24519 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO ILDI - ELECT
BUILDING DIVISION APPLICATION/PERMIT - PLUMB NG
BUILDING PROTECT IUF.NTIPICATION
PERMIT NO.
24519
BUILDING ADDRESS: f 1 -
I35 5 Ghia ON V 1 i J l a LCIY UNIT# LOT la
OWNERS NAME: PIIONE: CONTRACTOR'S NAME: LIC NO:
'S,*, ti N0 �xl�-C '36 2i0 Imo% C1A"44-X sd 3% C
' ARCHITECT/ENGIN LIC NO:CONTACgDDRE55: r
¢sIJ .ST...e-�QK;rg,
SANITARY NO.
APPLICAMRSSSUaB.MITTTAALDATE
CIS.
N/C
CONTROL#
PHONE:
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ELECTRIC PERMIT FEE729-77;Z
BUILDING PERMIT INFO
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UANCE �sLICENSED
BLD ELEC PLU MEC%9
CONTRACTOR'S DECLARATION
hereby affirm that I am licensed underpmvisionsofChapter9 (commencing with
Semion]OW) of Division3 othe Business and Pmfessinns Code, and my license ie in�0Sectifull on and7000 etf t.)).�LionewC s LiaN Y IO
Contractor r tQiTJMPS
S-RESIDENTIALI
MPSDate
W-7
OB DESCRI ION
ARCHITECTS DECLARATION
O 1 understand my plans shall he used as public records.
SQ. FT. FLOOR AREA $/SQ. FT.
OVER IOW AMPS
SIGNS ELECTRICAL
Licensed Professional
U OWNER -BUILDER DECLARATION
1 hereby art,. that I amexempt from the Contramors License Law for the
y following reason. (Section ]031.5, Business and Professions Code: Any city ar county
which requites is permit It, construct, alter, improve, demolish, or neater any strucwro
prior to its issuance, also requires the applicant for such permit o file a signed statement
pthat he is licensed Pursunnuo the provisions of the Contractors License Law (Chapter
T
W 9(commencing with Section'1000) of Division 3 of the Business and Prolamines Com)
of
.� arthat oheisexempt byany refromnnd the basis for the alleged exemant to civil
Section , Ill.. by any applicant for n permit subjects the applicant to a civil penalty of
Q
anot more than five hundred Dollars ($SW).
❑ Lmownerofiheproperty,ormyempinyees with wagesasthei...b compensation,
will Jothe work,and be loo mea rmlialendedoroffeedfersale(Sae. 9044, Business
end Professions Code: The Cmntraemals License Law does not apply 10 an owner of
property who builds or improves thereon, and who does such work himself or through his
ownemployces,providedlhatsuchimpmvementstrenotintendedoroffere forsale. If,
however, fee building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
SPECIAL CIRCUIT/MISC, �w
TEMP. METER OR POLE INST.
POWER DEVICES
—
SWIMMING POOL ELECTRIC
VALUATION
/� �d�
(V(
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTIALELECIR_SQ.FT.
STORIES
OCC. GROUP
TYPE CONSTRUCTION
RES. UNITS
I
QTY. PLUMBING PERMIT FEE
❑ I,asowneroflheproperty,amexclusivelycornmmingwhbliccnsedeonlrecmmm
construct the project (Sec. 7044, Business and Professions Coda) The Contractor's
License Law does not apply m an owner of pmpeny who builds m arnproves thereon,and
FLOOD ZONE
APN
PERMIT ISSUANCE
whocontracts forsuch projects with n ooatractodid licensed pursuant to the Contractor's
License Law.
Elm 1 aexempt under Sec. , B & P C for this reason
ALTER - DRAIN & VENT- WATER (EA)
BACK FLOW PROTECT, DEVICE
FEE SUMMARY
OUTSIDE FEES
Owner Date
SANITARY Y N
WORKMAN COMPENSATION DECLARATION
ens'Coyaffirrnthall..race or aceateof copydouosel&Insure,nr Lab C.)cam of
Workere' Compens s nIn der. ince or acetified copy thereof (Seo 3800, Lab CJ which
covers all elnpl0`e'I untl'r. Ni�peHni�.-�s
Policy# N ZZ ``ii
DRAINS
DRAINS- FLOOR, ROOF. AREA, COND.
RECEIPT#
TAX Y N_
RECEIPT'#
FIXTURES PER TRAP
PARK FEE
RECEIPT N
GAS -EA. SYSTEM -1 INC. 4 OUTLETS
Company NIA
GAS - EA. SYSTEM -OVER 4 (EA)
BUILDING DIVISI FEES
❑ Clumped copy is hereby famished.
Cenified copy is filed with the city inspection division.
PLANCHECK FEE
GRADING FEE �f
GREASIVINDUSTRL WASTE INTERCEPTOR
CERTIFICATEOFEXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASE. TRAP
SOILS FEE
(This sectlanneed notbe completed if the permit is for one hundred dollars (S I W)
or less.)
SEWER - SANITARY - STORM EA. 200FT.
ENERGY FEE
I cenify that in theserformanceof the work for which this permit is issued, lshall
not employ any person in any manner so es m become .subject to the Workers'
Compensation Lawsaf Califomia. Dam
Applicant
WATER HEATER W/VENT/ELECTR
PAID
Date eceipl#
TOTAL:
WATER SYSTERETREATING
NOTICE TO APPLICANT:If, after making this Cenificate of Exemption, you should
became subjectto the Worker's Compensation provisions of the Labor Code,
NEW RESIDENTIAL FUME, SQ. PT.
you must
forthwith comply with such provisions or this permit shall be deemed revoked.
BUILDI E
CONSTRUCTION LENDING AGENCY -
I hereby affirm that hem is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Cls. C.)
Lender's Name
SETS IC
O
ELECTRIC FEB
Lenders Address
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
I cenify that 1 have read this application and state that the above information is
ISSUANCE !
MECHANICAL A_�
correct I agree to comply with all city and county ordinances and state laws relating toPERMIT
building construction, and hereby authorize representatives of
bovthio chy m enter upon the
ae-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities,judgments, costs and expenses which may in any way accrue against said City
In coal a fthe nontin
ALTER OR ADD TO MECH.
CONSTRUCTIO TA%
AIR HANDLING UNIT (TO IO,0110 CFM)
AIR HANDLING UNIT (OVER Ig0(10 CFM)
1 eg p rg
!•
EXHAUST HOOD(W/DUCT)
-
Si morin ApplimaVunoomer D elf/
PAID
HEATING UNIT (TO I W,OW BTU)
HEATING UNIT (OVER 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupenino Municipal Code, Chapter 9.[ 2. and the Health and Safety
Code, Section 25532(x)?
Dam Receipt#
1
VENTILATION FAN (SINGLE RESID)
❑ YesNo
.t
Will the ecommitments as building occupantuse Area it Quality which emit
hazardous air contaminants az dented by the Bay Area Air Quality Management
District?BOILER
BOILER- COMP(3HP OR 100,000 BTU)
- COME(OVER 10ROS0BTU)
IS ANCE DATE
P i D
❑Yee B/No
NEW RESIDENTIAL MECH. SQ, PT.
1 have read the hazardous materials requirements under Chapter 6.95 of the
California health & Safety Code, Sections 25505, 25533 and 25534. I understand that
if the building does not currently have a ream, that it is my responsibility to notify the
occupant of the requirements which most be ma prior, m issuance of a Certificate of
Occupancy.
DEC '3 1992
fsl,I i V i t �rC 1
V 4
BY:
Owner or xuthoncan agent Date
ISSUED
OFFICE