23774 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildin Pr.'et tdeml(laelon
Building Addreea: � PERMIT NO.
23774
w ere ams:
CITY OF CUPERTTNO-BUILDING DIVISION
Coram"`°"N,ra: L'°•"°: APPLICATION /'PER IT a "l
Architect/Engineer. BUILDINGI].ECTRICALI'LIIMBINGM L CATEGORY CO
Lk No:
QTY ELECTRIC PERM U IV FEE BUILDING PERMIT INFO
Add..
PERMITISSUANCE ❑ ElLICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am llemsed under Provisions°f Chapter9(mmmenc APP11ANC D L O
Ingwlth Section 7000)°(DlWd
shm3 ofthe Buneasand ProleaalomCode,and pg N
license is In full force end died. P /!
License Clam Lk.Y aril
Date Corrrsdrr
ARCHITECTS DECLARATION '� I. AMPS
00 0O I understand my plana$hall be used as public remands V 1000 PS SQ.FT.FLOOR AREA $/SQ.FT.
u Lirenxd Profenbvl SIG EL CA DO iT .1
6 OWNER-BUILDER DECLARATION
,Zh�•7a iherebya(firmthallamexemptfromthe Contractor's License Law(mlhe SPECIAL IC TM19C
O .following recon.(Section 7031.5,Business and Professions Code:Any city or
P� rounly which rcquhrea a permit W construct,alter,Improve,dem°gah.orrepalr TEMP.ME RPOLEINST%
any atmture prlor to lis luwance,also requires the applicant for such permit to
r file a signed statemenl that he Is licensed pursuant to the provbioru of the POWER DEVICES
3ofn Contractors License Law(Chapter9(commencing with Section 7000)ofDivi-
,e gon3 ofthe Busheasand ProfakinesCode)orlhat heir eampt lharefromand SWIMMING ECIRIC �a VALUATION DQ
6 5 the basis for the alleged esemptlon. Any ,vlolrtlon o(Se tion 7011.5 re any OUTLETS. TCHFSFIXTURES {�►y Q V
o he bass for t alleged
exempts appAny vio a dull pewity n 700 more than -0
CJ�L
�� hundred ddlars(5500),
as owner o(tM Property,or m m to en with we n u
eir sole thNEW DENIIAL ELECTR_SQ,FF.
roma do k, ye P y R STOR16 TYPE CONSTRUCTION
k 6 a^ea rywWdotW won and lhealmdurc Lars[Intended or offeretl(or
5 O sale(Sec.7094,Budnee$and Pro(eelons Code:The Contractors License Law
�j $ don not apply to an ownerdproprty who Wilde orimprovn lhereory and
0.0. whodoneuch work hlmseEorthrough hiaownemployen,provided thatsuch OCC.GROUT' RES,UMfS
improvemenle ere not Intended orot(ered(weak.II however,thebullding or TOTAL:
Improvement hwld wilhlnoneyxarofcompldiorylh$owner-WllderwBl
t�5..�urdeno/pmvingthat he dW not Wild or Improve(or purposeot J. QTy, PLUMBING PERMIT FEE
ITi�,{L ae owner of the propery,am esdueively contracting with Iirenmd Fl.00D ZINE APN
ro tractors to ronstuctthe project(Sec,7004,Buskemand Pro(ealans Code: PERMIT ISSUANCE
The Contntori License Law dm rat app to an owner a(property who -
builds or improves thereon,and whom rate(m such ptojets with a ALTER-DRAIN&VENT-WATER(EAI
to
}B(dor(s)licensed uanttothc Cont ctor.Liceme Law. FEE SUMMARY
am exempt a de B &P C f this reason BACK FLOW PROTECT.DEVICE
OUTSIDE FFFq
Owner Data DRAINS FLOOR ROOF,AREA,CONI. SANITARY Y N
i� RKM MPEN ION DECLARA 1 N
that I have a RFLID'TN
C31 hereby affirm Brate of concent to R A'-Inure,or a FDnURES-PER TRSCHOOL TAX Y N
certlticneo(Worken'Compensation uranreoracertifledmpythereo((Sec. RECEIPT If
3800,Lab GAS FA,SYSTEM-1 INCA OUTLET'S PARKFM Y_ N_
Policy Y RECEIPT N
Com ray GAS FA.SYSTEM.OVER 4(RA) BUIL DING DI VISI FEES
[]Certified copy b herey ed with the
ad.city CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified mpyb filed with the city inspection division. �1 n a►
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRA 6 5 aS
COMPENSATION INSURANCE PAID
(Thlasectlon need not becompleted lftheprmlt b(orom hundred dollars SEVIER-SANITARY-STORM FA.2(IOFT• ate eCei tM
($10(fim1ee.)
Iartifythat In the pcdomuna ufthe work forwhIch this permit to heated, WATER HEATER W/VENT/ELECTR EN E Y N
I shall nor employ any person In any mnn
aer ro as 1.became=him to the
Workers'Compensatlon Laws of California.Date WATER SYSTEM/TREATING
O Applicant PAI _
Z Q NOTICE TO APPLICANT:If,alien making this CertRlate of Fsemptlon,you NEW RESIDENTIAL ELMS._SQ.Ff. D e Recei tF
should become subject to the W°rken'Compensatlan proh ima,of the Labor
W Code,you=at forthwith comply with such provisions or this permit shall be OTAL:
LU > deemed revoked. [{
IL CONSTRUCTION LENDING AGENCY S FEE
Thereby aork for w them isperutudlonkndingagency Civ. .) ptorm ELE RICFEE
M O ant of the work for which this permitis Issued(Sc,.3097,Civ.C.) TOTAL:
V _ Lander.Name PLUMBING FEE
ly H LenaarbAddreee QTY. MECHANICAL PERMIT FEE
O W Icertftylhatlhave readthk appBati°nand Rateehatthekbove ln(orrtatlon MECHANICAL FE
6. bcnrrm.Iagree0rmeoPlywithagdtyand noun ordlnanceaand tate laws PERMITISSUANCE FEES PAID:
N relating to building cmnkm ton,andherebyau mpresentativesofthls
F-. Z city to enter upon the above-mentioned pope (rWpction purposes. ALTERORADDTOMECH.
(We)agree to eve,Indemdty an d keep , em the chty of Ire mo Date eceiptk
agahnstliabi@lea,' me mksandexp mayhorsy ayacme AIRHANDUNGUNITfr010,000CFM) 5176 OTAL:
agar 1 1 cons recut f he g of this permit.
�� AIR HANDLING UNIT(OVER IO,000CFM) CONSTRUCTION TA
Si to Appll at/ them, are EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX AID:
HAZARDOUS ERIALS DISCLOSURE
WIIltheappBant m future building occupant store or handle hazardous HEATING UNIT(70 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.13,and the Date Rece
Health and Safety Code Section 25533(a)7 HEATING UNIT(OVER 100,000 BTU)
[:]Yn u No TO owt
Will the applicant or future building occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE ATF
which emit haaardouf air cartamimntaae defined by the Bay Area Air 1' (�0 YUE
Quality Management Dlstrid7 BOILER-COMP PHP OR 100,000 BID)
Yn ❑❑No
have read the hazardous matecials requirements under Cha pter 6.95 of BOILER-COMP(OVER 100,000 BTU) AUG 11 1992 -
the Callfomla Ilealth&Safety Code,Set ions 25505,25S33 and 25534.I
and etla rad that if the building don not m mently,have a tenant,that It is my NEW RESIDENTIAL MECFf. 5QF7.
responsibility to Actiof.y the Cerionvpa nt.P..cyhe ulremente which most be met CITY Qr VQrtn1AWTr1.
prior m issuance of a Certllkate of Occvpanry. ,
/<Lvd/
Owner or authorlaed agent Data
TOTAL: ISSUEDBF` A
OFFICE COPY