24421 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification ez PERMIT NO.
Building Address: . ama� �/ 24421
ne: q A
w^era. arse: o
CY p, CITY OF CUPERTINO-BUILDING DIVISION
Con ' or a Name: 11 Lie.No: APPLICATION /PERMIT
BUILDINGELECIRICA PLUMBINGMECHANICAL CATEGORY
hect/ CO
rchEn Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:t41�L92Q PERhBT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commenc APPLIANCES-RESIDENTIAL OB DFS RIIMON
in
Ingwlth Sedton7000)of Division3oftheBmineseand Profs msCmdc and my
Licenssela�lassfill6mve and ekfep til
Date 19.71_, Contract �l
ARCHITECTS DECLARATION 201-1000AMPS
I understand my plaru shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
O
�j
Licensed Professional SIGNS ELECTRICAL
D6 OWNER-BUILDER DECLARATION SPECIALCR(CUIT/MISC {►, {/V
t'�a Ihercbya(Orm that]firs exemptfromthe Contractor's,Licenx law fmrthe
pp following...(Seatlmn7W15,Businessand Professions Ccde:Anycityor
county which requiersa permit tocowtruct,alter,Improve,demolish,orespalr 'TEMP.METER OR POLE INST.
anystructure pdortolGl ance,alsorequl theappUnntforsuch permitto FEWER DEVICES
file a signed statement that heat lacnaed pursuant to the provisions of the
�04 Contractor's License Law(Chapter 9(commencing with Section 70W)ofDivi.
�0 slon3of1hellusinessandProfemiormCode)orthatheuemmptthemfmmandNG POOL ELECTRIC VALUATON
the basis for the alleged exemption. Any violation of Section 70315 by any Q�N'� OO N-V
appllcantfora permit subj[sthe applicant to a civil penalty of mat morethan ETS✓WI1CIiFSH)(nREs I� U
five hundred dollars(5.500).
�n ❑I,as own
er of the property, employees their
NEWft DFN77ALELECTRSQFI. SOWES TYPECONSTRUCTION
compematlonwBldotheovork and thestrocture at not Intended or
offered for
O
Is(Sec.70K Business and Professions Code:The Contractor's License La
j $ does not apply to an owner of property who builds or improves thereon,and
F-$ whodoes,such work himxlforthrough his awn emplo)ees,- decithatsuc OCC.GROUP RESUNII5
Improvements are net intended proffered for sale.If,however,thebuilding or `
Improvement Issoldwithln oneyearofcompletlon,the owner-bullderwill have
thetxrrden of proving that he did not build or Improve for purpose of sale.). QTY. B RMIT FEE F DZANE APN
u L as owner of the property,am exclusively contracting with licensed
mntexctrns to consumer the project(Sec.7DK Business and Profession Cade: PERMI T
The Contractor's License Law does net apply to an owner d property who ALTQLDRAIN 4 -WAIIIt 7
builds or Improved thereon, and who comment for such ptojects with a WA) le
,��lLffdor(s)11cen.e puouanttothe Contnctor'a Licenx Law. FEE SUMMARY
co
am exempt under Sec. B k P C for this reason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N
Owner EC RECEIPT'N
I WORKMAN COMPENSATION DECLARATION FIXTURFS PER TRAP i SCHOOL TAX Y_ N_
�l hereby affirm that I have a cortificate of conxnt to xB-Nsuce,or a 12 RECEB'C N
cedificete ofWmrken Coe'res. onlnueanceceacediflM copythrreof
380,Iab C.) S W
GASEA. C.4OUTLETS PARK FEE Y N
Polity N GAS EA.SYSTEM-OVER4(EA) RECEIPT M
Com ray BUI LDING DIV]SION FE ES
refilled copy Is hereby famished. GREASE/WDU L I R PLANCHECK PC'c
sax
Certified ropy V filed with the airy inspection division. A OS
C 6� 5
CERTIHCATEOFG(gMPDON FROM WORKERS' GR G'"c�L� "` PAI
COMPENSATION INSURANCE :$AMTpft STrOItM ^
(Thisdectios need not be completed if the permit is forms,hundred dollen 1 Dale RLYCI t#
(stao)rtifcertify that
WATERHFATIRW/v /¢EctTi ')' ENERGYFEE Y N
I shall notemploy any person in any manner do an to become subject to the
wmrkea compenenaatmn caws of California.a.Date e PAID
O Z Applicant Z O NOTICE TO APPLICANT.if,after making this Certificate,of Exemption,you NEW RESIDENTIAL PLMB. �}T, Daft Recei f#
FW should beoomeaubjeet to the Wmrken'Cumperuation provisions ofthe Labor TOTAL:
Code,you must forthwith comply with such provisions or this permit shall he t
LU > dermd revoked. BUILDING FEE
dCONSTRUCTION LENDING AGENCY SEISMIC FEE '
1 hereby affirm is ELECTRIC FEE
that there at a contruction fending agency for the perform-
Oance of the workfor which that permit Issued(See.3097,Civ.C.) ��
V I<sder's Name PLUMBING FEE `.
LL F Lender',Adderss FF QTY. MECHANICAL PERMIT FEE MECHANICAL PEE -2: r-
.O W Iced] thatlhavereadthisa Bationa^dstatethatthcaboveinfo vtlo
LU ismrrect.l agree to comply withal)cityand rountyoromorcestrol leo elawa PERMIT FEES PAID:
} W relating to building construction,and hereby authomee reprexntatives of th:a
F Z ciiytoenter,upon t aboveonvnt p yfor Wpectionpurposea. ALTERORADDTOMECH. Dale R2CCIP1#
— (We)agm v Inde a harmlevthe City of Cupertino -
agaie,tliabi me ,cm nxa which may In anyway accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
C. co a rating of Chi a permit.
3 AIR HANDLING UNIT(OVER 1,000CFM) CONSTRUCTION TAX
tureof Applicant/C tractor to EKHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000BTM Date C ] #
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Scnion25532(a)7 HEATING UNIT(OVER 100,W0 BTU)
Yes M No TOTAU1
Willtheapplicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
�aa ity Management District? BOILER-COMP OHP OR 100,0M BTU)
havereacithshavNouamaterialvrequlmm nbunder Chapter6.95of BOILER-COMP(OVER 100,000 BTU) a I�yv
the California Health k Safety Code,Seatiom 25505,2593 and 25SM. I H LLY
understand that lithe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQXT
ropy to Issuance
nailythe
icate on ccupaof the requiremenle which most be ort -
prfmrtmissaanrem,aCedifieate mfDacvpanry. JAN 27 1993
Owner or authodzed agent Out L jISSUED BY:rIJf'L
OFFICE COPY