24154 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
uin project Identification PERMIT
BuildingAddOress: NZ 4 1 5 4Z � ' XIe
A A
Qom, A x f P CITY OF CUPERTTNQBUILDING DIVISION O"— Z 6^q Z
c°^Iran° .N rnI^'�1 r LIc.Nm APPLICATION / PERMIT D -1
7 �`!.a BUILDING-ELECTRICAL.PLUMBING-MECHAMCAL CATEGORY CONTROL N
Architect/Engineer. U Lie.No:
- iQTY i") 'y'41,ELECTRIC PERMITI ' '1FEE.` •`V,, iBUILDINGGPERMIT,INFO(;i"i'�3,,of_ '
"LUxIH 1,411"
Address o SO 36 - PERMITISSUANCE
LICE:NSEDCONTRACTOWS DECLARATION
I hereby affirmthal l am licensed under provisions of Chapter9(mmdate. APPLIANCES-RESIDENTIAL JOB DFSCRE'TION
ingwlth Scolon 7(00)of Dlvidon3 ofthe Budnessand Profesdonscode,and my
license I.In force anddfecc. PANELS
s _ -_PM j r
nate conZ(;S- CmUR 2m-
ARCHITECI`S CLAR/ ION IOOOAMIS
�Woo+OZO I understand my pians shsB be used as public records .. OVER I"AMPS SQ.FT.H AREA $/SQ.Fr.
6 oku Licensed Professional , SIGNSELECTRICAL
Ci Fd OWNER-BUILDER DECLARATION SPECIALCRCUIT/MISC '
71„ lherebyaRrenthat l am exempt from the Contractor's License law for the
following mason.(Section 70315,Business and Penfeasions Code:My city or
'pc ntywhichrmpu apermittommtmdalter,improve,dennlbh,orrepair TEMP'METER OR POLE INST.
P��ffi5anN any structure poor to its issuance,also requires the applicant for such permkto
Ole a signed statement that he Is Ilemsed pursuant t°'the provl.lo®of the '' ROWER DEVICES
3 w G Comoomrb License Law(Chapter 9(comrrennng with Section 7000)of Divi- SWM, NG FOOL ELECTRIC
HO� Sion3ofthe Business and Professimea Cede)orthat he b exempt therefromand VALUATION
4,0 the buts for the alleged exemption. Any violation of Section 7031.5 by any
ryQ applicant forapermitsub ria theapplicant to a civil eral f of nnrethan OUTLE'ISSWITCHESFiX7l1RF5-
e ?Euf fihundred dollars($500).
p tyo n
�cyy 1,as owner of the property,or employees with wa es as their sole NEW RESIDENTIAL ELECTRSQ.Fr. STORIES TYPE CONSTRUCTION
❑ P pent• Y8
cote(Se.tion will Mz Business
work and Hes Code:reh net Intended or coffered for
O sale(Sec appy to alnowandf property Code:The or Improves
Llcenu Law
(�$$ docs not apply torn owner orpropertywhoWilds nemporimproovided thatand - OCC GROUP 'RES' .UNITS
F
who does such w no not intended
orthwghhis owale.It owev riltab ildingor
Improvementsarcnotlntenomyearfferedfor leio.theo eer,lheerwgl ve TOTAL:
Improvementbwld within°rnyearofcompiniory theowner-bu0derwBl have
tf,Ltiurden of proving that he did not build or improve for purpose ofule.). '67y; �AUMBINGPERMIT,I n ` I"il FEE,1'. PEp DzDNE APN
u 1,as owner of the property,am exclusively contracting with licensed pERM17755UANCE
commerce,to construct the project(See.7044,Business and Preffesskaft Code: l A
The Contnn°l.Lt..law does ria apply to as owner of property who ALTER-DRAIN kVENT-WATER[FA)
Wilds or improves Hrero
eon, and who ntranch 0 for supt°)ects with a
actor(s)licensed pursuant to the Contractor's License Law. '{ FEESUMMARY
I am exempt under Sac.'- B &P C for this reason BACKFLOW PROTECT.DEVICE,
DRAINS FLOG ROOF, SANITARY V N_
Owner / l Date R AREA,GOND. RFLEIPrN
WOR KMAN COMPRINSATION DECLARATION ' Y
C31 hereby affirm that I have a certRcate of consent to sel(-Insure,or a PER TRAP SCHOOL TAXN_RECEIPT N
certltlate of Workeri Compevatlon lruurancernacenlfled ropythereof(Sea AS EA.SYSTEM-1 INCA 3800,fab C.) GFA Y_ N_
policy N CAS EA.SYSITM-0VER 4(EA) RECET T N
Com any r BUILDING DIVISION FE ES
Certified copy is hereby filed
the ityi GREASE/INDUSTRL WASTE INTERCEPTOR PLANCI'IECK FEE
Certified ropyb(ibd with the city inspection division. - - ,
CERTIFICATE OF EXEM PTION FROM WORK ERS' GREASE TRAP PAID
COMPENSATION"Wmeedift aper At fo SEWER-SANITARY-STORM EA.200FT. Date ReceI t#
(I'hb section need not be compined if the perMt b(�rone hundred dollars
($1(0)or less.) I WATER HEATER W/VENT/F1.ECTR ENERGY FEE Y N
I curly that In the performance of the work forwhich this permit is Issued, .4
1 shall not employ any person in any manner so as to become subject to the WATER 5YSIEM/TRFATING
Workers'Compensation Laws of California:Date PAID
O Z' Applicant - Dale Recei t#
Z O NOnCETOAPPLICANT:ILaRerr kingthls Cenlficateof Exemptomyou NEN!REIDENTIALPLMB. SQ}T.
PN should becomesubject to the Workers Comperuatlon pmvblom oflhe Labor TOTAL:
Code,you must forthwith comply with such provbiom orthis permit shall be
CC j dooed revoked. - - E FEE
a m
3 CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there b a construction lending agency for the perford, ELECTRIC FEE
Z anmoftheworkforwhichthispermitbIssued(Sec.3097,Civ.C.) TOTAL: 2S=
U O Landers Name PLUMBING FEE
14, I= Lenders Addmea - QTY: t,MEC HAN[GAC PERINITf 'FEE�'9' MECHANICAL FEE
O W Irertifym.tlluvereadthlsapplicdi°..rulaatethattheabovelnformatlon
b correct.I agree to comply withal city and county ordinances and state laws PERMTTISSUANCE FEES PAID:
TL relating to building construction,and hereby authodue representatives ofthis
?N city to enter upon the ahove�mentioned property for Wpeion purposes. ALTERORADDTOMECH. '
(We)agree to save,indemnify an d keep harmless the City of Cupertino - Date Receipt#
a g.iwtllabiliti's odgmenb,costsandexpenseswhlch.yinanyw.y.¢r a - AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL:
ag.iest said Clty y.consequence of the g ing of this permit. -
n _ a// 'S_L6 (..L AIR HANDLING UErIT'(OVER 18,000cFM) CONSTRUCTION TAX
S 11f(hature oflAp`p'Isiwnt/Contractor�/� Date ) EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
It HAZARDOUS MATERIALS DI SCLOSURE
Will the applicant or'futumbu0ding occupant store or handle haaardous HEATING UNIT(TO 100,000 BTU) Date Recel f#
material as defined by the Cupertino Municipal Code,Chapter9.12,and the
IieaRh and Safety Code Seem.75532(.)1 HEATING UNIT(OVER 100,000 BTI) TOTAL:
❑Yes " MN. '
Will the a ppllant or future W ilding occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE 1 ATE
which emit havrdous air conta Mvnts as defined by the Bay Area Air 'J A '1177
Qua lity Malugement Dist do? BOILER-COMP OHP OR 100,000 BTU)
,vc ❑No -
eea
if.e adHebazarJuusmode,bdi.. mentsunder 533..d25534..95of eon.ER-cOMr(OVErzIro,BaoBTU)
. AUG 26 1992
the GItandt at lith 6:Safety Code,Sectovntly have
at and,that i{
understand that lithe the
eonupant not erequire encs tenant that it met NEW RESIDENTIAL hfEC){. SQ.FT.prior to
theoccupantoftherequirementswhich must be met
prior to Lssuance ofaCenlfiate of Occupancy. CITY Vi vx/I'1L�INl.I IIVV
Owner or authodaad agent Data ISSUED BY:
TOTAL:
OFFICE COPY