23224APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
Building Project Identification
Building Address:
.. PERMIT NO.
7
oo
2 3 LI 2 4
nersName: hone:
A A A
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
L`l 1.
3ctotsName:
C rG Lic.N.
II B+BUILDING-ELECTRICALPLUMBWGMECHAMCAL
CATEGORY
CCyPRQIN p' L
(LTJ L "I
Architect ghee'.. Lic, ce
QTY ELECTRIC PERMIT - FEE
BUILDINGTERMIT INFO_
Address: _dV
PERMITISSUANCE 0yL...
LICENSED CONTRACTO 'S DECLARATION
[hereby affirm that lam licensed under provblons of Chapler9(commem,
Ingwith5ection7000)of Division3ofthe Businessand PmlessionsCode,andm
APPLIANCES -RESIDENTIAL
g Rgx11
�F.�
'Cepdf�p
Llansa Cho B_Lic N--iFE
Date_!_Q—��Contranor vljh
ARCHITECTS ECLARATIO
[understand my platy shall be used upublic remrds.
PANELS ;
SD
f-7 Y/sJ� J
l �a ��(
VV r♦
O000
OVER
OVER 1000 AMPS
AM
SQ. FT. FLOOR AREA
S/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
O
$I'ECNLCIRCUIT/MLSC
OWNER -BUILDER DECLARATION
I herebyaffirm that I am exempt from the Contractor's License Law (orthe
�'TS
TEMP. METER OR POLE INST.
following reuon.(Section 7031.5, Business and Professions Code: Any city or
county which reefu ma permit to construct, alter, Improve, derrnlbh,or repair
'
anystructure prior to its bciance,also requirestheapplicant for such permit to
file a signed statement that he Is licensed pursuant to the provisions of the
POWER DEVICES
_
SWIMMING POOL ELECTRIC
Contractor's License Law (Chapter 9(mmmemdng with Section 7000) of Divi-
'on 3 ofthe Business and Professim sCode) or that he Is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7MlZ by any
appllant for a permit subjects the applicant to a civil penalty of act more tha
VALUATION
l 1 So N60
/�
OUMETSSWITCHESFIXTURES / - �(/
G (/
NEW RESIDENTIAL ELECTR SQFr.
dollars pr).
five 1, as owner
L eaowner of the property, or my employees n with wage as there sole
compensatlon,wBldothe work andthc structure boot Intended or offered for
STORIES
E p
TYPECONS(RUCTION
I N I
� � j
sale (Sec. 7044, Business and pro/essions Code: The Contranoes LicenseLaw
-
does not apply to an owner of property who builds or improves thereon, and
whodonsuchworkhi iself orthrugh Msownemployen, provided that such
(� J
PITimprovement
TTS
improvements am not intended oroffered for sale. ILhowevegthebuildingor
bsold whhinoneyearofcompl&ion, theowner-bu0derwill have
TOTAL:
'vo
the4urden of proving that he did not build or hnprove for purpose ofsale.).
u L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions Code:
QTY, PLUMBING PERMIT
1j*E
FLO
PERMIT ISSUANCE
The Contractor's License Law does not apply to an owner a property who
Wilds or improve thereon, and who contra. ab for such projewith a
tt et (a) licensed pursuant to the Contractor's License Law.
LJ I am exempt under Sec. B & P C for this reason
ALTER -DRAIN & VENT- WATER MA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y _ N
RECEIPT N
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a artiRcate of consent to self- mum, or
3certificate 800, abC Workers Comperuatlonlnsurance oracertlfkd copythereof(Sec.
Policy N
PER Twp
Q .
SCHOOLTAX Y_ N_
REEIPI N
GAS EA. SYSTEM -1 INCA OUTLETS po
PARKFEE Y N
RECEIPT N
CAS EA SYSTEM -OVER 4 (EAJ
CffCan
BUILDING DIVISION FEES
ertl(ed copy is heed with the
�ertlfled copybfiled with the city inspection division.
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHFCKFEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
SEWER -SANITARY -STORM EA. 200FT.
COMPENSATION INSURANCE
(This section need not be completed if the permit b for one hundred dollars
Date Rccei H
WATER HEATER w/VEM/ELFCTR
ENERGY FEE Y N
(5100)orless.)
I certifythat in the performance of the work for which this permit is issued,
WATIR SYSTEM/TREATING - /s
V
I shall not employ any person in any manner an as to become subject to the
Workers Comns
peation Laws of California. Date
PAID
Applicant
NOTICE TO APPLICANT: IL after raking this Certificate of Exemption, you
should become subpect w the Workers' Compensation provisions of the Labor
NEW RESIDENTIAL PCMB. SQ.FT.
Date Recef t#
.
TOTAL[
BUILDING '-E �"'
Code, you most forthwithrompiy with such provisions or this permit shallbe
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I hereby affirm that there is a construction lending agency for the perform,ELECTRIC
ante of the work for which this permit b issued (Sec. 3097, Civ. Q
Landers Name
Landers Address
I ceeifythatl have read this application and statethattheahove Information
bcorrect. Iag.to comply .[that[ city and muntymetimmeraand statelaws
TOTAL:
- Q d
FEE
PLUMBING FEE — 0
QTY. MECHANICAL PERMIT FEE:
MECHANICAL FEE X00
PERMITISSUANCE .�a•
FEES PAID:
relating to building construction, and hereby authodae representatives of this
city to enter upon the above-rreintioned property for inspection purposes.
(We) agree to save, Indemnify as d keep harmless the City of Cupertino
.&n%qialeflitics,judgments, costs and expenses which may inanywayaceme
Date Recei t#
P
ALTEiORADDTOMFCH. •�
AIRHANDLING UNIT (TO 10,000CFM)
SUBTOTAL:
a ns Id City in f h grintingoftMapermit.
✓ N
AIRRANDLINGUNTrroVER10,WOCIMO
CONSTRUCTIONTAX
g`na� liar/Contra r Data
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
-
HEATING UNIT (TO IDg000 BTU)
Willtheappllcantorfuturebulldingottvpantstoreorhandlehaezedime
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Health and Safety Code Section 25532(a)7
-0 Yn ' Lj No
Will the a ppllant or future bu ilding occupant use equipment or devices
Date Recei t#
HEATING UNIT (OVER 100,000 BTU)
TOT
ISSUANCE DATE
VENTILATION FAN(SINGLE RESID) Co
VV
which emit haeardous air contaminants as defied by the Bay Area Air
Quality Management District?
Q No
�f A D
r
BOILER-COMP(3HP OR 100,M BTU)
BOILER-COMP(OVER IOO,000BTU)
4Yes
havemadthehuammisrateriabrequirementsunderChapter6.95of
the California Health&Safety Code, Sections 75505, 25533 and 2553x.,
understand that lithe building does not currently have a tenant, that it b my
APR 1992.
NEW RESIDENTIAL MECH. SQ.FT
responsibility to notify the..pant of the requirements which must be met
-
prior to Issuance of a Certificate of Ocm pa ncy.
-
'CITY U, Y Ii Tn'i_ .au.x/ t'
Owner or authorized agent Data
TOTAL: yV
OFFICE COPY