23161APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Prn'ed laendflaJon
P1]t1AT NO.
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
BULDINGET.ECMCAI PLUMBINGMECHAN)CAL
Contra o N• rk.N.
CATEGORY
CO a 6
(� CJ
LL ginecr. Lfc N.
Qry ELECTRIC PE MIT FEE
BUILDING PERMIT INFO
PERMIT]$UA �'�
� �1 ❑ ❑
L
LICENSED CONTRACTORS DECLARATION
I hereby affirm that l am llcenxdurder pro W..fChapw,9(mmmenc
lioe.isinfullf99aa��and effect LlavcLk.I Z�Date
Ing MthS tl n7000)of Di lgw3ofthe BuMl and Pmfes Code, and mytEMNS
APPLIANC ENTIAL
)OB DESCRIPTION
SIuMerwrd
E_� 1C.mradarCHITECTS RATION
my plaroeluBhe usedapublicremrd>
M
�.FT. FLOOR AREA
f/SQ.FF.
LOWNER-BUILDER
CUIT/M1SC M.
Licensed Pr-rd.Urvl '
DECLARATION
I hereby affirm that I am exempt from the Contractor's Llaroe Law for the
E D I N 1
TEMP. METMOR POLE INST.
following masto.(Sedlon 703 l S, Buibim and Professions Code: Any city or
countywhkhrequl apermittomrotmct,akar,improve,de Lo l,orrepair
, 1
v
&nye mmprbrtoksl me,ahorequMtheappkontfwwchpermltto
file a signed statement that he Is liamsed pursuant W the proalbro of the
POWER DEVICES '
2
SlypdhgNC1'OOL ELECTRIC
MAC,TS
OUfLESWTTCHESFDn%fRES
Contractor's License Law IC),apter 9(comnenMg with Section 7000) of DIN-
sion3 ofthe Businemand Prof mbm Code)ortheth exemptthertfmmand
the ba.b for the alleged exemption. Any violation of Section 70115 by any
applicant for a permit subjects the applicant to a eMl penalty of not more than
ALUA N
C J
fiv hundred ddla, ISM,
I, as owner of the property, or my employees with wages u their sole
NEW RE ENTIAL ELxTB SQFI.
STORIES
TYPE CON'SIRIX:TION
mmperoaHon,wlll dothe work and thestructo t is rot Intended or offered for
ale (Sec 7014, Business and Professions Code: The Contractors Llceroe LAw
don wt apply to an owner of property who builds or improves therms, and
whodonsuchworkhimselforthrough hisownemployees, pnwlded that such
OCC.GROUP
RES. UNITS
lmpmvements ane not Intended orof Bred forsale. IL however, thebuiding or
TO
iomprovernentbeold wlthnomrarofcornplcikn,theowner-Wilde l"w
thckardenof provingthat he did rot boudor Improve for pe.po,eof„k.).
L_j L as owner of the property, am exxt .wely contracting with Ikensed
omwctors to construct the project (Sec 70K Bu,lnras and Profession Code:
QTY. PLUMBING PERMIT FEE
FL.00DWNE
APN
pOtMIT ISSUANCE
The Contradorb License Law does not apply to ae owner of property who
or Impr thereon, mm
and who racts for such p(o}Ma with e
+ctor(s) Licensed pursuant to the Comrnders Lkxese Law.
LJ I am exempt order Sec. B 4 P C for thio maonntqqmFvrvq
ALTER -DRAW 6 VFM-WATER CEA)builds
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y N_
RECEIPT It
Owen Date
WORKMAN COMPENSATION DECLARATIONFORURES
• certificate of consent to self -insure, or s
Fit hereby afMn that I haw. se
codificate ofWorke Compr:.roationlruunno wamrtiP mpythereof(Sec
3800, Lab C)
Policy a
.��,
SER -00L TAX Y_ N
RFiERrf /
GAEA. SYSTEM -1 C40ITILEIS
S EM W
PARK FEE Y N
RECEIPT a
(1_4& F.A.SYS EM -OVER 4 (EA)
Co ny -
BUILDING DIVISION",
rtNed copy Is herebywithtWed.
Certlfka mpynfueedwith me try inspection division.
GREASE/INDUSIRL WASTE WTFACFPTOR
PLANCHECK FEE �+
Q J
GREASE TRAP
CERTIDUTE OF EKEMPTION FROM WORKERS
PAID
COMPENSATION INSURANCE
(Ihbsecbn need not b, completed if the pemdt bfor one hundred dollars
DBIC cool tic
SEtiypR-SAMTARY STORM FA 200FT
WATER HEATER W/VENT/ELECTR
E FEE Y N
RIID)arlem3
I mnot bat nce
WATER SYSTEM/TREATING
so as tobthiopemdHsIwed,
employ any perrso in any
1 stall not employ any person U any manner at n to become eub)ed to the
Workers C®apenwbn lAays of Gllfomh. Date
ID
NIEWR DEN IALPIMB. SQ.FT.
Appbant
Reoel ted
NOTICE TO APPLICANT: D, after rt, king this Certificate of Exemptloo, you
should become subject to the Workers''Compenaim pmWslom ofthe Labor
OTA :
61AE FEE k I I I
Code, you most forthwith comply with such pro isloro or this permit &hall be
deemed revoked.
S
CONSTRUCTION LENDING AGENCY
I Aembyaffirm that them is a construction lending agency for the perform
ance of the work for which this permut b bared (Sec 3097, Civ. C.)
Lender. Name
Ierder.Address
Tart wread thbapp"tion and Mtethatthe above informsiloo
6m .Iagreeto omplywkh all city and countyondWnm and cote laws
ELECTRIC FEE
' TOTAL
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE.
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
Ing.,Z"ing v dim,aMherebyauthori mpreantatNesofthls
city to enter upon abs rnentbrcd property for inspection purposes.
(We) agm to w, WemNry barmiem the City of Cupralno
ALTERORADDTOMFCFI. .
Date ci tp
AIR HANDIJNG[ATf(N 10,000CFM)
against Wb expert yinany .ccrue
he
FAIR HANDLING TWIT (OVFlt lO,00acFM)
CONSTRUCTION PAX
Date
DGIAUST HOOD(W/DUCD
CONSTRUCFION AX PAID:
HAZARDOUS MATERIALS DISCLOSURE
'
HEATING UNIT (TO 100,0110 BTI!)
WOIt applkaad WmbuBdingo pantaomorhandkha rdms
material a. defined by the Cupertlro Murddpal Cade, Chapter 9.17, and the
fkafth and Safety Coder �Section 25531(a)7
ye,u Na
Date I t11
HATING UNIT (OVER 100,000 BM
T01^
VENTILATION FAN C31NGIk RESID)
ISSUANCE DATE
W01the"rdt mfuturebuilding occupant useequipmentBa Aro Qdevices
which emit haardow air mntamironte a, dNlned by the Bay Area Ak
BOB-ER-WMP PFiP OR 100,IXA BTU)
Quality hLvgenrnt Wtrkal
TY ❑ No
hav"t"readthellru'rousmae a q icons nb anacnc up er 5.95 of
,
p
P Iy 1 D
BOILER-COMP(OVIR I W,000 B T1)
the California Health k Safety Code, Se Toru 25585, 15513 and 75534.1
unddstand that if the building dm not mrrentry have s tenant, that It b my
rnporomility to notify the occupant of the requirements which mount be rret
JAN 16
NEW RE31DENTIAL MECH. SQFT
prim to Lmuanm d a artifiate of Ocarpancy. -
n 1992
ISSUED BY!—lA.r9��'
Owner or authonfud agent Date
TOTAL
OFFICE COPY