23955 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Protect Identification PER.wrNO.
Building Address:
on- 23955
nems one: - APPLICATION suflsurr=A-17—
CITY OF CUPER
' ICM
C 11 A 17 O RC DI I
_
CAI
CATEGORY CONTROL p'
A Rett/Engineer Llc `o - '
'r4, LECTRIC - �,E- - BUILDING PERMIT INFO
Address: 14 VPERXVTISSU
LICENSED CONTRACTORS DBC RATION
I hereby affirm that l am licensed under provisions of Chapter9(mmmenc- APPLIA L JOB D_SCRM70N
Ingwith Sec0on7000)ofcl effeon3 o(the Businessand leselonsCode,and my f
license ism fu anddfect. 1 P
License Gla Lica
Date �C.mracCrTTPTQ" MIS 56
p1-7000 AM
ARCHITECTS D LARATION
0 2. I understand my plans shallbe used m pubhe records. OVER 1000 AM II SQ.FT.FLOOR AREEA�' $/SQ.Fr.
CO
z(� Licensed Professional SIGNS ELEC1
6 w E7 OWNERBUILDER DECLARATION l0 s7
t.., Ihercby affirm that lam exempt fromtheConlraRorb Grense Law(or the
SPECIAL CIRCUIT/MISC
C)O O.. following reason.(Section 7031.5,Business and Professions Code:Any city or
y F TEMP.METER OR POLE INST. TIG.. lSt aas.,asa
� cwty
nwhich reguimapemNt to construct,alter,lmprove,dennlbh,orrepalr
.� anystm=mpdortolts Wuance,aLsorequimslheappErantforsuchpermitto )OWER DEVICES
c. file a signed statement that he b licensed pursuant to the provisions of the
04 Contractors License law(Chapter9(mure
nncingwith Section 7000)ofDivi-
ZS 3 SWLMMJNG POOL ELECTRIC
si.n3.fthe B.s ...d Profemlom Code)orthathetaexemptthemfmmand VALUATION
5 the busts for the alleged exemption. Any violation of Section 70315 by any
O appEwntforapermitsubjectstheappOcanitoadvllpemltyofnamorethan UILETSSWITCFiFSHX7URE5 O I ��
five hundred delta.($500).
,9, NEW RESIDENTIAL ELECTRSQ.Ff. STORIES TYPE CONSTRUCTION
I,as owner of the property,or my employees with wages as their sale
7Q compensation,will d o the work and the structure ta not intended or offeredfor
a ❑ sale(Ste.7D77,Business a rd Professions Code:The Contractor's License Law
q s does not apply to an owner of property who builds or improv.thereon,and OCC.GROUT' RFS.UNITS
does such work himself or through his own employees,provided that such
improvements are not intended oroffered for sale.If,l owevep thebuilding or
improvementbsoldwithinoneyearofcompletlo theowner-builderwlllhave
the knirden of proving that he did not bund or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE
"L as owner of the property,am exclusively contracting with licensed F100D TDNE APN
contractors to comtroct the project(Sec.7074,Business and Professions Code: PERMIT ISSUANCE
The Contractors License Law does not apply to an owner of property who
buALTER-DRAIN&VENT (EA)
Wild, or Improves thereon,and who contracts for such p - -
rojects with a
cactoKs)licensed pursuant to the Contractors License Law, BACK FLOW PROTECT.DEVICE FEE SUMMARY
1_j I am exempt under See B&P C for thin mason
OUTSIDE If ES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N
Owner Date RECEIPT 0
WORKMAN COMPENSATION DECLARATION PER TRAP �. SCHOOLTAX Y_ N_
I hereby affirm that I have a certificate of consent to self-Insure,or a RECEIPT N
33880)0LatbeC'Worken'Compewatlonlwuranre ora certified ropy thereo((Sec. GAS EA.SYSTEM-S INC70UTLETS PARK FEE Y_ N_
Policy If REC a
C
om n4, GAS EA.SYSTPMAVER<(EA) D NFEES
[rCertifiedeopyisheiebyfumished. GREASE/INDUSTRL WASTE INTERCEPTOR PISA
r [DCert63ed copy bfiled with the etylespection division.
CERTIFICATE OF]EXEMPTION FROM WORKER$' GREASETRAP PAI
COMPENSATION INSURANCE _a
(Chis section need not be completed lfthe permit u for one hu III Y- Date Reeei 1
(8100)mly that
W, EC E
11
Icertlfy thatin oy an Fortson nce
the work w as
bee.h thispe It la d,
1 shall not employ any person In any manner at as to become t L
Worker%Compensation laws of California.Date _ / PA
Z Q Applicant NOTI ETO APPLICANT:IL after making this Certificate of Exempt P SQ.Fr. Date It
should beeneaubjecl tothe Workeri Compereatlon Prov waft TOT
m
N Code,you most forthwith comply with such provisions ortkspermit shall be BUIL IN /a
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC
d I herebyatfirmthat there isamwtwctlon lendingagency forthe perform ELE
Z once of the work forty is thispermttie Lssued(Sec.3097,Cie.C.) TOTAL:
V Tenders Name ' ���� PLU NG rfE
LL h- Lender's Address QTY. ' MECHANICAL PERMIT FEE F N[ LFEE lb I
OW 1 crAifythat I have mad thisappliwtion and state thatthe above Information -
1 Is correct.I agree to comply with an,city and county ordinances and sate laws PERMIT ISSUANCE '^� EE AID:
} relating to building cowtmattn,and hembyauth.man representaiivoofthb
f' N city to enterupon theabove-mentioned property for twpection purposes. I ALifltOR ADD TO MECH. -�
Z_ Date Recei t#
save,(We)agree to ve,indemnity an d keep the City of Cupertino - - P
V agaWtiiabWties,jmdgmenls,cossand expensees whi whichh may In anywayaccrue AIR HANDLING UNR RO 10,000 CFM) $l1BTOTAL:
aga tot said City In con yuence of the gram ing of this permit. CONSTRU ON TAX
' AIR HANDLING UNIT(OVER lO,WOCFM)
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUC ON TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE /
Will the applicant or future building occupant store or handle hazardous HEA TINGUMT(TOID0000B"fU) j � Date R
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the \\\ _
Health and Safety C a mon 25532(a)? HEATING UNIT(OVER 100,000 BTU)
YesNo
WWtheapplicant tore building onvpant use equipment or devices VFN111ATION FAN(SINGLE RFSID) - I$$U CE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Qu a lity Management D ct? BOILER-COMP DIU`OR 100,0(10 BM '
4Yes P ,A I D
have read the haaar=ccuurnals requ lerments under Chapter 6.95 of BOILER-COMP(OVER 1 00,DOO BTU)
the California Health&Safety Code,Sections 25505,25533 and 25534.I
u oderstand that it the building does not aumntly have a tenant,that it is my NEW RESIDENTIAL MECH, SQ.Fr SEP 1 1992
I mpote ibility to notify the occupant of the requirements which most be met
p' oessu ce maarti Ocateof Occupancy. cify
V VI"th I llvu
th agent Date ISSUED BY:
TOTAL:
OFFICE COPY
i