23253 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ear IdemUleadan PERMITNO.
Building Address: 23253
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EA/A!/5 CMR$/i G/K aS7- LIGO(,. CITY OF CUPERTINO-BUILDING DIVISION 'S „ s— /9' 4�_
Contractor',Name: Lic.N. APPLICATION / PERMIT
BUILDINGF2.ECTRICALPLUMIBING.MECHAMCAL CATFOORY CONTROL N
Anchited/Englium.. Lic,No
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add.. PERMQTISSUANCE f��. ❑ O ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under prwWmu.1'Cha per 9(commenc APPLIANCES-RESIDENTIAL ]OB DESCRUITON
i ng wl t h soo to n 70DO)of DiA.f on 3 of the B u,i es,and Pro fesslons Code,and my
license Is Inufoce and effect.
PANELS
ClalLic.
c (a.
Date Contescim
ARCHITECTS DECLARATION 201-1030 AMPS
IQ�M 2 I understand my plaro shall be used sa public records. OVER I ODD AMPS SQ.PWLM ARE $/SQ.4T.
EO Licensed Proreanknil SIGNSELECTRICAL L � ICJI
<� OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISE E
s' �.ri (hereby a/Once tlutlam Sectrept(mmthe Cnntractor'•Llcense Law brthe
Zg
10llowingresaon.&C1.70315,Busineesand Profealon.Code:Anydtyor ^ /�
r4p,8 =ntywhlchreq imsaper ttoconrtmMalter,Impmv dem lWh,ornpalr TEMP MEI'PRORI'OLE(NST. `
y L,< anystructum petorto Its Issuance,aborequlresthe applicant forsuch permit to POWER DEVICES DATE
C a O file a signed statement that he b licensed pursuant to the provisoes of the
O - Contractors Llcenx Law fChe 9(commendn with pier gw SWIASMING FOOL ELECTRIC \ VALUATION
O IleSiobasis for
Business and Prolesaion.CodeAny orthat lation of
therefrom and
4 5 the dab far the alleged exemption. Any violation of Stolon 7011.5 6/anyOUTLETSSSWITC]TES-F'IXTURES
,c. applicaodredaperoo(S500)cts the appilcanttoactvll penalty a0 not mart than
L^� rro,.ej�1,ndrm dollars(S500).
pro
p^ Psf L u owner of property,or my employees with wages as their seic NEV.'RESIDFMIAL ELFLTR SQFp, STORIES TYPE CONSTRUCTION
CZ6 compensation,wilidothewor"zolthestroctumbnot Intended or offered for
S ❑ sale6ec.7004 Bootee.and Profession Code:The Contractors License Law
does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RES.UMTS
who does surh work himself or through his own employees,provided that such
improvements an not Intended oroffered(orsale.11,however thebuilding or TOTAL:
improvement b sold witM1ln orcyeara(compiellon the ownerbullderwlll have
t"idenofpmving that he did not bund or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
u I,as owner of the property,am exclusively contracting with licensed PPlthfR LS6UANCE
contractors to construct the project(Sec.7044 Business and Profession Code:
The Contractors Llcenae Law dm out apply to an owner of property who
Wild. or Improves thereon,and who contra for so& plujMs with a ALTER-DRAW k VENT-WATER(EA)
,,Il➢.k.1actor(.)licensed punu..t to the Contractor.License Law. FEE SUMMARY
IJ I am exempt undy Sec. B k P C for this mason BACK FLOW PROTECT.DEVICE
C DRAINS-FTOOR,ROOF,AREA,COND. SANITARY Y_ N
• Owner r i a par._ yta 9� RFGEDTN
C31 hereWORIQIIANCOMPENSATIONDECLARATION Fa[VRF_S I'FR TRAP SpiOOL TA% Y_ N
by affirm that I have a certificate of consent to self.Insure,or RFLID'I N
renifiateo(Wark Camp tlonirouranmoramni(Iedmpythen f�ec. GAS FA.SYSTEM-1 INC40UTLETS PARK FEE Y N
3800,cob Cd
C. M GAS,EA.SYSTEM-OVER 4IF A) RECEIPT N
Com a BUILUINC DI VISION Fr.ES
0 Cenified copy b hereby with
thehed.
❑Certified copy bfiled with the city inspection division. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER.SANITARY-STORM EA.200FT. Date RCOCI 1#
(1'hislMbn need not he complcted tithe permit Jaime.hundred dollars
(SIM)or less.) WATER)-IFATFx W/VpNT/EI.EL7R ENERGY FEE Y N
I certify that In the pedormana of the work for which this permit 1.Issued
I shall not employ any person in any manner m as to become subject to the WATER SYSTEM/TREATING
Worker'Compensation Laws of California.Date PAID
O Z Applicant Date Recei t#
Z O NOTICE TO APPLICANT:H,after making this CenTGte of Exemptlan,you NEW RESIDENTIAL PLMB, SQFf.
Hshould become r'subject to the Workers Compeesat ion provisions of the Labor TOTAL:
N Code,you most forthwith mm ply with such provbiamorthls permit shallbe
> deemed revoked. BUILDING FEE
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm that there IS a construction lendingagenry,for the perform 7 TOTAL:Z ance ofthe work which this permit b bsued(Sec.3197,Civ.C.) ELECTRIC FEE
(� O lenders Name PLUMBING FEE
IL ~ Iendersnddre.s QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icenlfytbti have rtadthb.ppllatlon and tlatcth,t the.Wve Information
bcorrect l agree to complywith all city and countymdmances and sate laws PERMTTISSUANCE FEES PAID.
} fl relating tobullding construction,and herebyiuthorain mpresentathmodthb
= city,to enter upon the abwcmentloned pmpeety,for Inspection purposes. ALTERORADDTDMECH. Dale RCCCI t#
— (We)agresave, ino
e to ve,indemnify an d keep harmless the City of CupertP
against liabilities,Pilgessid,conund expenseawhich nuylo ary.syattrue AIR HANDLING UNIT CIO 10,000CFM) SUBTOTAL' [
agalnt aasd Clty 1 fce of tMe granting of this permit.
AIR HANDLING IATf(OVER IO,000CFM) CONSTRUCTION TAX
signature of Aparwp iaot/C°ntnnar DDaate � EKILIUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfutum building occupant store or handle havrdom HEATING UNIT(TO 100,000 BTU) Date ReCCI t#
material as defined by the Cupeniao Mudan
dpal Code,Chapter 9.12 d the
Health and Safety Cede Section 7SS32(a)?
❑Yes n No HEATING UNIT(OVER100,000 RTU) TOTAL: 21
Will the applicant orfuture building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCkTE
which coot hanrd....ir contamtruntaas defined bythe Bay Area Air P /H\ I
• Quality Marugement District? BOfLER-COMP OIs'OR 100,00E BTU)
Y.[ No No
.s have read thehaxar�ousmtertabregdremnotsorderCh.plerG95of HOILERICOMP(OVER 100,000BTU) FEB 5 1992
the California Health A Safety Code,Seetions 75505,5533 and 25534.1
understand that it the building docs not currently have a tenant,that it b my NEW REMDFNTIAL MECH. SQ.Irr
responsibility to notify the occupant of the requirement,which most be met �s
prior to Wuance o(a Ccrtiliate of(laupanry. CITY OF CUPEhILAV
Owner or authorimd agent Date TOTAL: L�ISSUEDRY:
OFFICE COPY
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