23823 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Ifialldioll Project Identification .Nf. PERNUTNO.
Building Address:
;o / f O► & �-I . 23823
cera ame: Phone
Ike- W '{lS' � - Z3I CITY OF CUPERTINO-BUILDING DIVISION q A A
Coniranor•aname LIc.Nn: APPLICATION / PERMIT 6 -12 '
Opn x BIIILDING-ELECTRICALI'LUIMBINGMECHAMCAL CATEGORY CONTROL X
Architect/Engineer. Lie.No:
QTY t ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address O Z 'S TERMITISSUANCE
LICENSEDCONTRACTOR DECEl Ll �
El[heilamprovisionsofCh9c- APPUANCESRESIDENTIAL JOB DESCR 'ITON
ingwlthSedion7OOD)ofD'Wsim3ofthe BusinessIand ProfessionsCode,and
my '
license is in fuB(m and effect. PANELS
License Class C - la Llc.X K R 1 g P / P I
Date ontrator jL.�1a1.�Nie 201-1000AMPS
ARCHITECT, ispu ATION
rs0 Z I understand my Fire shag be used a public records OVER 1000 AMTS SQ.FT.FLOOR AREA $/SQ.FT.
OSIGNS ELECTRICAL
� I., Licensed Professional
<c. OWNER-BUILDER DECLARATION SPECIALCIRCUIT/ML9C
s. L I hereby affirm that am exempt from the Commerce's License Law for the
7.9 following reason.(Section 7031.5,Business and Professions Code:Any city or (� �
O t H p� TEMP.METER OR POLE INST.- I," E "�
rountywhich requires a permittocorstmt,alter,improve,demolish,orrepair /
''4�a anystrueture priorto its Issuance,also requuestheappllcart forsuch permit to POWER DEVICES I,m '1
rY2 U Ille a signed statement that W Ls licensed pursuant to the provisions of the
O o- Contractor's License law(Chapter 9(commencing with Section 7000)of Divi- - 1\
G7 3 O�n B w SWLMMINC Ii70L ELECTRIC
a the basis fo the alleged Professions Any)violation
f exem therefrom and / jI A7TON
F the basis for the alleged exemption. Any violation of Sectlov 701.5 re any OUTLETS-SWITCHES-FIXTURES
`�GG
fiveapplicartfora permit
ars(S . the applicant ince dull pemltyo(nt mnrethan ������
y� five hundred dollarshepr. NEW RESIDENTIAL ELECTR SQFP. STORIES TYPE CONSTRUCTION
x(11 p I,as owner of the property,or my employees with wages a there door
�7¢ compensation,Business andIldo the randthnst ode:Th net Intended oramoffered Law
a ❑
sale&c.apply
Business property
Code:The or Impoves License Law
p � whoddoes oessuch torn owner ofp or rough who nemporees,prated that such
OCC.GROUP RES.UNITS
whodoessnts amwork himededorugh Msowale.If omprovidedildingch
Improvementdarenaithindedoroofcreordale.I(h mer-gilder ilIhave TOTAL:
Improvement bsoldwithin oneycaro(completiogthcowner-bullderwill have
(burden of proving that he did not build or improve for purpose of sale.). QTS. PLUMBING PERMIT FEE }TpODLONE MIN
u 1,as owner of the property,am exclusively contracting with licensed
contractors to mrotruct the project(Sec.7044,Business and Professions Code: ' PERMIT ISSUANCE
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VFM-WATER(EA) _
Wilds or Improves thereon, and who contracts for such projects with a FEE SUMMARY.
,,IlIltI([atoKs)licensed pursuant to the Contrache's License Law. BACK FLOW PROTECT.DEVICEI_J I am exempt under Sec. B h P C for this reason
Owner ate
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
RECEIPT
WORKMAN COMPENSATION DECLARATION N
FIXTURES PER TRAP SCITOOL TAX Y
❑I here _
by N
a(Ovn that I have o certificate of consent to spytheure,or RFLEB'I'X
U00(1IabC�Workers'Compersanonlmurancemacertified mpythermllSec. If GAS EA.SYSTEM-1 INCA OUTLETS Qa PARKFER Y N_
RECEIPT X
Policy p GAS FA.SYSTGI-0VER 4(FA)
Co any ]RECEIPT
DIVISION FOES
r1CertlOed copy is hereby furnished. GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
ftl Ceased copy's filed with the city inspection division.
'/� CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Remi t#
(This section need not be completed If the permit V forone hundred dollar
($100)or less.) WATER F&ATFR w/VENT/F].ECTRTW ENERGY FEE Y N
I certify that In the performance of the work for which this permit is issued,
1 shall not employ any person In any manner so as to become subject to the WATLA SYSTEM/TREATING
worku%Compensatmnlaws of Callfomia.Date - PAID
OZ Applicant NEW RESIDENTIAL PLMB. SQ_ET. Date Remi t#
Z O NOTICE TO APPLICAM:If,after making this Certificate of Exemptionyou
should become subject to the Workers'Compersatlon provislom of the Labor TOTAL:
V) Code,you most forthwith comply with such provisions or this permit shall be BUILDING FEE
ll1 ] deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Ihereby afRrmfiat them Is a mwtrutlon lending agency for the perform, TOTAL: ELECTRIC FEE
D Z anceof the work for which this permit isbmed(&c.3097,Civ.C.) ,
Q O Iemdrrs Nrmr PLUMBING FEE
iy - Lender:Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icendythatlhavereadthlsappbmtionandatatethattheaboveinfor tion
1 iscamt.I agmetocomplywith all etyand countyordlnancesand state laws PERMIT M6UANCE FEES PAID
-} relating to building construction,and herebyauthorize nepresentativesofthb
(— W city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH.
? (We)agree to save,indemnify an IF keep harmless the City of Cu Fenlon Date Receipt#
L) against liabilities,judgments,mats and expenses which may in any way accrue AIR HANDLING UNIT CTO 10,000 CFM) SUBTOTAL- '
zgalrst said City in consequence of the ga ing of this permit.
AIaxANDUNC UNIT(OVER Ia,eBBcrM) CONSTRUCTION TAX
ignaturLlof Applicant/ contractor .Date IXHAUSf HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haaardous HEATING UNIT(TO IOO,ODO BTU) Date Reaei t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
Ilealthand Safety Code Setmn25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: . r
M Yes , M No
Will the a ppilant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
whichemu ha,rardous air coria entrants as defined by the Bay Area Air P A I D
�
Qluaallityyes Management Di❑stricNo
t? BOILER-COMP ped'Oft 100,000 BTU), `Fhavc read theft moor materials requirements under Chapter 6.95 of BOILER-COMP(OVER100,0001ITU) []
the California I lealth k Safety Code.SetioreMS05.25533 and 25534.I JUN 12 1992
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MSCI 1. SQ.FT '
responsibility to notify the occupant of the requirements which must be met
prior to issuance of a Certificate ofoccvpanq, °CRY Vf`LUCi.:nIIIVU
Owner or authorised agent Date ISSUEDB < "�L C s
70'TAL:
OFFICE COPY