20913 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building project Identification I PERMIT NO.
Building Address:,Z . I �auA17— �� 126�� , ��a 20913
Ltwsere acre: /7/ one; .
G - r L/N CITY OF CUPERTINO-BUILDING DIVISIO �/ O
c°"o-adara"ante: Lie.No: APPLICATION / PE5MIT
BUTLDINGELECTRICALPLUMBING-MEC CAY f CONTROL / h
Archltect/Engineer r Lk.No: CJ J
Liu QTY ELECTRICPERMIT FEE ING PERMIT INFO
Address: �0 /O v ry I� PER]WHISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions o(Chapter9(commene. APPL1ANCESRESIIjElkI1WJOB DESCRIPTION
ingwith Secdon7000)o(Dv1,ms 3ofthe Busie suland ProfessloesCode,and my
LJcAr lCL.ss fo___L fed.
License Clan Lk.M A
Date Contractor T
Y,/S G,r.
ARCHITECTS DECLARATION 20-1
p�p�uu
9
0 ZO 1 understand my plans @hall be used as public records. WERTIJJOAMSQ.Fr.FLOOR AREA I $/SQ.FT.
E E Lim"xd Professional NS ELEC
]6 OWNER-BUILDER DECLARATION SPECIAL CIR T/
7 f,ui (hereby af@rn that am exempt from the Contractor'@ License Law for the
O
following reason.(Sedlon 70315,Business and Profession@ Code:Any city or TEMP.METER POLE ST.
Pry cmntywhich requlresa issuance,also rsuch,alter,impmvent fors ch,orreitto
a neasuRurctatemetthpriortolls atheisalcensed ursuamthe npplcaetlmmionsofte POWERDE'VICPS
y V ,Ie a signed statement that he V licensed pursuant to the provisions of the
O w Contractor's License Law(Chapter 9(mmmendng with Section 7000)of Dlvl-
30 sion3 ofthe Buslnnsand Professions Code)orthat be lsexempt tberefmnand SWI.ShtING LELECIRIC VALUATION
the bade for the alleged exemption. Any violation of Section 7031.5 by any OUTLE SWITCHPSFIXDO�
apphcant for a permit subjects the applkant to a civil penalty of not nnrethan 'NRFS 6
five hundred dollars($500).
'9..' ❑1,as owner of the property,or my employees with wages as their sole RESID1 TIAL ELICTR SQ.FI'. STORIES TYPE CONSTRUCTION
compensation,will do the work,and the structure b out intended or offered for
0 sale(Sec 7014,B.umsuand Pwfenlons Code:The Contractors License Law -
$� does notapply to an owner of property who Wilda orimprovesthereoo,and OCC.GROUP RES.UNITS
CRR,: whodoeasuchworishimeself orlhrough hisown employee@,provided that such
m --
improvements are not intended oroffered forssls.If,however,thebuildleg or TOTAL:
int , itswI i withinomrarofcompletlon,theowner-buUderwill have
t rdenof Provleg that he didnrt build or Improve for purpose ofsale.). QTY. PLUMBINGPER T WD ZONE APN
a@ owner of the property,am exclusively contracting with licensed PERMIT AN
curs, n to construct the project(Sm 70K Business and Profasslom Code:
Contractor's License law don net apply to an owner of property who ALTERARAIN k -W 1'ER 11
Wilds or Improves thereon, and who comment for such p(oject@ with a u FEE SUMMARY
s$g((ador(s)Brensed pursuant to the Cushadars License Law. BAIX FLOW PRO E'` a
L_j I am exempt under Sec. B k P C for this mason
Owner DRNNS FLOOR ROO ND ARY Y N
Dale RECEIPT@
WOR KMAN COMPCNSATION DECLARATION FIX.fIJR� SCHOOLTAX Y N
❑I hereby affirm that I have a co ificatesuranc of convent to opytherrc,ora RF-CEIPT X
3800,1&1,of Workers'CompeswHonlnsunnmora mrdfkd copythereof(Sec.
3800,Lab C.) GAS FA.SYSTEM-]INC.40UTLLTS PARK FEE Y_ N
Policy 0 GAS PA.SYSTEM-OVER 4(EA) RECEIPT M
Cam any BUILDING DIVISION FEES
�Cesti,edcopy is hereby fumi.hed. GREASE/INDUSDtL WASTE INTERCEPTOR PLANCHE KFEE
Certified copy la Ned with the city Inspection division. ys a�
CERTIFICATE OF FXEM PTION FROM WOR KERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM G.200FT. ate RCtt'I (#
Qhis aedion need red be completed Bthe permit la fesone hundred dollars
($10eaddyth WATER HFATER W/VENT/ELECTR ENERGY FEE Y N
I mout thatinthe person mm�y mares,.hework as
become abject to the
0 WATER SY5TEM/TRrATINC
Workers Compenntion Lova al Gl(omla.Date PAID
Applicant
Z � NOTICE TO APPLICANT:If,after making thio Certificate of Exemption,you NEW RESIDENTIAL PLMO. SQ.Ff. Date Recei t#
Should 1x mesubject to the Workers Compensation proelelom of the Labor TOTAL:
N Code,you=at forthwith comply with such provisions or this permit shall be
7 deeed revoked.
BUILDING
W
mCCONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there Is a construction lending agency for the perform ELECTRIC.FEE
Z ancoofthe workforwhichthla permit is Issued(Ser.3097,C0v.C.) TOTAL ELECTRIC EEE
o2 1-ender.Name
LL H Under'@Add.. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I mdilythat l haveread this applica,anand atatethat theabove information
4 Iscorrcd.I agreelo comply with all city and countyardinances and State laws PERMIT ISSUANCE FEES PAID:
} N relatingtobuildi.gmnetrudi.n,..dhercbyawthorlumpmwntativnofthis
Z city to enter upon the abovcmentioned property for Inspection Purposes. ALTER OR ADD'TO MECH.
— (We)agree to nve,Indemnify an d keep harmless the City of Cu ped Ino —Date
Against liabilities,judgments,mets and expenses which may in Any way accrue AIR HA NDLING UNIT(TO 10,000 CFM) BT AL'
againtsaid Clty onaegyees'aft a sting of this permit.
2 Zst AIR HANDLING UNIT(OVER 10,ODOCFM) CONSTRUCTION TAX
Si of Appilcant/Comradar Date EXFIAUSr HOOD(W/DL)CT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE _
Will the a ppticantorfuture building ocm pant store or hand Is hazardous HEATING UNIT(TO 100,000 BTU)
.tM,i.lasdefinedbytMCupedino M.Wdpal Cad,Chapter9.IZandthe Date Rmci t#
I lea,h and Safety Code Section 75532(a)? HEATING UNIT(OVER IOD,OID BM TO
❑ YesNo
Will the applicant or tare building occupant use equipment or deviate VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit havrdous air contaminants as dented by the Bay Arca Air
Quality Management District? BOILER-COMP OFR'OR 100,000 BTU) f251 L1 I RT
4 Yea 1 1 No r U N
i have read the hazy sus materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
understand tharrua t lithe buildinealth g doesnet currently e3 tenant,tha3 and t it is my NEW RESIDENTIAL MECH. SQjrE AUG 25 1992
rnponsiblity to nobly the occupant of the requ lremenls which creast be met
prior(o issuance of a Certificate of Oo stpancy.
GIIY Ur vorcr ,
Owner or authorized agent Data ISSUED OY;
TOTAL
OFFICE COPY