23445 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Ra ert Identification - - PERMIT NO.
Build lag Address: - - 23445
cosecs ^f••C_7 - one: - A
CITY OF CUPERTINO-BUILDING DIVISION
Contractors ame'. Na: APPLICATION / PERMIT G•�
j, BUILDINGELECTRICALPLUMBING,MKIIAMCAL CA BY CONTROL
Anhitect/Engineer. Lk.No
Cl E... 'BUILOING PERMIT INFO' -
QTY J ELECTRIC PERMIT F
Address:87 PERMITISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION '—F'
I hereby affirm that l am licensed under provisions of Chapter9(commeno APPLIANCES-RESIDENTIAL JOB RIPTION
ingwlth Se ion7000)of Division3ofthe Busineasand Pmfession.Code,and my
license is In full force and affect. PANELS
License Cie._a_Lic.#_r39���44s ,
Data Contactor
akp
ARCHITECT'S DECLARATION - , -1000
{qq{uu IV
X'y I understand my plans shall be used as public records. OV 1000 SQ.FT.FLOOR AREA b/SQ.FT.
E �j Licensed Professional SIGNS ELEC f O/�1 O r"•
p: OWNER-BUILDER DECLARATION SPECIAL CIRC T/MI V
Iherebyaflrnthat Ism exempt from the Contractor's License Law(orthe
'Zo p following reason.(Section 7031S,Business and Professions Code:Any ctty or
�z a countywhlch requiresa permitteconstruct,alter,improve,demolish,orrepair T 'P.METERO L Sr.
., any structure prior to its Issuance,also requires the applicant for such permit to
file a signed statement that he is licensed pursuant to the Emulsions of the ]OWER DEVICES
O kI� Contractole Litems Law(Chapter 9(commencing with Section 7000)of Owl.
307 slon3ofthe Buseme and ProfemiomCode)orthatheisexempttherefromand SWIMMING POOL VALUATION
'�p.•,77 the bails for the alleged exemption. Any violation of Section 7MI.5 by an ETSSWITC}IFS FS 2 s�,-/� O
"yg'{ applicant for a permit subjectsthe applicantto a civil penalty of not anrethan D Z�� (03 C)
Cy$ live hundred dollars($500), NEW RESID LELECTR SQ}T. STORIES TYPE CONSTRUCTION
G1 �a ❑Las owner of the property,or my employees with wages as their sole
compensation,will do the work and the structure Isnot intended or offered for
qsale(Seo 7044,Business and Prof esmas Code:The Contractors License Law
j$ does notapply to an menerol property who Wilde orlmproveathereon,and
OCC.GROUT' RFS.UNITSwhodon such work himself orthmugh his own employees,provided that such
improvements are not intended mattered for sale.If,howevep thebuildingnr T '
improvement issold withinoneyearofco ipletioMtheowner-WBderwill have
the rden of proving that he did not build or improve for purpose of sale) Q'py,. PLUM ING PERMIT .a FEE'. FLOOD ZONE APN
�
I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7064,Business and Professions Code: ,
The Contractor's License Law does not apply to an owner of property who ALM-DRAIN k VENT WATER MA)Wilds or Improves thereon, and who contracts for such IxWocts with a
c jLt actors)licensed pursuant W the Contractors License Law. '.FEB".SUMMARY'.
u I am exempt under Sec. B Is P C for this reason BACK FLOW PROT[CT.DEVICE
OUTSIDE FEES
Date RECEIPT#
DRAINS FLOOR ROOF,AREA,COND. ANITARY Y N
M
Owner
WORKAN COMPENSATION DECLARATION FIX �,, I�
!� ❑I hereby affirm that I have a certificate of consent to ael(-Insure,or ., II IOOLTAX Y_ N RECEIPT M
certificate o(Worken'Compematlonlmurance oracertifled copy thereof(Sec. GAS 'EYSIuA I WC{OVfLEf5 ARR FEE Y N
3800,lab CJ - - ' RECEIPT It
Polity# GAS EFS.SI'SIEM-OVER (EA) a •�
Cam any - BUILDING DIVISIO FEES
�Certilied copy is herebyfamished.the city GREASE/INDD5IRI,WASTE INTERCEPTOR LANCHECK FEET
❑
Certified copy k filed with the city Inspection division. _
CERTIFICATE OF EXEMPTION FROM WORKERS' GI L
P I
COMPENSATION INSURANCE SEWER .2 ate(Fhls section need not be completed if the permit Is for one hundred dollars(S1I10)or rtifyi.) WATER HEATER W/VENT/ELECTR RGY FEE Y
Ice northatoin theperoout in ofthework sorwhkbthis permitc Issued,I shall not employ any tenon In any manner ro az to become subject to theWATER SYSTEM/TREATING Workr%Cmpensation Lwso(Callfornla.Dare PAID
O Z ApplicanNEW RESIDENTIAL PLMB. Date
Z O NOTICE TO APPLICANT:If,aRer makingthis Certificate of Exemptlonyou
should become subject to the Workers'Compensatlon provisions of the Labor TOTAL:
M N Code,you must forthwith complywith such provisions orthb permit shall be BUILE
W > deemed revoked. ,
CL C CONSTRUCTION LENDING AGENCY 'mC SEISMIC flp
I heabyafBrm that there is a construction lending agency forthe perform ELECTRIC FE
Z once o(theworkforwhlch thk permitis(sraed(Sec,3097,Civ.CJ
TOTAL.
(,) O Lender's Name
PLU BING FEE
IL I— I enderaaddreaa QTY: MECHANICAL PERMIT ANICAL FEE
OW Imrtify that have read this application and elate that the above information
6 Incorrect,Iagresto comply with all city and county ordinances and nate laws PERMIT ISSUANCE IIID:
�. N relatinglo Wilding construction,and herebyauthorize representatives ofthis (�J
U) city to enter upon the abovcmeutioned property for inspection purposes. ALTER OR ADD TO MECH.
— (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
againetliabl N J dgme is,coateanda eases which maylo anywayaccrus AIR HANDLING OMT DO 10,000 CFM) SUBTOTAL'
a8'last Cl. In on
quenanftM an,i Sof this permit CONSTRUCTION TAX
7 AIR HANDLING UNIT(OVER]0,000CFM)
Signature Applicant/Contract Da EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARD0 MATERIALS UISCLOS RE
Will the applicant or tutu uadingoccupantstare or handle hazardous HEATING UNIT(TO 100,0DO BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date Reaei
Health and Safety Cade Section 25532(a)7 HEATING UNIT(OVER lOQ000 BTU) TOT
❑ Yes n No
Will the applicant orfuture building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) I $U NC6DATE
which emit hazardous air contaminants as defined by the Bay Area Air fA�
�L+�Iity Management District? BOILER-COMP DHP OR 100,000 BTU)
�t I Yes No .
haveread eafth&he h oet Code,materialsreons255ntsunderChapter6.95of eo1LER-COMP(OVER IOO,BOORID) 'APR 23 1992
the California Health he building
Code,Sections 25505,25S33 a tenant,and,that. I
understandytonhg if tify the occupcee not t of errently equire encs whichthat It met NEW RESIDENTIAL MECH. SQ.FF
responsibility to asuanc of a Ceheicateo Occupa requirements which must be met /�
prior to Issuance Ma Certificate of Occupancy. CITY UF CUPEI"QijIVV
Owner or authorized agent Date - ISSUED BY�
OFFICE COPY