23414APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project ldeml(lotIm
Building Add rem: I OIL w I L-k*z Q So W P63
PKItMIT NO.
3414
23414
A "LetG tonne.
B
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION 1 PERMIT
BUILDINGELBCTRICAL-MUMBING-MECHAMCAL
/' A
cont eme'sNared Lic.No:
CATEGORY
CONTROL M
Architect/Engineer. Lk. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Addresw
❑ ❑ ❑
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm that lemlicensed under provisions
tand Pr/Cssions9(commesc
It...i in fon 7gp)and effean3oflhe Budnemand Fro/emlomCade,and my
licencelClion force and c,a
DdeChm Lle a
Date Cantnctor
ARCHITECTS DECLARATION
I understand my plxmshallbe used as pubecremrds.
Licensed Professional
OWNER -BUILDER DECLARATION
following asormthalIn 7exemp fromthe Contractors Licence law forthe
ntywhichmuimaon7Bitto..nemand professions
emle hnycity or
cauntywhich requires a pemNt to comtmct, altep Improve, demoW h, arrepalr
mpair
anyeWcture prW to its Wuance,abo mqulreetheappllnnt (oreuch permit to
file a signed statement that he b licensed pursuant to IM provisions of the
Contractors License Law (Chapter 9(commencing with Section 7000) of Divi-
don3 of the Business and ProfessionsCode) orthat he Is exempt there(romend
the basis far the alleged exemption. Any violation of Section 70312 by any
applicant fora permit subjec athe applicant to a civil penalty of not more than
ve hundreddollam($500).
, a owner of the property, or my employees with wages as their sole
co p sation,wllldothe work andthe structure is not Intended or offered for
e (Sec. 7044, Business and Professlors Code: The Contractor's Llceme Law
d N not apply to an owner of property who builds or improves thereon, and
' who does suchwork himself or through his own employees, provided that such
Improvements are not Intended or offered for sale. If, however, the building or
Improvement issold wilhlnomrarofcomplelion,theowner-builderwlll have
tlj!jp en of proving that he did out build or improve for purpose o(eale.).
[_f 1, act owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions Code;
The Contractors License Law does nat apply to an owner of property who
builds or improves thereon, and who contracts for such pknjects with a
cpq[,tor(s) Ilcemed pursuant to the Contractors License Law.
LJ I am exempt under Sec. B A P C for this reason
APPLIANCESRESIDENML
JOB DFSCRB'HON
LW e -t9+
(/�^,T P�Pa �i
PANELS
UP TO 200ANU-5
201 -IOW AMPS
OVER1000AMPS -
SQ. FT. FLOOR AREA
S/SQ.FT.
SIGNS ELECTRICAL
SFECIALCIRCUIT/MISC
TEMP. MEI ER ORPOLE INST.
POWER DEVICES
SWIMhBNC POOL ELECTRIC
OUTLETSSW[TCHFSEXTURES
VALUAT &c -
Q /<^ VV''
J✓
NEW RESIDENTIAL RLECTR SQ.FT.
STORIES
TYPE CONSTRUCTION
_
TOTAL:
QTY. PLUMBING PERMIT FEE
PPRMpI•fS5[IMrCE
ALTER -DRAIN kVENT-WATER (EA)
OCC. CROUP
RFS. UNITS
FLOOD ZONE
APN
FEE SUMMARY
-
BACKFLOW PROTECT. DEVICE
OUTcIDE FEES
DRAINS FLOOR, ROOF, AREA, COND.
FIXTURES PER TRAP
SANITARY Y N
RECEBrf M
Owner Datc
WORKMAN COMMSATION DECLARATION
❑l hereby effm lrthat 1 heve a certificate of consent to self-maure, or a
mnifimteof Workers CompematlonlmuranmmamnifWcopythe of(Sec.
M00,Lab C.)
1'ollry Y
SCHOOL TAX Y N
RECETTIf
GAS EA. SY9I7EM-1 INCAOUTLE15
PARAFEE Y_ N
N
RECEGAS
EA. SYSTEM -OVER 4 MA)
Com any
DING DI
BUILDING DIVISION FEES
an fied copy b hereby th the city copy bfiled with the d4, Wpection division.
CERTIFICATE OF F3(EMPrION FROM WORKERS'
COMPENSATION INSURANCE
(fhb section need not be completed If the permit b (Drone hundred dollam
(5100)mlm)
[certify that ti the person in an tha wmk (o at to b this permit is blued,
1 shag not employ any person in any manner n m to become subject to the
Wmkcm'Compenmtbn laws of Gg(ornb. Date
Applicant
NOTICETO APPLICAM: V, after making thismim late o(Exemptlon, you
should berome subject to the Workers'Compewllon provbiom of the Labor
Code, you =at forthwith comply with such prawid=or this permit shall be
deemed revoked,
CONSTRUCTION LENDING AGENCY
I hereby affirothat there Is a construction lending agency for the perform
ance of the work for which this permit le Issued (Sec. 3097, Clv. CJ
Lenders Name
Lenders Address
n and a ty hm ordinances a Information date laws
Irmctf thatl agree t comply read y with all
bconeat9agreeto ndmetih all cityand countyenerepnaesand datelawe
of this
relating to building a mmm,men and hereby property
or Inspection
city (We)aenter
eetosae,inde-men anedpropharredrWpecCtyofCoses.
(We) agree to cove, Indemnify an d keep harMem the City of Cupertino
against l[abllltles, Pdgments, coatsand expenses which may In anyway acme
against mid Cltyin sequence of the granting of th s permit.
<,
Z
GREASE/WDUSIRL WASTE INTERCEPTOR
PLANGI-IEGK FEE
PAID
Date Recei tq
.
GREASE TRAP
SEWER-SANTTARY-S ORM EA ZXFT
WATr.RHEATERW/VENT/E.F.crR
ENERGY FEE Y N
PAID
Date Remi t#
WATER SYSIFM/TRFATING
NEW RESIDENTIAL PLMB. SO.FT.
TOTAL --
FEE T
DING
roTnl:
SEISMIC FEE
I few
ELECTRIC FEE
Q1Y. MECHANICAL PERMIT FEE
PLUMBING FEE
PERMCf ISSUANCE
ALTER ORADD TT3MECH.
AIR HANDLING UNIT (TO 10,000 CFM)
MECHANICALFEE
FEES PAID:
Date Recel tN
SUBTOTAL'
AIR HANDLING UNIT (OVER 10,000CFM)
CONSTRUCTION TAX
re of AppllcnDae
HAZAR AlARDOESOUS MATERIALS DItatom or hand
Will the definedpplicant
theC pertr futum imingocnpo I Code, hapten 9. Zandoua
material as dented by the Cupertino MuNcipal Code, Chapter 9.1 2, and the
I Iealth and Safety Cade Section 25532(a)2
❑ Yea No
Will theappliant or tore building ottvpmt use equipment or devices
which emit hazardous air contaMnsnb act defined by the Bay Area Air
Quality Management District?
4Ya ❑No
havemaHealthd the za3ommaleeSectumremenb5533an 25536.95 of
the erstae nla Health building
Cods SectWm 25505, have a t and 25534. I
the occopent of not
usponsindthm If the notify exxluu,, aotalamhLthat It bray
responsibility to ngltythe occvpa nt of the requlremenb which must be met
prior to Lmuancc o(a Certificale of Ocnrpa my.
EXHAUST HOOD (W/DIKT)
CONSTRUCTION TAX PAID:
HEATING UM7(TO 100,000 BTU)
Date Recei t8
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN( SINGLE RESID)
ISSUANCE DATE
p B
PSI
I1f111D 16 1992
IVII'1I� c7 s7/�
CITY \r 1r Curitilliv
ISSUED BY:
BORER{OMPOHPOR 100,000 BTU)
BO LERCOMP(OV[RiW,OWBTU)
NEW RESIDENTIAL MECH. SQ.FT.
Owner or authorized agent Date
Tnrnc
OFFICE COPY