22799 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
13WIdingAddress: Lt*
� , R GG I( 7VI
ne ante: one.
-e CITYOF CUPERTINO-BUILDING DIVISION 61
Con ra ors _ _ Lic.No: APPLICATION / PERMIT
e I,Le P [ti C BU LDINGELFCTR CAL MBINGMECHAMCAL CATEGORY OE
f .�Amr'mct/Engines¢ CO Lk.No: 10Nq
Addmnn:a-77a Le-U-D
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
-
.O/I PouarlssuANCE
LICENSED CONTRACTOR'S DECLARATION .
I hereby affirm that l am Rcensed under provisions o(Chapler9(commen APPOANCESRRSIDE L ]Oe DESCRIPTI2V
Ing with Section 7000)of Division olthe Business and PmfcamoraCode,and m TT
license le In(uLL( and m(. PANELS �
Lice nre Class Lk.X _ V\`aa'
Date Contmcto
ARCHITECTS DECLARATION I
µQS 2 I understand my plans shag be used a public remtda. AM �SQ.R.I7.00R!ViEA $ .Fr.
E� Llcensed Professional SIGNS ELEC ' L 325 yrni 3
«<< OWNER-BUILDER DECLARATION SPECIAL CB2C /s�yyOQ
7i.., Ihereby atBrm Wtlem exempt(romthe Contractor's Llrenss law(m `-�-
o following reason. 41
7Qi1.5,8uslness and Pro(esilona Code:Any dty
ct =nty which requires a permit to construct,salter,impmve,denollsh,orrepalr TFMP•ME I LB INBT. w�� `�
3il777 anystructumpdortoitsluuanceal mquimatheappRentforsuchper tto r
stD
OV the a mns
gned statement that he V Ilreed pursuant to the provisions of the TOWER D CES
3GGYw(� Contractor's License Law(Chapter 9(commencing with Section 7(RD)ol Dlvl- NC POOL ELECTRIC
X07 cion 3 of the Business and Professions Code)orthat he V exempt therclromantl VALUATION
�n.••7777 the basis for the alleged exemption. Any violation of Semon 70115 by any ���� ``
fiveapplicant fora permitaubjects theappllcam too dull pensltyof not more than OU7LETSSWITCHESFI)CMtES
flue I Aas owner
of the pr. NEW RESIDENTIAL ELECTR SQ,Fr, STORIES 'TYPE CONSTRUCTION
e s owner of the properly,or my employees with ween as thele sole
P a c 1c IS,, 044,wfildBoxi thework,andthemmde:The C ntractintende or ictrue,d forLaw ,
O
does
e(not apply to asnsowne d Professions Code:The Contractors hereon Law
docs not apply to an owner of property who n builds or Improvesded t art and OCC.GROUP RES.UMTS
who doessuch mentsa not
elf or dedorough hisowne.If,hoeer,thedthatauchg or y�,�_
improvements am not Intended oro(lered tonal¢.](,howevegthebullding or T
improvement hwld withlnoneyearofcompletion,the owner-bullderwlll have 'All me 15
Il urdenofpmving that he did notbuddorlmprovelorpurposeolsale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APNr
uu L as owner of the property,am exclusively contracting with licensed PERMITISSUANCE
contractors to consttud the project(Sec.7644 Buamman and Professions Code:
The Contractors License Law don not apply to an owner of property who T
Isea
ALTER-DRAIN&VENT-WATER[FA)
Wilda or improves thereon, and who contracts for such plolects with a
off�gBtTaRar(s)homsed pursuant to the Contractors License Law. 1R D FEE SUMMARY
loom"am exempt under Sec B k P C for this rcnon _
D NS FLOOR;ROOF,.
'SANITARY Y N
Owner Data REC=N
WORKMAN COMPENSATION DECLARATION PER SCHOOLTAX Y N
I hereby affirm that I have o lmurate of consent to self-Insure,ora RECEPT N
rertifin[eofWorkeri Compensatienlnsuranceoracertl(kd ropy thereof(Bee. GAS EA SYSI'EM1 O PARK PER Y N
3800,Lab C.) ,I
Pollq GAS • .SY RECEIPT X
Company BUILDING DIVISIONFEES
L Cer ified copy is he d with he city CREASE/INDUSTRL WASTE INTERCEPTOR PLAECK FETI,,``aaaa,,
�Ccrtifled mpybflled with the city Inspection division. _ ,41F' 1 �/sa
CERTIFICATE OF EXEMPTION FROM WORK ERS' GREASE TRAP PAI
COMPENSATION INSURANCE SEWER-SAMTARY-STORM F.A.200FT. DBfC Ccel t#
TTM.sedion need not be completed lithe permit is for one hundred dollars ssss3////��I��I^��
($10 mdifyss.I WATER HEATER W/VENT/ELECTR ; G N
I cert ieso.)t N the performance of thework lorwhlch this permit Is Issued,
I shall not employ any peraon in any manner so as to became subject to the WATER SYSTEM/TREATING
Workcrs'Compensatlon Laws of California.Dae PAID _
O Z Applicant NEW RESIDENTIAL PLMB. Date R Q�j
Z 0 NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you _SQd'T• X`+
ahwld beconr subject to the Warkets'Compensation provisionso(the Labor TO-PAL:
I^ N Code,you must forthwith comply with such provlalonsor this permit.hall be BUILDING
FEE
W > seemed mvokea. SEISMIC FEE
CONSTRUCTION LENDING AGENCY
CL O Ihereby.M thatthemis ocrawctlonlending agency for the perlomm TO ELECTRIC FEE Iia p-
Z ance of the workfor which thbpermit k issued(Sec.3D97,Civ.C.)
00 Iznder's N.. PLUMBING FEE
LL F- I<nder's Address QTY. MECHANICAL PERMIT FE MECHANICAL FEE
OW Icertifythat I have read this applicalionand state that theabovelnformatlon
C Ismrred.Iagree to comply with all city and county ordinances and mate laws PERMITISSUANCE FEES PAID:
r W mlating to building mnstrudfon,and herebyauthorizerepresentativesofthls Z /164
Z
city to enter upon the above-mentioned property for Inspection purposes ALT17t ORADD'N MECH.
(We)agree to save,Indemrdly an d keep harmlen the City of Cupertino Date Recei t#
V against liabilities,judgments,costs and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,foo CFM) SUBTOTAL:
ago Lot said City in consequence ofthe granlingo(thlepermit AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX 6 7
. grata an
Appht/Conte m Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE _
Willtheapplicanl orfuture building occupant store or handle hazardous HEATING UNIT(TO 100,000 BN) Date RCCCI t#
material as defined by the Cupertino Municipal Code,Chapter9.IZ and the -
Ikalthand Safety Code Section25532(a)t HEATING UNIT(OVER 100,000 BTU) TOTAL: 63
M Yes M No
Will the applicant orfuture building occupant use equipment or devices VENTILATION 17AN(SINGLE RESTD)) ISSUANCE.....-
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Mansgement DBtnd7 BOILER-COMP OHP OR 100,003 BTU)
4 Yea g No
have read the hazer et Code,lsregWe25505, 5533underand 25534.
of BOR.GR-COMP(OVER 100,000 BTU)he p� p '
oCaltfomla Health&Safety Code, of currently
have a tenant,that
1 Ir M
- understand that if the buildNg don not mmently havcatenanl that ltbmy h'EW RESIDENTIAL MECH. BQ.FT `\
responsibility to net lfy the occupant of the requirements which moat be met
prior to issuance of a Certificate of Occupancy. JAN 29 7992
Owner or authonzed agent Date ISSUED ��
TOTA17
OFFICE COPY