24168APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
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Bulidsang Addna: 9 W `1 Va
PEItWTN 4168
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
BUILDING.ELECTRICAI.PLUMBINGMECHANICAL
? s
�i3 — C �'
Contractors Nama: Lie. No:
CATEGORY CONTROL
ArchltM Englmer. Llc. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
- Address
PERMITISSUANCE �O
'mil 1:1❑
�f
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under previsions of Chapter9(commen
Ingwith Sedlon 700Wof Dtvtslon3ofthe Buslnessand Prvfesslons Code, and my
It... iCla full force and effect.
Le.. Cs
lcenx m LILY
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records.
Lkenxd Professional
OWNER -BUILDER DECLARATION
I herebyafBrm that I am exempt from the Contractor's License Law for the
following reason. (Sc Mon 70I1S, Business and Profavions Code: Any city or
county which requlresa permit toconsm
truct, alter, Improve, deolish,orrepair
any structure prior to Its Issuance, also requires the applicant for such permit to
file a signed statement that he Is licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9(commendng with Section 7000) of Divi-
sion3 ofthe BuAnessand Professions Cade) orthat he s exempt lherefromand
the basis for the alleged exemption. Any violation of Section 70315 by any
applicant lots permit subjects theapplicamloa civil penalty of not morethan
4flue ndred dollars (8500).
, as owner of the pmperty, or my employees with wages as their sale
compensation, wllldothe work end thertructure is not intended or offered for
sale (Sec. 7014, Business and Professions Code: The Contractors License Law
does not apply to an owner of property who builds or improves thereon, and
who does such work himself orthroogh his own employee% provided that such
Improvements are not Intended or offered for sale. If, however, the building or
Improvement hsold within oneyearofcarnpletion,the owner-bullderwill have
thA*rden of proving that he did not build or improve for purpose ofsale.).
-;dip-LJ I, as mune, of the Property, am exclusively contracting with licensed
contrarian to construct the Project (Sec. 7054, Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who
WIWI or Improve thermM and who contracts for each ptujeris with a
adoralliansedpunuant to the Contradm'e License Law.
I am exempt under Sec 0 A P C for s
Owner Date As
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
(Y 6
PANS
UP TO 200 AM
201-1000 AMPS
OVERIOOOAMPS
SQ. FT. FLOOR AREA
$/SQ. FT.
SIGNS ELECTRICAL
SPECIAL CRCUIT/MLSC
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUILETSSWITCHr1,FIXHJRES a
VALUATION
j�
/O O 0
J 9
NEW RESIDENTIAL ELECTR FT.
SQ
STORIES
7YIPE CONSIiRIX:770N
TOTAL:
QTy, PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER -DRAW kVENT- WATER (EA) n
OCC GROUP
RES. UMTS
FL.00DZONE
-
- � •-
!,FEE Un�I ,� Y
BACK FLOW PROTECT. DEVICE
SANITARIYJ�FRT� 1 I
I
DRAINS FLOOR, ROOT, ARCA, GOND. ,^ I
WORKMAN COMPENSATION DECLARATION
❑1 hereby affirm that I have a certificate of consent to self -Inure, ora
unifimteofWorkers'Compensationlraunnmoramrtifledcopythee f(Sec.
3800, lab C.)
Polley Y
FIXTURES. PER TRAP
R —
GAS EA. SYSTEM-11NCA OUTLETS
PARK PLR .Y. _N —..,.
RECEIPT M
GAS EA. SYSTEM -OVER 4 (PA)
Cam any
BUILDING DIVISION FEES
d.
Certified copy s hereby tumle ty
Certified ropy s filed with the cidty inspection division.
CERTIRCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Rhos Im.) ed net W completed lflhe permit s!Prone hundred dollars
(9100)or rtifyt.)
' Imdi(ytha[In the performance of the work forwhlch this permit le slued,
I shall not employ any person In any Panner se an to become subject to the
Wmico'Compeneatronlawsof Catifomla. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subFct to the Workers' Comperuation provisions of the Labor
Code, you mart forthwith comply with Such provisions orths permit shall be
deemed revoked,
CONSTRUCTION LENDING AGENCY
Hurebyaffirm that there III construction lending agency for the perform
anmPfthe work for which this Permit s (9e
Issued
lenders Name
Lendce.Add.
I certllythatl have madthsappUmtlonand statethat theaboveinformatlon
scorml. l agree to comply with all chyand county ordinances and orate laws
relating -to building cotatroction, and hereby authorize representatives of the
city to edter upon the AWve-mentioned property for inspection purpose.
(We) agree to save, Indemnify an d keep harndess the City of C.pedtno
against iktlee, jadgmenn,roxsand expenses which rtay In anywayaceme
out '4d City In ro...q. thegamingofthispenult.
d 'S1
p 6' l
GREASE/WDUSTRL WASTE INTERCFPTOR
PLANCHECK FEE
PAID
Date Recei fit#
GREISETRAP
SEWER -SANITARY -STORM EA 200FT
WATERHEATIRIN/VENT/ELECTR
ENERGYFEE Y N —
PAID
Date Recei t#
WATERSYSTEM/,TREATING
NEW REEDP.M'IAL PLM B. FT.
-
TOTAL:
BUILDING FEE
SEISMIC FEE
Yrp
TOTAL:
ELECTRIC F E
IT—74-7
QTY. MECHANICAL PERMIT FEE
PLUMBINGFEE
MECHANICAL FEE
41_
PERMRISSUANCE
FEES PAID:
e
ALTER OR ADDTD MECH.
Date Recei t#
AIR HANDLING UNIT 10,000 CFM)
SUBTOTAL:
AIR HANDLING UNIT(OVER 10,IX70 CFM)
CONSTRUCTION TAX
Sigmtumof Applicant/Conusdor Date
HAZARDOUS MATERIALS DISCLOSURE
Willtheapplicant or future building occupaN Ammer handle hanrdous
material as defined by the Cu rtino Municipal Code, Cha ler 9.t
y pep 2 and the
Health and Safety Cade Section 25532(.)7
� Yea � No
Rill
I ernh haprd usa ont.mwm urm.ding cupmtux equipment ayArea devices
which eMt ha omn.t Dbt,ftnlaminanl5 as defined by the lay Area Air
Quality Mavgement Dlst No
' Ye 4No
'CAliforead Healthe h aChapter.x95of
ar Pusmaterialsod,Se ions 25505,25533
the ersto rms Health k Safety Code, Sections 75005, have a tenant, and 2that I I
understand that nutty the the ing doesoc upon nm mmquir menshichthat It Is
,nor to bility isuato notifytheoate,of of the .parequlrcmentawhich must be met
prior to ssuanre ofaCertiflcale ofOuvpanry.
EYF IAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,000 BTU)
Date Recei t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VFNULATION PAN (SINGLE RFSID)
I$$UAN�G}j DATE
1+
AUG 31 1992
CI'II La'i"yIpITTYCPIHYU
ISSUED BY:]��'1
BOILER -COMP OFNOR 100,0(10 BTU)
BOILER-COMP(OVER 100,000BiV)
NEW RESIDENTIAL MECH. SQ.Ff
Owner or authurired agent Date
TOTAL:
V
OFFICE COPY