23464 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY.
Building Peced Identification - PERMITNO.•
Building Addmss: , (// 1
A / 5Z6 ` S7`� EJ�s ��� � �+ 23464
A
e ams: ane.
w CITY OF CUPERTINO-BUILDING DIVISION
Count r : Name, /q/ Lf.Na: APPLICATION / PERMIT
`O J BUILDING—MECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL X
Aachlted/Engineer.. - - Lk.No:
d
°`- '- '"- " I " •'BUILDINGPERMITINFO
,QTY• I 'ELECTRICPER CFr' „•TLE 1' _ _i" t
Address: PIBthBTISSUANCFI ❑ '❑
LICENSED CONTRACTOR'S DECLARATION Ij�
I hereby affirmthat l am licensed under provisions of Chapter9(com
menc- APPLIANCFSRESIDE L JOB DESCRIPTION
ingwith Sect1on7000)of Dlvislon3o(the B,,u/aIlnessand Profeadone Code,and my /+ �_
licensese iE o�dled. 3/Y 7 . PANELS
Lkense Ian Lk.p .l
Date ontractor X11-1000 -
ARCHITECPS DECLARATION
NO ZOO 1 understand my plans shall be used as public record.. OVER 1 PS SO.FT.ELL)OR AREA $/SQ.FT.
Licensed Padessimnal - G TRI Z to
�1
6 OWNER-BUILDER DECLARATION CIRC "
ys' a Iherabyafflrmthatlam exemptfrom[Ke Contractors License Law for the _
oo following remon.(Section 7mt.5,Buslneuand Pm(es.lan.Code:Anyd or
OZs: P.METED LEINST. •:
lr� countywhichrequbeaapert ttommtmMalteglmprov dem )Nli,orre 'r
Q anystructure paorto its issuance,also requirestheappllcant for.uch permit NPOWTrR DEVICES t
f5 Q file a signed statement that he at licensed pursuant to the provlsloru of the
Gp1� Contractors urines Law(Cha er9(mmmentln withxempttherefunDfvl-
SWIMMING POOL ELECTRIC slon3of the Business and Professlors Code)orthat heatexempt theretromand VALUATION
6 the basis for the alleged exemption. Any violation of Section 7MIS by any OUTLEISSWITCHESFIXTURES'
I$O applicant fora permit subjects the applicant to a civil penalty of not more than
fivehundreddollae%SDO). MiWRFSIDENnALELECTR SQ,Fr. - STOWES TYPE CONSTRUCTION
�j.. ❑Las owner of lhe property,or my employees with wages as their sole -
compensation,wBldothe work and lhe.structure b not intended or offered for
OIn(Sec.7064,Business and Professlom Code:The Contractors License law
(11 does not apply to an owner of property who builds or Improves thereon,and OCC.GROUP RES.UNITS
who does such work himself or through his own employees,provided that such
Improvements are not intended motioned for sale.If,however,the building or TO
improvement issold withinoneyearofcomplellomtheowner-bullderwlll have
' tta.Iiurdenof provingthat he did not build orlmp ave forpurposeofsale.). QTY• PLUMBING PERMIT'. 'FEE FLOODZDNE APN
u L as owner of the property,am exclusively contracting with Ikenaed PERMITISSUANCE
contractors to amstautl the project(Sec.7044,Business and Professions Code:
The Coriontar's License Law does not apply/o an owner of property who ALTERDRAIN&VENT-WATER(EA)
Wild.or Improves thname,and who contracts for such p -
lajects with a _.
ador(s)licensed pursuant to the Contractor'.License Law. FEE'SUMMARY
- 5I am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE
rrcc
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y Nr
Owner Date RECEIPT X
WORKMAN COMPENSATION DECLARATION pLXNgFq,pgR TRAP SCHOOLTAX Y N
❑I hereby affirm that 1 have a certificate of consent to self.Insure,ora - RECEIPT X
cedifimteof Worken'Co Nmatlmlmunnmoramnifiedmpythereof(Sec. CAS F.A.$Y$rQd-I INC.40UTL[TS PARK FEE Y N
38M Isis C.) ,
i _ _ GAS EA.SYSIFAf-OVER4(EA)
Co nv dam= reeby farm w.ew�.— -BUILDING DIVISION FEES
' �Ifled copy is hlad'wtumle ed.city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
ified copy atflled�w•Iththe dry inspection dlvlNon. x
CERTIECATE OF EXEMPT ION FROM WORKERS'. CREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 700FT ; Date RCCCI HY -
(fhis sen loo need net be completed if the prau t 1.ftir one hundred deltas
(810 ly that
NWATER HEATER W/VENT/ELFGTR ENERGY FEE Y N
Imceadrdfytbat lnthe performance of the work for which this permltb issued, ..
I shall not employ any person In any manner so as to become subjed to the WATER SYSTEM/TREATING
Workers'Compensation Lxwso/Gllfomla.Date PAID
—
Z
Z NOplican TICE TO APPLICANT:If,after making that Certificate of Exemption,you NEW RESIDCNTIAL PLMB. �.FT, DB6C Receipt
O should become subject to the Workers Compeauation provisions ofthe Labor TOTAL: +
Vl Code,you at forthwith comply with such pmA,ioms mthis peault.hall be BUILDING
W j deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE L
aa Iherebyaf(imthat there isamastruafonlending agency for the perform ELECTRIC FEB
Z once of the work(car which this permit atLseued(Sec.3097,C1v.C.) TOTAL: _
V O Lender's Name - - PLUMBING F
IL — Lender's Addmss QTY. ,MECHANICAL PERMIT FEE• I MECHA E
Ocekifythatl havcrbadthatapplicatlonand natethat theabove information
S ucorma.I agree to comply with all dtyand county ordinancesand pate laws - PERMIT ISSUANCE FEE P D:
� relating to building corutmdion,and hereby authorize representatives of this
F Z city to enter it pon the above-mentioned property for inspection purposes. ALMORADDIUMECIL .
(We)agree to nue,Indemnify an d keep harmless the City of Cupertino D CCeIPt44
V against liabilities,judgments,missend expemnwhlch mayln anywayaccrue AIR HANDLING UNIT(TO 10,ODO CFM) - SU TOTAL:
against said City In consequence of the granting of this permit.
AIR HANDLING UNIT(OVER.IlLMOCFM), CONSTRUCTION X `
Signature of Applicant/Contractor Data EXHAUST HOOD(W/DICT) CONSTRUCTION'AX PAID:
HAZARDOUS MATERIALS DISCLOSURE '
Will the applicant orfuture building occupant store or handle hazardous HEATING UNIT(TO 100,0DO BTU) Date R Ci 1M'
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the - _
Healthand Safety Caxllon7S537(a)7 HEATING UNIT(OVER 100,000 BTIB TSkAL
❑ Yea f2 No
Will the applicant or future building occupant use equipment or devkcs VENTILATION FAN"INGLE RESID) ISSUANCE&TE
which emit hazardous air mntamlnanls as defined by the Bay Area Alr pp
alley Mawgemant DN is7 NOILER-COMP pkIP OR 100,0(q BTN _ P I D
Ys No
have read the hazar ous materials requirements under Chapter 6.95 of BOILER-COMP(OVEt 100,000 BTU)
the Glifemia Health&Safety Code,Se 25505,25533 and 75534. I 1 frysfrXl (�
understand that if the but s m ❑yhaveatenanL that itkmy NEW RESIDENTIAL MECH. ' SQ.FT MAR 26'' 1992
caponsibllity to nal( eompa (them ulrementawhlchmust bere=t. /s
rlort issuanceof Certiflcatal ccvpan 'CITY Ut' LUf Ln111�
Ow er rau mizedag r Data ISSUEDBY: / ,
TOTAL:
OFFICE,COPY