23037 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES—, USE BALL POINT PEN ONLY
Building Project Identlflatlon - PERMITNO.
Building Address: I ^ O
o QVe. G V{
n ante:
CITY OF CUPERTINO-BUILDING DIVISION � /
I'M
e ,Name: Ne: 2
APPLICATION 1 PERMIT' L— ,4-7
BUI
rchltect/En a LDING-ELECTRICA4PLUMBINC MECHANICAL CATEGORY CONTROL Y
r Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address flr7l N• PERMITISSUANCE E:1 1:1 El LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l amllcensed under provklonsof Chapter9(comment, APPLIANCES-RESIDENTIAL - jOB DFSCRIPDON
Ingwith5 di n7000)ofDlvislon3ofthe BuslnessandPmfessionsCode,andmy
Hal is in a -' effect. � PANELS
Lice aIcp �� /� , '• �� /�
Date Contracto --
ARCHITECTS DECLA ION 201-1000 AMPS
�q+OCV I understand my plana shall be used as public records. OVER1f100AMPS SQ.FT.FLOOR AREA S/SQ.FT.
W I u Licensed Professional SIGNSELECTRICAL LED IN
V! - OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MLSC u E R
Z 1., N Iherebya/Orth tOWNE eUILDE m the DECLARATION
License Law for the
QQ following reason.(Sectlan 70315,Businessland Pnefeaalons Code:My Ary or
Ft'� countywhich requireaa per ttocor mcLMter,impmve,demlish,orrepalr TEMP.M=ORPOLEINST. rj -
'�
d statement that he k licensed pursuant to the provkkns of the
anyemcture prlorm its issuance,able requbeathe applicant for such permit to pOWERDEVICFS )ATE Z
ilia a dgne
HBOu, ConIrsROes License law(Chapter9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
O slon3oflhe Bualnnsandr,d.s mCode)orthathekettmptthemfromand VALUATION
< the bask for the alleged eaemptlon. Any violation of Section 70315 by any OUTLETSSWITCHD3,FIXTURFS
applicant for a permit subjects the applicant to a civil penalty of not room than
fivriundred doll..(S500). , NEW RESIDENTIAL ELECTR_SQ.Fr. STORIES TYPECONSIRUCTION
I,as owner of the property,or my employees with wages as their sole
G coreponetice,will clothe warkand thestructure is net Intended or offeredfor 1 ,
❑ ale(Sec,7044,Btedra and Profehslom Code:The Contractofs Lkeme law
, $ does not apply to an owner of property who builds or Improves thereon,and OCC.GROUP RES.UNITS,whodoessuchworkhmselforthrough hisown employees,provided that such
Improvements arc not Intended oroffered foreak.11,however thebuilding or TOTAL:
Improvement ksold within oneyearofcumpletlon the owner-bullderwlll have '
tlA,lvrden of proving that he did not build or Improve for purpose o(sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
U 4 as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors,to construct the project(See 700 Business and Professions Code:
ILe Contractors License law does not apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)
Wilds or Improves thereon,and who contracts for such iny" with • - FEE SUMMARY
colicensed Fuel to the Contoomar's License Law. BACK FLOW PROTECT.DEVICE
I,J I am esempl under Sec B k P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECEIPT I
WORKMAN COMPENSATION DECLARATION FIX.IVRFS PER TRAP SCHOOL TAX Y N
1 hereby affirm that I have•certificate of consent to selM1lnsom,ora RECEIPT Na
cert Cate ofWorkeri Compensation Insurance ova callcopy thereof(Sec. CAS EA.SY51'FMd WC.40UTLEIS PARK FEE Y N
- 3800,IaECJ •tnJ1 - RECEIPTA
Pollrya lt� a GAS EA:SYSTEM-Ol4(FA)
Com only
1 V BUILDING DIVISION FEES
ertNedmpykherebyfumished. CREASE/INDUMLWASTE INTERCEPTOR PLANCHECKPBE
coned copy k coed with the city Inspection dlvkmn.
CERTIFICATE OF EXRMPTION FROM WORKERS' CREASETRAP PAID
-
(This
SEWER-SANITARY-STORM EA200FTDate Revel tg '
Ohlesess.) need Act be completed](the permit k . .(�rone hundred dollam -
(S]W)orfytha permit WATER kFATER W/VFNT/ELWTR - ENERGY FEE Y N
' Icertlfy that In the performance o(thework for which this peitbkaed,
I shall not employ any person In any manner n as to become subject to the WATER SYSD7d/TREATHa7G
Worker'Compensation Laws of Califomk,Date PAID
0 Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Revel tis
Z O NOTICE TO APPLICANT:If,after making this CertRiole of Exemption,you
should become subject to the Workers'Comp m at ion provisions of the Labor TOTAL:
N Code,you resat forthwith comply with such provisions or this permll shag be BUILDIN '
W > deemed revoked.
O CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Ihercby affirm that them kaconstruction tending agency for the perform. ELECTRIC FEE
� Z once of the work lor whmi
khthk pedt ktuued(Sec,3097M,Civ.C.) TOTAL:
O O Iarlder's Name - PLUMBING FEE
LL I- liedce.Addree QTY. MECHANICAL PERMIT FEE MECHANICAL FEE tl
O.W 1 certlfythat l have read this application and statethatthe ancommlormatlon
1 kcormet.I agree to complywith all city and county ordinances and slate laws PERMIT ISSUANCE �. FEES PAID:
},y relating to building construction,and hereby authorlu representatives ofthk _
r Z city to enter upon the above-mentioned property for inspection purpose,. ALTERORADDTOMECH.
(We)agree to save,indemnify an d keep harmless the City of Cupertino - Date Recel PI#
.V against Babllltks,1utlgments,cosh and expense which they in anyweyacrnse AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: O
a i said City In conaequ re It granting f this p mpit. _ .
AIRHANDUNG UNIT(OVER 10,0MC17,M) CONSTRUCTIONTAX -
g tum of Applicant/Contactor rte I EXIiAUSTHOOD(W/D(1C'D CONSTRUCTION TAX PAID:
HAZARDOUSMATERI L DISCLOS RE
Will the applicant or futurebunding nt,lorer" lehazardous HEATING UNIT(TO 100,000 BTU) Date RCCCI tN
material as dcMed by the Cupertino Municipal Code,Chapter 9.12,and the
IlealtMand Safety Cede, NoEA
Section 25532(a)? HEATING UNIT(OVER 100,000 BTU)) - TOTAL: �tl0
Rill the applicant or future building occupant use equipment or device VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which endt havrdoua air mntaminants as defined by the Bay Area Air
Quality Management District? BOMER-COMP OFR'OR IOO,IXD BTU) - r P A ' D
Yea No
have read the hazy sue matedak requirements under Chapter 6,95 of BOILFR-COMP(OVER 100,000 BTU)
the California health k Safely Code,Sections 25505,25533 and 2SS34. I - DEC 26 1991
understand that lithe building does not currently have a tenant,that It k my NEW RESIDENTIAL MECH. SQ.FT
responsibility,to not lfy the occupant of the requirements which most be met
prior to issuance of a CcIrtlflcate of Occupancy. CU -
Ci r uF r'cl,I, .
..
Owner or authalzad'agent - DaleTOTAL: ISS
OFFICE COPY