24068APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
Building Project Identification
PERMITNI],
ddmss
Bull ingA:U.
(
�G)
4 0 6 8
s ares: Phone:
w'
A A A IE
Q zCITY
O-
OF CUPERTINBUILDING DIVISION
APPLICATION if PERMIT
Contractor's Name: Lic. N.
BUILDING-ELECTRICAL-PLUMBING-MECHAMCAL
CATEGORY
CONTROL N
Architect/Engineer. Lic. No:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO -
Address:
PERJMTISSUANCE �Q
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
IherebyaffUmthat l am licensed under provisions of Chapter9 immrnmc-
Ing with Section 7000) of Division 3 ofthe Business and ProfessiansCode, and.
license is in full force and died.
APPLIANCES -RESIDENTIAL
JOB DFSCRI'HON
s
'
PANELS
License CUss
Date Contractor
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
— UP TO 2DOANMS
2(11-1000 A.MPB
OVER 1000 AMPS
SQ. Fr. FLOOR AFLFA
$/SQ.FI.
SIGNS ELECTRICAL
Licensed Professional
SPECIALCIRCUIT/MISC DD
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt fromthe Contractors Lfcenx law for the
TEMP. M CM OR POLE INST.
following reason. (Section 70315, Business and Professions Code: Any city or
cmntywhich mqubesa permit tommtmd, alter, lmpmve, demoltsh,ormpair
anystm=mpdortoit Lcwancgals requirntheappUmntfmrsuchper tto
Ile a signed statement that he is licensed pursuant to the provisions of the
POWER DEVICES
-
SWIMMING POOL ELECTRIC
Contractor's License, Law (Chapter 9(commencing with Section 7000) of IRA-
slon 3 ofthe Bustnessand Profeasloru Code) orthat heis exempt therefromand
VALUATION
the basis for the alleged exemption. Any violation of Section 70315 by any
applicant for a permit subjects the applicant toe civil penalty of nm more than
OU LETSSWITCHESFTXTURES
five hundred dollars (5500).
E] 1, as owner of the property, or my employees with wages as their sole
NEW RESIDENTIAL ELECTR SQ.FC -
STORIES
TYPE CONSTRUCTION
compensatloo,willdothe work and the structure is not intended or offered for
sale (Sec.7044, Buafness and Pmfessi.. Code: The Contractors License Law
'
TOTAL: '�.✓�
does not apply to an owner of property who builds or imprevn thereon,and
who doessuchworkhimself orthrough hisownemployees, provided that such
improvements are not Intended oroffered for sale. IL howneegthebullding or
OCC.GROUP
RFS. AMTS
'
Improvement tsxld withinoneyearofcompinlon,eheowner-builderwlll have
-
—
th men of proving that he did not Wild or improve for purpose ofsale.).
c6jIT(il' 1, as owner of the property, am exclusively contracting with Ilcenxd
X ctors to construct the project (Sec. 7044, Business and Professions Code:
QTY, PLUMBING PERMT FEE.
rp(pQp p
1 N
PN
p RMIT ISSUANCE I r
The Contractors License law does not apply to an owner of property who
WIWs or Improve ereon, and who mnvam (w such p(ajeets with a
t{jactor(s; censer{ .m to the Contractor's License Law.
LJ I am o crept a er Sec B k P C for this reason
I
ALTER -DRAIN &VENT- WATER (EA)
'FE$ MARY
BACK FLOW PROTECT. DEVICE I
DRAINS FLOOR ROOF, ARCA, ND.
A Y N I
FLFIPf N
Owner Date
WOR A ION DECLARATION
❑[ he affirm at I cue a certificate of consent to self -insure, or
cxmiflcateu Worker.Com abon Insurance or a certified copythemof(Sec.
3800, Lab C.)
Toney tl
pIXTUgES PER TRAP
SCHOOL TAX Y N
RFLEIPr p
GASEA. SYSTEM -1 INCA OUTLETS
PARKFEE Y N
RECEIPT N
Cam any
Ch
GAS EA. SYSTEM,0VER 4(EA)
BUILDING DI V) SION EF F.S
copy Is hereby furalshed.
❑ Certified .py b filed with the city i.penfon divfslon.
GREASC/INDUSIRL WASTE INTERCEPTOR
PLANGI'IEGK FEE
GRRASR TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
COMPENSATION INSURANCE
(ThissMlon need mat be completed if the permit is foron hundred dollars
Date Recei IN
SEWER -SANITARY -STORM FA 200E7
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N
($lW)orlcssJ
I really that in the performance ofthe work forwhlch this permit b issued,
WATER SYSTEM/TREATING
I shall not employ any person In any manner so as to become subject to the
Workers Compensation Laws of Cal{fornb. Date
PAID-
NEW RESIDENIIAL PLMB. SQFT.
ApplicantNO TICET
NOTO APPLICANT: R, after making this Certificate of Exemption, you
should become subject to the Workers' Compematim pmvblors of the Labor
Date Recei of
TOTAL:
FEE
Code, you most forthwith comply with such provisions orthis pemdt shall be,BUILDING
revoked.
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirmthat there is aconstruction lending agency for the perform
ance of the work for which this permit Is issued Tec 3097, CIv.C.)
Lender's Name
Ianders Address
I coolly thatl have mad this application and statethat theabovelnformation
IscorrM. l agreeto comply with an city and county ordinances and state laws
TOTAL:
ELECTRIC FEE -
- V 19
PLUMBING FEE
QTY. MECHANICAL PERMIT' FEE
PERMIT ISSUANCE
MECHANICAL FEE
FEES PAID:
relating to building construction, and hereby authorize representatives of this
city to enter u pan the above-mentioned property for Inspection pu rpows.
No) agree to save, Indemnify an d keep harmiess the City of Cu pert Ino
abin,n,n, mems,rortsendex rases which ma 1 an a accrue xgaire Pe Y n Yw Y
again IdCityi rase ttenceofthe gradiegoftN"syr 't.
ALTERORADDTOMECH.
- Date Reeei til
P
AIRHANDLINGUMTGO10,000CFhf)
SUBTOTAL:
00
AIR HANDLING UNIT (OVER I0,000CFM)
CONSTRUCTION TAX
Sign re of ppli t/Con ctar v J Date[
IXHAUSr HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
I 7AR SM ATERIALSDISCLOSURE -
HEATING UMT(TO 100,000 BTU)
-
Date Reeei tU
Wil the appllo torfu building occupant store or handle ha>'rdous
material as defined by the Cupertino Municipal Code,Chapter 9.12, and the
Health and Safety Code Section 25532(x)?
❑ Yn M No
HEATING UNIT (OVER 100,000 BTL. ,'
TOTAL:
46-0,9
VENTILATION FAN TINGLE RFSID)
ISSUANCE DATE
,
Will the applicant orfutum building occupant use equipment or devim
which coon, hazardous air contaminants as deflned by the Bay Area Air
Quality Management District?
yes
BOILER. COMP QEm OR 100,000 BTU)
BOILER-COMP(OVER 100,000 BTU)
No
Thave read the h.9 materials requirements under Chapter 6.95 of
California Health k Safety Cod, Sections 25505, 25533 and 25534. 1
understand that lithe building does not currently have a tenant, that it is my
AUG 1992the
NEW RESIDENTIAL MECH. SQ.FF
responsibility to notify the occupant of the requirements which most bo met
prior to issuance of a Certificate of Occupancy.
VIhUr VVVlr T1111`iv
/I
)SSUEDBY _V.-41.. 1 !1 VC,C �-
x=�-�-�-'l-�
Owner or authorized agent Data
-
TOTAL:
OFFICE COPY