23111APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Protect Identification
B°itding Address:
8 Z Lu I l �hsoti
PERMIT NO.
23111
Mrs ams: one.
Jercy 1znKkM0k1
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDINr—ME RICAL-PLUMBING-MECFIAMCAL
J �
C ntra sore: Myi �t,�( Le. No:
CATEGORY
CONTROL p
Architect/Engineer. Lic. Na
QTY ELECTRICPERMIT
FEE
BUILDING PERMITINFO
Addrcsc
❑ 1:1❑
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
Iherebyeffbm that l am Bernard under provisions of Chapter 9(commen
IngwllhSttt1on7000)of Dlvhlon3o(the Buelnmand PmfeaslonsC cJ,,and my
license is in to rce and effect. ' r�-- o �/
License Cia Lk.0 OZ �l 1 / (
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
OUT a i
a V 1
PANELS
Date Contractor
UP TO 2DO AK7S
701-IWO AMPS
ARCHITECT'S DECLARATION
I understand my plaossha0 bc re
be used as pubcords.
Licensed Professional
OWNER -BUILDER DECLARATION
Thereby afBrmtOWNE -BUIL ERRDE DECLARATION License law for the
following reason. (Section 7U 1.5, Business and Professions Code: Any dty or
county which requires a perto commucL alter, Improve, demolish, or repair
mit
OVER 1000 AMPS
�y
4SSQFT.7�fjy�FA I S/9D.FT.
H L 1{�� U
PUT ER
SIGNS ELECTRICAL
SPECIALCIRCUIT/MLSC -coM
TEMP METER OR POLE INST.
anystructure prbrto Its auuance,alan requlreethe applicant fonuch perrniuo
file a signed statement that he Is licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9(commenMg with Section 7000) of Diel-
sion3 ofthe Business and Professions Code) orthat he Is exempt therefromand
POWER DEVICES
VALDATION
SWIMMING POOL ELECTRIC
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant fora permit subjects the appleant to a dell penalty of one moreth m
OUTLETSSWITCHMFIX URFS
C
J
NEW RESIDENTIAL ELECTR �'�'
five hundred dollars ($SM.
❑ I, as owner of the property, or my employees with wages as their sole
STORIES
TYPE CONSIRIIC'I'ION
compensation, w0ldothe work and theshructure Is reat Intended or offered for
sale (Sce 7044, Business and lio(enlov Code: TM Contndofe Llarue law
does not apply to an owner of property who bullda or Improves thereon, and
who doesuch work himself orthrough his own employm, provided that such
OCCGROIIP
RES. UNITS
improvements are not intended oroffered forsale. It, however, lhebuildleg or
TOTAL:
Improvemen issoidwlthin omyearo(completion,theowner-bullderwlll have
thlZurden of provingthat he did scat build or improve for purpose ofsale.).
j_j I, as owner of the pmpetTy, am exclusively contacting with licensed
contractor, to creamer the project (Sec. 7044, Business and Professions Code:
QTY. PLUMBING PERMIT
FEE
FLOOD ZONE
APN
PERMITISSUANCE
s
The Contactor. License law does not apply to an owner of property who
Wllds or Improve thereon, and who contracts for such pipjects with •
coywaer. dorW licensed pursuant to the Contractor's License Law. v
Ll I am exempt under SB & P C for this reason
ALTER -DRAIN (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR, ROOF, AREA, COND.
FaTVREB'rER TRAP
SANITARY Y N
RECEIPT M
Owner Data
WORKMAN COMPENSATION DECLARATION
I hereby affirm that 1 have a certificate of consent to self -insure, or •
certiflate afWorkers'Compersatlonlwm(Sea
uranaora certified copytheo(
3800, lab C. _
Policy I, �(i �inAL]r 1.,
any
SCHOOLTAX Y N_
RISC T N
GAS EA. SYSTEM -1 INCAOLITLEPS
PARK FEE Y N
N
RECEIPTCom
GAS EA. SYSTEM -OVER 4 (EA)
BUILDING DI VISION FE FS
I fCozieffbel copy Is hereby furnished.
rtNed copy a filed with the city Iropc Hon division.
CREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECIC FEE
GREASE TRAIT
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
EA. POOP
COMPENSATION INSURANCES-EyER,gANgT,lgy-STORM
(fhls°edlon need not be completed lithe permit a forone hundred dollars
Date Remi t#
WATER HEATER W/VENT/E.ECTR
ENERGYFEE Y' N
PAID
(51007 or IenJ
I artifythat in the pedormanceof thework forwhich this permit is Issued,
I shall not employ say person In any manner n u to become subject to the
Worken'Compensatlan Laws of CahfomIs. Date
WATER SYSTEM/TREATING
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the Workers' Comperuatlon provisions of the Labor
NEW RE9DENT[AL PLMB.__SQ.Ff.
Date Recei t#
-
TOTAL:
Code, you =at forthwith comply with such provisions orthis permit shall be
deemed revoked.
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
Ihembyaffim that there Is a construction kndingagency forthe perform
arra of the work far which thIs permit Is Issued (Sec. 3097, Civ. C.)
Lender's No
[enders Addrrn
I certlfythatl have readthbappllcattonand inatethatthe above Information
Iscorred. l agrerto comply with all dty and county ordinances and gate laws
TOTAL,
t
ELECTRIC FEE
QTY. MECHANICAL PERMIT
FEE
PLUMBING FEE
MECHANICAL FEE
PEtMITISSUANCE
FEES PAID:
relating tobullding comtructloo, and hereby auehorla, representatives of thl,
city to enterupon the above-mentioned property for Impedian purpose.
( agree to save, Indemnifyn d keep harmlem the City of Cupertino
,galDor bllitln,pdgmenb,cogsande non which may In anyway accrue
a net ty In consequ o tis got thin -permit
2- 9'
'—Date
ALTER ORADDTO MECH.Date
Recei t#
AIR HANDLING UNIT (T010,W0 CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,000CIM)
CONSTRUCTION TAX
SighatTreof ApplicarthContr4,dor Date
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HA RDO S MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
-
Will the applicant or future bu0ding occupantgore or handle haaardous
material as defined by the Cupertino Municipal Code, Chapter 9.1 7, and the
I lealth and Safety Cede�a -S�edum 5537(a 7
❑yes M No
Date RCCCI t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
Will the applicant or future building occupant use equipment or devices
which emit haaardous air contaminants as defined by the Bay Area Air
BOILER-NMP(3HPOR 1W,000 BTU)
Quality Management District?
Ye No
have read the Fav cause materlais requirements under Chapter 6.95 of
R'R p B
P A
BOILER -COMP 100,000 BTU)
the California I le.hh & Safety Code, Sectlons 75505, 75533 and 75534. 1
understand that if the building does not currently have. tenant that it 1, my
reeporaibility, mo
to notify the occupant of the requirements which at be met
®EC 16 1991
NEW RES] DEN77AL MIiCH. - SQ.PT
prior to (s,uanm of a Centfiate of Oc vpancy.
Cu i
V OF CUI-tn, I �
ISSUED BI\
Owner or authorised agent Data
'TOTAL:
OFFICE COPY