19720APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building PrWevt Identification
Building Add ne":"'
.
PERMIT NO.
a� n i�O
I99 G
wells ame:Ph.. e
Contmetofe Name: , Lie N
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING-ELMTRICAI.PLUMBING MECHAMCAL
Z —�
CATEGORY
CONTROL X
Architect/Engineer. Lk. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:
PERMITISSUANCE
❑ ❑ O
LICENSED CONTRACTOR'S DECLARATION
I hereby am700ha(Diet.mseauMerprovblomsofCssJora9(nand no-
7W0)ol Dl&Led ofthegusinnsan ProfesslonsCodG and my
Inerso1 In
Timms ISIn full )d tc.#
Lk"Classrp-Llc.p
Date ar}.E,=�4Cor �CCk 1
ARCHITEHITECTSDECLARATION
Iundcrstand my plans shall be used nspublic remrda
Limned Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt fmmthe CmBmcfm`. Limns. Law for the
following mamn.(5edlon 7031.5, Business and Profeelons Code: Ary city or
county which requires a permit tomnstmet alter, Improve, demollsh,areepalr
any structum prior to lb Issuance, abe, require the applicant for such permit to
file a algr ed statement that he b limned pursuant to the provisions of the
Contractor'sLicense Law (Chapter9(commencing with Section 7000) of Divi-
slon3ofthe Bualnsi...d ProfessionsCode)orthat he is exempt therefromand
the balls fmr the alleged exemption. Any violation of Saokm 7031.5 by any
appllrant fora permit subjects the applicant to a civil penalty of not more Than
five hundred dollars ($500).
F1 1, as owner of the property, or my employees with wages as their sole
ompensatlon,will Bothe work, and thestmchare b not intended or offered for
ale (Sec. 7044, Business and Profession Code: The Contractors License Law
does not apply to an owner of property who Wilda or improves thereon, and
who does such work himmlforthmugh his own employees, provided that such
Improvements are not Intended oroffered for sale. If, however, thebullding or
Improvement bsold withinoneyearofcomple lon,theowner-builderwill have
Badenof proving that he did net baud or improve for purpose o(sals.).
L -f L as owner of the property, am exclusively contracting with llrensed
contractors to construct the project (Sec 7DK Business and Professlon Code;
The Contractor's Llmnsc Law does not apply to an owner of property who
Wilda or Improves therecn, and who contracts for such pkp" with a
o,bactor(s)IlreneM pursuant to the Contractors Licnse Law.
LJ I am exempt under Seo B k P C for this masonntlTqIIIV
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
a]
R,li
PANELS
_ UP TO 200AMPS
00 AMPS'
OVEROVER 1000 AMT'S
SQ. FT. FLOOR AREA
$/$Q, FT.
SIGNS ELECTRICAL
SI'FCIALCETCUIT/M75C
TFMP.ME[ER ORIOLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETSSWITCHFSFTXTURES
VALUATION '
NEW ftFS[DEN7IAL ELFLTR SQ.Fr.
STORIES
TYPECONSMUCT70N
TOTAL.
QTY. PLUMBING PERMIT FEE
PERMRISSUANCE
ALTER -DRAIN k VFNE-WATER (EA)
OCC. GROUT'
Dl
RES. UNITS
FLOOD TINE
APN
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y_ N_
RECEIPT X
Owner Date
WORKMAN COMP ENSATION DECLARATION
❑I hereby affirm that I have o lmum to of consent d self-insurs, ora
cedifiLrb of WorkersCmmpewtion[nsunnreoraredl(Ied mpythereot (Bee.
3600, Lab C.)
I'eliry p
FDCrURFS PER TRAP
SCHOOL TAX Y N
RFGEIPT X
GAS F.A. SYSTEM -1 WCAOIITLETS
PARK FEE Y N
p
RECEDING
CAS EA. SYSTEM-0OVER
Com an y
DI
BUILDING DIVISION FEES
Certified copy Is hereby e
Certified copy b (fled withth the cityInspedlon division.
ity
CERTIFICATE OF DIEM PITON FROM WOR KCR S'
(this
Ohle section need not be completed If the permit b forone hundred dollen
($]00)orfy that
Imnot len In the pedormanaof theworkfors bthleperrnitbbsuee
I shall not employ any person In any manner m u W me sub d to the
law a1 Qs11( b. D)t��
Applicant
Applicant 11 LI (.{
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECKFEE
PAID—
Date Recei t#
GREASE TRAP
SEWER -SANITARY -STORM PA 2110111,
WATER HEATER W/VENT/ELFCTR
ENERGY FEE Y N
PAID—
Date Recei t#
WATER SY51IM/TREATING
NEW RESIDENTIAL PLM B._SQ,FT.
shoulNOTICEco become is ExempBery you
ttothea ompeang this Cc ion provisions Labor
surtotothe Work en' such prumionprovhis permit hall
Code, you
Codgyau rrwet forthwith comply with each provisions or this pemNt shall be
rimmed invoked.
CONSTRUCTION LENDING AGENCY
Ihcreryaffirm thatthere baconstmdlon lendingagenry for the perform,
anm of the work for which thio permit b issued (Sec. 3097, Clv. CJ
Landers Name
landce.Addes..
Icedifylhxt l have read this applleztmetand stat.that lheaboveleformatlon
ismrred.I agreeempty to cply with all city and county ordinances and state laws
relating to building construction, and hereby authorize representatives of this
city to enter upon the above-mentioned property for Impaction purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cupertino
against liabilities, judgments, msteand expenses which may In anywayaccme
against said City In con.equenm of the granting of this permit.
TOTAL:
BUILDING
SEISMIC FEE
TOTAL:
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
(�
1r� .as
PERMIT ISSUANCE' rL.00
FEES PAID:
ALTER OR ADD TO MECH.
Date RCCCI t#
P
AIR HANDLING UNIT (TO 10,010 CFM)
SUBTOTAL'
AIR HANDLING UNIT (OVER tO,Dq CIM)
CONSTRUCTION TAX
Signature of AppRmnt/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
WllltheappReartorfumrebullding.pamammor Ma dlch.M ue
morriala.deMed bytMCupedlno Munlcip.1cwd,Chapter9.12,andthe
Ilealth and Safety Code Section 25532(a)i
nn Ym No
X4111 the zppllmnl or uturebullding omvpant us<equlpment mraevices
which colt hazardous air contaminntsas defined by the Bay Area A],
Quality Management DbMd7
4havYes No
emadthehoz Srfa.s.t�rialsmqd.,S.Cio iremenh5533rnhapter6.95o1
the Call(ornla health &Safety Code, &Bion 25505, 75573 and 25534. I
understand that if the building does not currently have a tenant, that it b my
responsibility to notify the occupant of the requirements which must be met
prior uenc of.cmificafee Occupancy. ,r
n�I rU L,t A4 V
or aui rl'agent -Date
D(IIAUS'T HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATINGUMT( ""B"OBTU) 9'Co
Date RCCCI t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
2t ,W
VENTILATION FAN (SINGLE RFSID)
ISSUAIVI[Ti IIA'j'E
a 4, O
U 1990
r11D 1I1D
City, e { a
ISSUED BY: I R F+.
-_��,�ly�(��
BOR.FR-COMP OHPOR 100,000 BTU)
BOILER-COMP(OVFR100,000B UI
NEW RESIDENTIAL MECH. SQ.IT.
' TOTAL: u.�
OFFICE COPY