmk.).
Lf I, as owner of the property, am exclusively contracting with IlrensM
contractors to construct the project (Sec. 7044, Business and Professions Code:
The Contractors License Law does rad apply to an owner of property who
Wilds or improves thereon, and who contracts for such pkojeds with e
at5actor(s) Ileensed pursuant to the Contractor's License Law.
LJ I am exempt under Sec B & P C for this reason
TOTAL: l
CITY. PLUMBING PERMIT FEE
PERMRISSUANCE
ALTER -DRAIN &VENT -WATER (EA)
FT.00D ZDNE
APN
FEE SUMMARY
BAER FLOW PROTECT. DEVICE
QIJTqlDEFrUS
DRAINS ROOK ROOF, AREA, COND.
SANITARY Y— N
COPT #
Owner Dat.
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a cvrtlfiate of consent to
p))[gPER TRAP
SCHOOLTAX Y N
self -Inure, ora
cenifiateo(Wurkers'CompemattonlmumnmoraaenlfWcopythemof(S.c.
3800,1.6CJ
RECEIPT #
GAS, FA. SYSTEM -1
PARK FIX Y_ N
Pol try #
RECEIPT M
Com an Y
GAS PA. SYSTEM -OVER 4 (EA)
BUILDING DIVISION PEGS
Certified copy is hereby filed
�CertQied copy is filed xvllh the city Inspection division.
the city
CREASE/INDUSIRL WASTE INTERCEPTOR
P FEE
CREASE TRAP
CERTIFICATE OF MEMPHON FROM WORKERS'
COMPENSATION INSURANCE
(This section need nu he completed if the permit is for one hundred dollars
(SlWer less.) in
Ill notfily thatoy an person in nce the workmunner for whkbcomeemNtic Iso ed,the
1 shall not employ any Uwe In any manner sat m to become subject to 1M
Workers Compensation Ewa of California. Date
Applicant
NOTICE TO APPLICANT: If, after nuking this Certificate of Exemption, youSFT•
should Wcome subject to the Workers' Compemzt ton provisions of the Labor
Code, you must forthwith comply with such provisions or this permit shall bex
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hercbyalRrmthat them Isamnsmuctlon lending agency (orthe perform.
ance of the work for which this perm it is issued (Sec. 3097, Clv. C.)
PAID
SEWER-SAND'ARYSTORM EA 200FT
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N —
PAID
DRIB RCcel (#
WATER SYSTIMITREATING
RESIDENTIAL
L:
A r
SETS
'�
PDrA
TOTAL:
I<ndcrb Name
Iendce.Addmns
I certlly that I have read this appBalkn and state that the above Informatlan
Escorted.I agreeto comply with all city and county ordinances and state law.
relating to building construction, and hereby authorize representatives of this city to enter upon the abovearentloned property far Wpedlon purposes,
agree tosave, Indemnify an d p baroness the City Of Cupertinoagaimthabgltks,jod rat,AIR
ul t neeque rant' • t.(IOOZAt
MIT FEE
PERMITISSUANCE 1-2xCO
ALTFRORADDTOMECH.(We)
f 0
Mr7KF0T.<Lr-k7R';-
HANDLING UNIT(TO IO,ODOCFM)agalmt
r
AIR HANDLING UNIT (OVER I O,CIM)
C RUCTION TAX I
a reo(Appllonto or ate
IXHAUSTIIOOD(W/DUCT)
CONSTRUCT AID:
rR
A DOUS MATERIALSDISCLOS E
ant or future building occupant Store or handle hazardous
WilltheliMuN
matedalm eflmd by the Cupertino dpal Code, Chapter 9.12 and the
DRIB RCCDi f# a
HEATING UNIT (TO IW,WD BTU)
-
HEATING UNIT (OVER 1 WOOD BTU)
_
TOT
I lealth and Safely Coder. -S�ection 25532(a)7
RYes u No
VENTILATION FAN(SINGLE RESID)
�
APR 1 1991
ill the applicant orfuture W lld beg occupant use equipment or d evices
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management Distdd7
Vea❑
have read the haz[rt NNo materials requlrcmenh underChapter6.95 of
BOILER -COMP OHP OR I04,000 BTT))
BOILER-COMP(OVF]21WW B
,OTU)
)he California Health &.%fety Cade, Stolons 25505, 25533 and 25534. I
NEW RESIDENTIAL MECH. SQ.FT.
understand that if the building docs not cvmently have a tenant, that it is my
responsibility to notify the occupant of the requirement, which must be met
City of rl Dapt! -,t
s
prior to Lsuance of a Certificate of Ca=panry.
Owncrorauthorlud agent Date
TOTAL:
OFFICE COPY
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