23389 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - - - PE"ITNO.
Building Address: I " n
ill 1/ Jf�V�45�VCGc�— G
wherea one:
• - -
Cv y'/J/10 UC9"'� T ✓�.�Fis His,9v4-S4o CITY OF CUPERTINO-BUILDING DIVISION
Contractor's Na1/1Je LIc.N. APPLICATION I PERMIT
Si /9 &Z/'M6 BUILDING-ELECTRICALPLIJNBING-MECHANICAL CATEGORY CONTROLp y
ArcbltM/Engineer yah e� Jr�^� Lk.No: " 61 ;I
QTY + 3 i',ELECTRIC YERM17W t;l �l!'FEE ta�i 'If. . ;';BUILDING PERMIT INFO 'it .
Add. PERMITISSUANCE -Qp ❑
LICENSED CONTRACTOR'S DBCLA RATION
LithherSe alHrtn that lamlicensed 3ofthe usin aldP ffe aonsCode, mens' APPLIANCESRESIDENTfAL JOB DFSCRIP770N
ingBeer.1 SIn fall 000)of d efelon3htthe Busineuand ProlesUomCade,and my -
licen�eisinful B , a-d effect. �T yPANELS
LicenuC Cont
Date 3 -Cont'ador' UP TO 2DO ANTS
ARCHITECTS DE RATION 701-1000 A.MI'S -
^ Z Liyderst cad rtry plain shagIbe used u public records. OVER 1000 AMPS SQ.IT.FLOOR AREA 5/SQ.FT.
�d�ail O ��gC�G7L J{/i/ rO I'/!5
b� Licensed Profemlanal SIGNS ELECTRICAL E p I N �
¢ .
OWNER-BUILDER DECLARATION - SPECIALCIRCUIT/MISC -
zL 6 owing asfirmtbmlam IS,B(roessandnothe Contractor's License LawAny yor the p�
Qp following reason.(Section rQ t w Business and Professions Code:My city or , E
07.` caantywhich requlreaa permittomratrud,alteq bnprove,demoWh,or repair �' `P:MEIPR ORIOLE MSI. .
9F �,'a�- any structure priortoItbmance,also requlreatheapplleantfor such permit to POWER DEVICES - � lin?�./
9E6file a signed statement that he is Becosed pursuant to the provislore of the
SOw Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- '� _ D VALgA O
OS .sion3ofthe Rust ..cad Prof i..CMe).rthathetexemptthemtmmand SWIMMING POOL ELECTRIC (////jT
6 5 the basis for the alleged exemption. Any violation of Section 7031.5 by any a Na.OUTLETSSWITCIiESFl%TURES^
applicant fora permit subjects the applicant to a civil penalty of not morethan
five hundred dollarshe pr. NEW RESIDENTIAL ELECTR SQRT. STO TYPE CONSTRUCI ION
�n ❑Las owner of the property,or he employees with wages as Their dole
compensation,(So. 044,will doBlume ihe s awork,and ims Code:
Th nm Intended or loflereL for
O sale bee ot apply to BusinessandCode:The or improves theme,
License Law
�$ door oessucly torn owner ofpropertywho nem oyees,povided eoMand OCC.GROUP RES.UNITS
wprov:mnts anwork himself edorweredhis owne.If,ho evr,thebuhataucding r,
Improvement arenor ithinde yearo(complfor sion,th owner,buddei illhavr TOTAL: .LTO
improvementtmld within oncyeamlcompletion,the ownervbu0derw111 have _
t
den ofproving that he did not build or improve for de ofsale.), iP) �i; '+ 'tdi'
l�S. P R P carpo ' QTY. .,.1, PLUMBING PERMIT',th',,, '' `FEE„� FT.00D ZONE APN
Ltr L en owner tr the property,am exclusively Busi contraccss.rd ing Ponwith Ilmnxd PERMIT ISSUANCE -
Tbe Conon 10 construct the project(Sec.apply
Business and of property
Code: '-
The Coor improves
Lienee law does not apply tc an owner of property who ALM-DRAIN&VENT-WATER(EA) -
builds t r Improved.thereon,and who contracts for mets w.okds with a i j '') Yi FEE SUMMARY'
<q➢tfador(dexemptt under into the Contractor's Llrenx Law. ; - - "`' 1 . �h'", 1
L�I am exempt under Sr. B& P C for this rcuon BACK FLOW PROTECT.DEVICE
DRAINSFLOOR ROOF,ARECOND. SANITARY Y N
OUTSI 5E FEES
Owner Date A, RECEI T N
it WORKMAN COMPENSATION DECLARATION
111mI7%1'URES PER TRAP SCI100L FAX Y N
I hereby affirm that 1 have a certificate of consent to self-insure,or .RECEIPT N
.certificate ofWorkera Compensation Insurance or a certlfkM copy thereof(See. GAS EA.SYSTEM-I INCA OUTLETS PARK FEE Y N
3800,Lab C.):_
Polley a# GAS-EA.SYT .OVF4(FA)
RECQPTN
CECBUILDING DIV
ISION FRES
crtified
copy t hereby furhbhed. - GREASEANDUSTRL WASTE INE.IiCEPTOR PLANCHECKFEE
❑CertifietlropyIsfiledwiththscityinspectiondivision: p
CERTIFICATE OF EXEMPTION FROM WORKERS' ' PAID -7 .iZ fP /�V ��•�
GREASE TRAP ,
COMPENSATIONhepeR INCE - SEWFR.SANITARY-STORM EA.MFT. Date ReceI t#
(T)rlc..) need hat be completed Kthe permit tfor one hund�M dallare
(8100)orfy the WATIRHFATIRW/VENT/ELECTR ENERGY FEE Y N
' Ihrtify that in the performance of the work forwhkhthis'pemdt Is tamed,
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workeri Compensation laws of California. Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date Remi t#
Z �. NOTICETO APPLICANT.If,after making this Certitlote of Exemption,you
F- ahold become eubFct 1.the Workeri Compauaeon pmvblmu Dfthe Labor TOTAL:
N' Code,you moat forthwith comply with such provisions or this permit shall be
LU j dremaa revoked. BUILDING ^' 02'''
IL _ CONSTRUCTION LENDING AGENCY' . SEISMIC FEE
tl Ihembyaffim that there is a construction lending agency for the perform TOTAL: ELECTRIC FEE B_Q
D O scare.(the work for which this permit is Issued(Sec.3097,Civ.C.) TOTAL:
- PLUMBING FEE
LL'F Lender.Adderaa QTY MECHANICA lPERMIT 'i 'FEEi' MECHANICAL FEE `
OW. I cenifythat I have readthbapplicationand statethxtthe above Information -
1 Iamreect.I agree to comply with act dtyand rountyordinances and state laws PERMIT'ISSUANCE FEES PAID:
r mlatingtobullding roratmdlon,and hereby autherlim representatives ofthb
F W city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
? (We)agree to save,indemnify an d keep harMen the City of Cu Penko - Date Receipt#
V against liabilities,judgments,was and expenseswhkh may In anyway accrue AIR HANDLING UNIT(T010,000 CFM) SUBTOTAL:
gam old City In consequence ofthe Botming edthis permit
AIRI-IANDWNG IIMT(OVFlt 10,000CFM) CONSTRUCTION TAX
SlgnalureofAA'ptplicant/Coulmetor !•Date ExHAI15'THOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
y - Will the appReani or future building occupant store or handle haeardous HEATING UMTHO 100,000 BTU) Date RCCCI (N
material as defined by the Cupertino Municipal Code,Chapter 9.l Z,and the - - - —��
1 _ He❑altYnnd Safety Codr,Se N'�Don7553Z(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL
I Will the applicant or❑future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air NL
Quality Mawme
gent Distrin7 BOILER-COMPOEI'OR100,0(10A
BTU) P ID
` Yea No
/ havereadthehaza ou.materiabrequlrementsunde,Chxpter6.95at. BOILER-CONP(OV IR 101,000 BTU)
the California Health&Safety Code,Sections 75505,25533 and 75534. 1 MAR 23 1992
understand that lithe building does not currently have a tenant,that it is my NEWRESIDFNIIALMECH. SQ17 .
responsibility to notify the occupant of the requirement which most be met /
prior to Issuance of a Certificate ofOccu pa nry. C11 YUy�ra�C�VI'�tPl i l)
Owne,reauthorized agent - - - "Date ISSUEDBY:
t TOTAL:
OFFICE COPY