23805 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulldin Pro'en Identification - PERMIT NO.
BWIding Address: �� 1.2-57-656 23805
cera ante: one: APPLICATION SUBMITTAL
CITY OF CUPERTINO-BUILDING DIVISION _
Contractor's Name: L j. APPLICATION /PERMIT O
BNLDING-E,ECTRICAL-PLUMBING-MECHANICAL CA RY CONTROL X
rc hed/Engineer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO -
Add ;203-7 O PFRKTISSUANCE _00 � � ❑
LICENSED CONTRDECLARA
ACTOR'S TION
I hereby affirm that l am licensed under ptwWonsof Chapter 9(commrec APPLJANCESRESIDENLAL JOB DESCRIPTION
Ingwlth Secrm700D)of Dlvtdon3ofthe Busln esaand ProfeulonsCode,and my
11 LlmnxlClam.�ILf^q��NdLIc.8 'LS513'ID PANELS /
Date_/__/i,._l�J.a Comut., �` (�L�
� ARCHITECTS DECLARATION 701-1000 AMPS
aO pO I understand my plans shall be used as public records. OVER 1000 AMPS SQ.F7.FLOOR AREA 5/SQ.FT.
Ez(0 Licensed Professional SIGNS ELECTRICAL
6 OWNER-BUILDER DECLARATION SPECIALCIRCU1T/MISC
F, Ihereby affirm that l am exempt frornthe Contractor's License Law for the
Z following reason.(Section 70315,Business and Professions Code:Any city or
TEMP.METEROR POLE INST.
5 =y.tmnimpr rtoia mdttocoorequ altheapB=tfwsus prrepairito
ale.si fined statement
he I,alcensed pursuant
of
POWER DEVICES
file a signed Matement that he b licensed pursuant to the provisions of the
3 w Contractor's License law(Chapter 9(commencing with Section 7000)of Diet. SWIMMING POOL ELECTRIC
F, OJ ekn3ofthe Bus eumdPmfenlom Code)orthathehemmpttherefmmand ..��3 VALUATION
E9 ...777 the basis for the alleged exemption. Any violation of Section 70315 by any OUTLETSSWITCHESPIK'I'URES a J V
pappH.t fora perms subjeneithe applicant to a civil penalty of not caner than
$ five hundred dollars(SM. NEW RESIDENTIAL ELECTRFT.
❑I,as owner of the property,or my employees with wages as their sole STORIES TYPE CONSTRUCTION
7a compensation,will do the work and the stmdure is not Wended or offered for
❑ ule(Sec 7044,Business and Prof®koro Code:The Contradoes LI¢roe Law
�$ does not apply to an owner of property who builds or Improve,thereon,and OCC.GROUP RFS.I1N175
who does such work himselforthemgh his own employees,provided that such
Impmvementsamn Ntendedorofferedforuk.ILhowever,thebulldingor TOTAL: �r0
Improvement issoldwithlnoneyearolcompletion,theowner-builderwill have
t rden of proving that he did twtbuudorlmpreveforpurpoaeofule.). QTY. PLUMBING PERMIT FEE
as owner o!the property, FLOODZONE APN
L p party,am exclusively Business
contracting with Reamed PERMIT ISSUANCE
The Co.rstocoroWdtheproject(Sec.apply
BusNessand of pro oro Code:
The Conendproco's esLicthen Lew aces n¢apply tct an owner of property who ALTER DRAIN A VENT WATER(M
builds t r Improves thereon,and who urd e. !m such plvjem w!th a FEE SUMMARY
�q_j I a e empt pursuant m the C.ntnctor'a LI¢nse Law. BACK FLOW PROTECT.DEVICE OUTSIDE FLIIS
LJ I am exempt under Sec 'B h P C for this reason
Owner Drte DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N
• RECEII'I X
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP "001 SCI TAX Y N
�1 hereby affirm that I have a certificate of consent to self-Insure,ora 1/ RECEIPT M
certificate of Workera'Compematlon haunn¢ora caddied mpythertrof(See. GAS EA.SYSTEM-1 INCA OUTLETS PARKFFB Y N
3800,GbCJ RFCEB NM
PultcyX skno,7E Fuu�
aG OVCffCyNed copy ts,hereby furnished. ER4(EA)_ BUILDING
DIVISION FEES
F-1 Certified ropy 6 filed with the city Inspection awbm . G E/ 1 R PLNCHECK FEE
CERTIFICATE OF EXEMPTION FROM WOR KERS' G .IRp(si I`( ♦� PAID
COMPENSATION INSURANCE SEWER.SAMTARY- 50 1' Date Revel tN
ITNssedlon need n¢becomplded lithe perout h(Drone hundred dollars
a100).rfess.) 09
WA ENERGY FEE Y N
I¢rtlfytfiat Ntfie perforrran¢olthe work fgrwhiN this permit lshmed, i
I shall not employ any person ts any manner n as to became subject to the WATER SYSTEM/TREATING
Workam'Compemationlawsof California. Date PAID
SQFr. Date Revel t#
Applicant
Z O NOTICETO becomer.bjeAM:U,after residing this Certificate o(&emptbn,you NEW RESIDENTIAL PCMB.
H Code,you
forth it the
co Workers'xuciprowlslo teen s Lab he TOTAL:
W Cade,you rtwst forthwith comply with auU proWlgro grthls permit shall be
BUILDING 410
W j deemed revoked,
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Iherebyaffirmthat there Is a construction kndlegagenry,for the perforrm �D
Z) Z anceoftheworkfor hkhthb t is Issued(Sec.3097,Civ,C.) TOTAL: ELECTRIC FEE s 4
O O lender:Name fJ.O N PLUMBING FEE , 00
F Lenders Add. QTY. MECHANICAL PERMIT FEE
LL MECHANICAL FEE
O W (cent.I agree
havemply with
aBcaty and cmtatethatthe aabovedAsia laws
IL bcoingt building complywlth a and
countyize representatives
and Asiaftwe PERMIT ISSUANCE PEES PAID:
} fA rehting to building construction,and hereby authorize repre,enlativn afthh
U) city to enter upon the abovo-mentloned property for Wpectlon purposes. ALTERORADDTOMECH. Date Recei tp
V (We)agree to save,indemnifyan d keep barrel.the City of Cu Facile.
,agoiatl titin,judgments,oats and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: 6
ggalroI Citylnc.nP.rmardthegrant gofthlapertnit, AIR HANDLING UNIT(OVER tO,WOCFM) CONSTRUCTION TAX
Signfureof Applicant/Contractor Date EXHAUSTHOOD(W/DUCT) CONSTRUCTIONTAXPAID:
-
HAZARDOUS MATERIALS DISCLOSURE
Will the appllunt or future building occupant store or handle haeardous HEATING UNIT(TO 100,000 RTU) Date ROCeI til
material as defimd by the Cupertino Municipal Code,Chapter 9.1 7,and the
Health and Safety Code Section 75537(1)? HEATING UNIT(OVER 100,000 BTU) TOTAL: +D
M Ynrla��b No
Wllltheapplka.torr'vturebuilding.pantuuequipmentocdevlces VENTILATION PAN(SINGLE RESID) ISS�j Cff ATE
which rout hazardous ale contamirunh as defined by tha Bay Area Air N
Oijahty Management District? BOILER-COMP OHPOR 100,000 BTU)
YY. P❑�No �y
have read the M1azardOus materials requirements under Chapter 6.95 of BOILER.COMP(OVER 1W,OfJO BTU)
'JUN 10 1992
the California Health A SafetyCede,Sections 75505,75533 and 25534.1
understand that if the building don not arremly have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT
respmaibgity to not iy the occupant of the requirements which most be met /s
prior to Issuance of a Certificate ofOccvpamy._ C11 T Ut- G'Urr ri I IIVl)
Owner en authorized agent Date ISSUEDBY: y,
-h Ilea
TOTAL:
OFFICE COPY