23151 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Build Log Address: 23151
?6 z o� E n
ears came: one: A q
C c3d Ci4 vAe ff CITY OF CUPERTINO-BUILDING DIVISION 1 'Z
c°ntrennra Name: Lie.No: APP I ATIO P RMIT
BU1LD1IJ TRICAL B M HAMCAL CATEGORY CONTROLM
Architect/Englew,. Lk.No:
QTY ECTR P FEE BUILDING PERMIT INFO
Address: SSUANCE A 1:1 El
CONTRACTOR'S DECLARATION
,vithSyti 70thatlam Monaedhe Ber rovtslom°fC,j.ter9dm,and c ANCES E. L 08In ON
Inonsei in
force anDtvifect. the Budneuand ProleaioneCode,and my 0006 (
limnx Is In full force and d(e# s/ w
DateLiceClam Lim p
Dale Contnnor
ARCHITECTS DECLARATION t-1000
re0 Z I understand my plans shall be used as public rem ds. VER I AM SQ.Fr.FLOOR AREA S/SQ.FT.
O
Z to Licensed Pmfesi°nsl SIGNS ELEC L
<c, OWNER-BUILDER DECLARATION SPECIALCRCUfT/
F Z Ihercby a(llrmthatlam exemptfmn
from Contraora License Law for the
Z O..-' followin ....(5ectlon 70315,Busineu and Pro(mlona Code:An ci or
�yFp'c� county which requbesa permit rommtruct,alter,improv,dennLLsh,m erpair TEMP.MEI77i0 LE INST.
anystmu mpr rto Re Wuancealsomquireatheapp8wntforsuchper tto POWER DEVICES
Q 3 a file a signed statement that he Is licensed pursuant to the provbiona of the
Ou. Commences License Law(Chapter 9(commencing with Seaton 7000)of Divi- SWBMMING POOL ELECTRIC
O don3ofthe Busi .e dPmfextons Code)orth&hebexempttherefmmand VALUATION
Y.' the basis for the alleged exemption. Any violation of Section 7811.5 by any O �+
' < applicant fora permit subjects the applicant to a civil penalty of not more than OUTLETSSwITCHESFIXfURPB
five red set of t(5500). NEW RESIDENTIAL ELECTR
i s owner of the property,or my employee with wage az their sole �'�' SIOWES TYPE CONSTRUCTION
Frenetic ,wdI do the work and the structure is not intended or offered for p
O Ie(Sec.7044,BualMss and Professiom Code:The Contractors Llcetue law
$$ don not apply to an owner of property who builds or improve thereon,and
whodoessuchworkhlmselforthr gh Msownemployeeaprovided thatsuch �' I-• f1 '«C R .UNITS
Improvements are not intended°roffered formic.If,howeverthebul)dingw T LTJ' �-•v �I
Improvement b sold within ane year ofcompidlon,the owner-bullderwill have
thg*"Icn of proving that he did not build or Improve for purpose of ask.). QTY. PLUMBING PERMT •E ,N
IZJ�aas owner of the property,am exclusively contracting with licensed pFRM17ISSUANCE
undranon to construct the project(Sec.7044,Business and Pm essbm Code:
The Contractor's Limnse Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)builds or Improves thereon, and who contracts, for such p4oicm,with a
m,tdTactor(s)Ilcensed pursuant to the Contractor:License Law. FEE SUMMARY
IJ I am exempt under Sem B&P C for thin meson BACK FLAW PROTECT.DEVICE
Owner DRAINS-FLOOR ROOF,AREA,GOND. SANITARY Y N
Date RECEIPT#
WORKMAN COMPENSATION DECLARATION
❑1 hereby affirm that I have a mrtifiale of consent to self-insure,ora FIXTURES.PER TRAP SCIiODL TAX Y N_
mrtiBateof Workers Compensa0on Insurance or a certified ropy thereof(Sec. RECEIPT#
3800,Lib C.) GAS EA.SYSTEM-1 INCAOUTLE15 PARK FEE Y N
Policy Y RECEIPT#
Cum any GAS FA.SYSTEM-OVER 4(EA) BUILDING DIVISIONF'EES
Certlfied copy in hereby furnished.
[3Cerlmed copy is filed with the city Inspection division. GREASE/woUSM WASTE INTERCEPTOR PLANCHECKFEE ^
CERTIFICATE OF EXEMPTION FROM WORKERS' GRE'A'SE TRAP PAID 9,.-7 '!57
5
COMPENSATION INSURANCE SEWERS NTTARYSTORM EA"FT Date Recei t#
Rhissenlon need out be campined lithe permit la ne ionohundred dollars
Imrtifyify that
ENERGY FEE Y
(4100)rVENT/ELECTR hat In the performance o(thework(orwhkIssued,
h this permit lsWATER HEATER W/ —
N
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
workers'Compensation laws of Callfomla.Date PAID
O Z Applicant
Z O NOTICE TO APPLICANT.If,after making thin Certificate of Exemj"b you NEW RESIDENTIAL PLMB. SQFE Date Recei t#
should become subject to the W°rken'Comensation pprovisions of the Labor TOTAL:
W~ W Code,you must forthwith comply with such provisions or this permit shall be
> deemed revoked. BUI DING 'E
CL o CONSTRUCTION LENDING AGENCY SEISMIC FEE _
M Z fhercbyaffirtnthat there in a mmtmctlon lending agency for the perform- SEISMIC
FEE
an¢of the work for which thin permit Is issued(Sec.3097,Civ.C.) TOTAL:
U O Lender's Na PLUMBING FEE
LL L mdeespddreaa QTY. MECHANICAL PERMIT FEE
O W Icortifythatl hsvercadthis apptlatlonaM statethat theabovemformation MECHANICAL FEE
LU is corms Iagree to comply with all city and county ordinances and state laws PIRMITL94UA ci: FEES PAID:
>. N relating to building construction,and hereby authorize representatives of thin
Z city to enter upon the above,mentioned property for Inspection purposes. ALTER ORADDTOMECH.
_ (We)agree to save,Indemnify an d keep harness the City of Cu pectins Date Receipt#
against liabilities,judgments,mats and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against mid Ci Inconsexplenceofthegrantl athi penult.
AIR HANDLING UNIT(OVER 10,oao CFM) CONSTRUCTION TAX
SI tort ,pliant/Con neon P Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Ill the applicant orfrtam building oaupant store or handle ha>ardous HEATING UNIT CFO 100,00 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the Date Recel t#
Health and Safety Cade Section 75532(,)? HEATING UNIT(OVER 100,000 BTU)
M Yes M No TO
Willtheappliant or future building occupant useegWpment ordevices VENTILAITONFAN(SINGLE RESSD) ISSUANCE DATE
which ant Inurdous atr mntanrunb a defined by the say Ares Air
Quality Management District? BOILER-COMP OIMOR 100,000 BTI,
qYe n No
have read the It ons material,reqM
requirements under Chapter 6.95 of BOILER-COP(OVER 100,000 BTU) !P 4A 6611
the California Health&Safety Code,Sections 75505,75533 and 75534I i0
understand that lithe building does net currently have a tenant,thntit is my NEW RESIDENTIAL MECH. SQ.IT.
resporeiissusne of a Ceheicmp.nt of theteofOcui ps ncquircmentswhich must be met JA�y 02 1992
prior ts Lvuty to°fay theBcateof Ocmpa nq. •r a_ �J�J
Owner or authorlrcd agent pate 1 I�1 Y
TOTAL: ISSUEDBYY
OFFICE COPY