23828 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES,— USE BALL POINT PEN ONLY
BuildingProject Identification a, �, PFZthIT"2 3 8 2 8
Building Address: /1
AaS'. G �A-. �x{ CU p C SO�
wnere �I.�O one:
tv /'fy,fa CITY OF CUPERTINO-BUILDING DIVISION Z_ G Z_
cone. A pre: Lie.No: APPLICATION /PERMIT
a O BUILDINGELECTRICALPLIJMBINGM[CHAMC L CATEGORY CONTROL M
Archl gine r: Lie Na:
i VBUILDINGLL�l PERMIT IPLUMSNFO
QTY ELECTRIC PERMIT FEE
Address /-</S N V I, PERMATISSUANCE .� � ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm thetlaunhomsedurelerprovLdon..f Chapter9(rommenc APFUANCESRESIDE JOB DESCRIPTIONingwlthSection7000)of Dlviaton3ofthe Businweand PmlemlonsCmde,andmy 1
license le In full force and effect. PANELS y
License Clam Lia./ - r
Date Cmdcacmr
ARCHITECTS DECLARATION 701-1000 AMPS
quq�au 9OCZI understand my plans shall be used as public records. OVERIODOAMPS �Q�T.FLOOR AREA $/SQ.Fr.
Si0Licensed Professional - SIGNS ELECTRICAL EL-
e_ ROWNER-BUILDER DECLARATION SPECIAL CIRCUIT/ Q
2f K Ihercbyafflrenthatl ame.empt fromthe Contractor'.License hwforthe
O p following reason.(Section 70115,Business and Professions Code:My city or /J
E'F2 cwn whkhre bass n tW.Mtu0,aller,im rove,demolls TEMP.METER ORIOLE INST. `•ty qu pe p h,arrepalr
qqq nystmctumpriartot4h ance,alsorcquimatheapplicantforsuchpermltto POWER DEVICES
file a signed statement that he is licensed pursuant to the provisions of the
3w Con3ofth's LkerueandProession(commenmg with SMlonherafof Divi- /s� VALLA TION
O{e SWIMMING TOOL ELECTRIC
III... ebn3o(the Businewand ProfessbreCode)orthat he is exempt lhere(mmand '
the basis for the alleged exemption. Any violation of Section 7mi.5 by any Z OUTLETSSwITCHESFIXTURE4 D
appBcant fora permit subjec sthe applicant to a civil penalty of not more than a
five hundred dollars ,M.
❑I,as owner of the property,or my employees with wages as their sole NEW RESIDENTIAL ELECTR SQ.FI. SMIELS 'f Yl'ECONSIRIICTION
compensation,wOl do the work,and the structure Is not intended or offered for -
0
does
e(sm apply
andf presslore Code:TM Contractors the me Law
r3'$ who not apply wean owner of property who builds or improves therwrt and OCC.GROUP RES.UNITS
whodaementsasuch not Intelfedorweredgh his ownemployeeyemthebuildvided twch ,
Improvements are not Intended oroHered for We.If,however,thebullding or TOTAL:
Improvement LawidwlthlnoneyearofcompltloR theowner-bullderwlllhave
trden of proving that he did not build or improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
L�/j;as ownor of the prepeny,am exclusively contracting with licensed
_
roa[rectos tomrotwn the project(Sec7014,Busineseand Profmisma Code: PERMIT ISSUANCE
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN k VFM-WATER(EA)
Wor Improve.thereon,and who contracts for such p(o)em with a FEE SUMMARY
con 1 0r(9 mneedpursuanttothe Contractors License Law. BACK FLAW PROTECT.DEVICE
LJ I am exempt under Sec. B h P C for this reasonOUTSIDE FEES
DRAINSLOOR FROOF,AREA,COND. SANITARY Y N
Owner Data RECEIPT M
WORKMAN COMPENSATION DECLARATION PIX'IVRFS PER TRAP SCHOOLTAX Y_ N_
❑I hertby affirm that 1 have a certificate of consent to.If-Insure,ora RECEIPP N
cenificeteafWorkera'CompewaHuce ce
an lrunnor a rtlfnd copy lhercofoec. GAS-PA.SYSTEM-t INC.40UTLET$ PARK I'EE Y_ N
3BOQ lab CJ RECEIPT M
Company
M GAS.EA.ESYSTEM-OVER A)VER 4(E
Cany BUILDING DIVISION FEES
MC
ertitled copy la hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy V filed with the city inspection division. ?_ /
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID Q b
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date Rem! t#
CThlssectlon need not be completed If the per it is forune hundred dollars
(f100)or less.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
ce
I rcifythat In the performance of the work for which this permit is issued,
I shag not employ any person in any manner w as to become subject to the
r Worken'Compenwtlo.Lm.fCalifomla.Date WATER SYSTEM/TREATINGPAID
z Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date Remi t#
Z Q NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
should become subject to the Workers'Compereatlon provisions of the Labor TOTAL:
CCN Code,youmustfonhMthromplywlthwchprovbioworthfepermitshallim BUILDING FEE
.D
W j deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC PEE 4
CL a M Thereby workffirce
wtherebacoretwctlsued(Sc. agency for the perform ELECTRIC FEE
L) Z Lerder'.Nwark far which this permit is lowed(Sec.30117,CIv.CJ TOTAL:
U O Lenders Name PLUMBING FEE
LL H Lender'sAdd QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I certilythatl have read this applicatiunand tatethattheabove informed.
C iscorrm.l egreeto comply with all dtyand county ordinances and state lawn PERMIT ISSUANCE FEES PAID:
>. N relatingtobuliding construction,and hereby authorlre representatives ofthls
H U) city to enter upon the above, rty fmi.pectlonpurpoeea. ALTER OR ADD TO MECH. Date Receipt#
(We)agree to save,Indemnify a ep harMew the City of Cupertino
V
against liabilities,jud men est pe n..which may In anyw amus AIR HANDLING UNIT(TO III, 0CFM) SUBTOTAL:
ago Wt sold Ityn e grant ofthle permit.
/ AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Sigrutureo AppB rat ntratnr d EXHAUSTHOOD(W/DUCD CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSUItE
Wlil he applicant or future building occupant store or handle hacardoes HEATINGUMT(T0101),000BTU) Date Reeei t#
material as defined by the Cupertino Municipal Code,Chapter 93Z,and the -
HeaithandSaftyCodIon 25532(1)7 HEATING UNIT(OVER I00,0(0 BTU) TOTAL:
Y
❑ e N
illthe o applicant o m building occupant use equipment or device VENTILATION FAN(SINGLE RESID) ISSUPN�G�DATE'
which emit haaardous air contaminants as defined by the Bay Area Air jJ -
Quality Mavgement Distrl BOI.ER-COMP PEIPOR 100,IXq BTV)
4 Yes
have read the h.a R uH.L,require is under Chapter 6.95 of BOTLEILCOMP(OVER 100,000 BTU)
tthe CalHomia Health k Sa ty Code ctlo ,25533 and Ei534., JUN 12 1992
understand that l(the b §dol ly have atenanL that itbmy NEW RESIDENTIAL MECH, SQ.FTe Ircmenb which stbepriorloLss n arcy. / CII Y Uf L'UT'CTIIIIYU
Owner or hon ge to - ISSUED BY:
TOTAL;
OFFICE COPY