24105 'APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PIRRMI7N0.
i Benamgneare^�ebl7G�`7� 24105 .
Uweer.Name:` a Pnone: AI'1UL IIUN SUM111111ALOAle
CITY OF CUPERTINO-BUILDING DIVISION ' �,
Contractors Name: - - LIc.No APPLICATION 1 PERMIT 9—(`'l'ae-(��. l G.
• 1 ON F CG'11.'57 K-2, I c y t BUILDINGELECTRICAI PLUMBING-MECHAMCAL CATEGORY CONTROL p
Amhihct/Engineer: Lk.Net L
;BUILD!NG,PERMIT INFO'
QTY ELECTRIC PERMIT"
re "
Addss:3 Yk3 C/18rt hir 5•/4evjr'4 C16kn I PERMITISSUANCE tlLll(. ILIA.( I'LUMU �r��T1
LICENSED CONTRACTOR'S DECLARATION
hemby Secdo 70(salamslost3 ffluBupessand of Cssions oda,annmc-1 MPLIANCESRESIDEN7IAL
ingwhh In 7000)onde elon3o(the9uelnesaand ProfmdonsCode,and my
license b In full force eras effect. PANES
Date Clam -• Lk.p - -
Date r'onbador U 1-10DO PS'
ARCHITECT'S haute used as public OVER00AM_I".R I
�02 Iundentnd my ptra shall be used upubecremrda DYER 1000 AMPS � �1 �•I� /\ I� _ � � ASa.FI,FLOOR AREA � f/5(j;FI',
'V
Licensed ProfemiO.1 SIGNSELECTRICA �, 1)
el OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/ ('-cJ tl vl
2r' a Iherebyaffirmthat l am exempt frornthe Contractor's License Law for the
o followingI reasrn.(Section 7031.5,Buslnses and Profession Code:Any city or
O z IIIdP.METER OR POL
county which rcqulresa issuat tOmrutmd,alt theaprovnt ormpair
-
anystmcturepriortoltbwaancgaborequireatheappliont forsuch permit to ppyygg DEV[CFS ,
ilia a signed statement that M b licensed pursuant to the provisions of the
O
Du, Contrador'a License Lew(Chapter9(com ccbgwlth Sectkm7 000)o(DIa- SWAIMING TOOL ELECTRIC
LAS slon3oflhe Buelneseand Pro(embru Code)arthat hetsexemptthere(mmana VALUATION
`�a'Sp+yyyy the basis(or the alleged excmptlon. Any violation of Section 7031.5 by any I OO
applicant lore permit subjects the applicant to a evil penalty anet vnretban OUTLETSSWITCHESFIXT'URES V
five hundred dollars(SM.
�n I,as owner of the property,or my employees with wages as their sole NEW RESIDENTIAL ELECTR c"Q Ff,I I STORIES TYPE CONSTRUCTION
compensation,will do the work and the structure is not intended or offered for
O
sale(Ste.7044,Business a ed Professiora Code:The Contractors Llmme l.aw
(1d3$ does nut apply to an Owner of property who build$or Improves therver,and -
whodonauch work himself or through his Own employees,provided that such OCC,GROUP RES.UNITS .
t improvement are not intended Oroflered(or sale.ILhowever,thebuildingor TOTAL:I� �
improvementbsoldwlthRoney earo(compldio theowner-budderwi:[- -
th,L4+rden aproving that he did not build or improve for purpose a(sale.). IQTY.1" "ll..IPLUMBING PERMIT }I t1'17EE •1 FLOOD ZDNE APN
IJ L as owner of the property,am exclusively contract re
contracting with Rnsx' PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Pro(essims Code: '
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or lmprovm thereon, and who contracts for such ptO)ede with is
cg0.t{ador(s)Ilanxdpunuanttothe Contractors Lkenae law. 1I : ,FEE SUMMARY'
1_I I am exempt under Sec. B&P C for this reas BACK FLOW PROTECT.DEVICE
on I' I
,FEE
errG
Owner Da,. DRAINS FLOOR ROOF,AREA,CON). ' I SANITARY Y N—
WORKMAN COMPENSATION DECLARATION
RECEIPT p
❑I hereby or( m that I have o lmumne of consent to"pytheren or a FIXTURES.PER TRAP I I SCIdIX)L TAX Y N-
mrtlBatof Workers Comperaatlon lrsunnaoraartllicd mpythelmf(Sec. 1 ' RECEU'fp
GA FA. INCA I IPARK FEE Ymoo, abc) RECEIPT X Polly p 0 V _
ray GAS EA.SYSTEM-OVER4(EA) BUILDING DIVISION FEES
Cem(led copy Ls hereby famished.
the city CREASE/INDUSTRL WASTE INTERCEPTOR I / PLANCFIECK FEE q
edified copy t filed with the city inspection division. - 0
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRM I PAID C�
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT.' Date Rccei
Tfhlaeemon need rat be
COMPENSATION NI permit t(oronehundred dollars Pt#
($1(0).elom.) WATER I{FATE2 W/VENT/ELECTR ENERGY FEE Y_ N
I certify that in the performance o(the work for which this permit ie issued, I —
I shall not employ any person In any manner en se to become subject to the WATER SYSTEM/TRFAI]NG L
Worken'Compenntmn Laws of Gll(omia.Date I :(PAID a
0 Z Applicant ff]]
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.FT. I 111 Date Receipt#
_ should become sub)eet to the Workers''Compensation proWicrs ofthe Labor I / TOTAL: I
W CWa youmust(orthwithmmplywlthsuchprovlslomorthbper ta .11Itc
y deem d revoked. BUILDING FEE -
ap CONSTRUCTION emis a LEwDING AGENCY - SEISMIC FEE p _
lhcrebyalflrmt hat there taconatrudlon lendingagcnry(oaths perform- TAI; ELECTRIC FEE
and of the work tar which this permit b issued(Sec.3097,Cie.C.)
(.) 0_ Lander'.Name - a. r PLUMBING FEE
14, 1- Lenaera nadrcea q'rY. „MECHANICAL PERMIT t 1. "E MECI-IANICAL FEE '
U• I artilythil l have read thlaapplicationand s atethattheabove information
O W bcormet.I agreeto comply with all cityand county ordinances and sate law.I PERMIT ISSUANCE I / FEES PAID: 'I
} 1 relating to building construction,and hereby authorize representatives of this
F4, city to enter upon the abovcmenaoned property(or Inspector,purposes. ALTERORADDTOMECH. I , S 1
Z (We)agree to save,indemnify and keep harmless the City of Cu pertin.. Dale Receipt#
O against liabilities,judgment,cmtsand cxpnesss em lch may in any wayaceme AIR HANDUNG UMTIG6 I a"CEM) I I SUBTOTAL: I
agairstioddC In consequence of the granting of this permit.
:7,4- j" 2 AIR HANDLING UNITIOVER 10,000CN- ) I' I CONSTRUCTION TAX
Slgnattya Applicant%�ractor T3ete EXHAUST HOOD(W/DUCT) I (CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building Occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RCCCIPt#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the I -
IlealthandSa fety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yes I]No "'S�C111
Wlllthcapplicant or future building Occupant use equipment or devmes VENTILATION FAN(SINGLE RESID) I ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? ., I BOILER-COMP CHPOR 100,000 BTU) , I PAID
q Yes No
Tvc read Health&r et n ode,t Lions ement 5533 and 255 . I of I BOILS&COMP(OV[R 100,000670) I
the Ghandt Heahh&Satety Code,Sectkna25505,25.t3and25534. I AUG 18 1992
uspoovindthat oally the mmpoes not a rreuirenrves which that b Lamy NEW RESIDENTIAL MECH. SQ.FT�
resporslbllityiO ndifythe occupant o(the requircmnnt which must be rant �� ,
prior to issuance of a Certificate ofOmpanry. ,
a- I CITY yr vurc/n�uwU .
Owner or authodzM agent Data
TOTAL: �ISSUEDBY:�Z_ /
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OFFICE COPY