23598 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm'ect Identification PERMIT NO.
8.11ding.Addocal. 3 S �►� 95b'Y 23598
Owmr
. oA h / K y7S d�Y A
ZC 0 CITY OF CUPERTINO6BUILDING DIVISION
co r Mo' a f{tNA11CO a y�! APPLICATION / PERMIT a�l
Arehitni/Enginaar. Lk.No: BUfLDINGELECTRICAL7'LUMBINGhfECF1AMCAL CATEGORY CONTT
ROL N
/V
Qn ELECTRIC PERMIT FEE ��._.NN,,BUILDING PER INFO
Address: PERFITISSUANCE ��N.1 ❑ ❑ ❑
LICENSED CONTRAROr pr DECLARATION II ••
Ihercby affirm that lam licensed under provisions of Chapter (commenc APPLIANCFSRESIDENTIAL ]OB DPSCRETION
inense is in fon 7000)of d efteon3oRhe Buslneseand PmfesslonsCodG and my (a '`�
license le in io.70 d MlM. 88 aI PANELS v�[,
Limnsed�q FLk.N aaaN
Date S(J//qv3 Contractor nf• p1I000AMP5
j CHallbeuB CLARATION OVER1000AMPS e.Q.FT.FLOOR AREA $/SQ.FT.
ON G I understand my plans shall bo used a public records
CO SIGNS ELEC
(� Licensed Professional - J i
L
<<w OWNER-BUILDER DECLARATION t s
�n Fn SPECIAL CIE NT/MLSC f
i.., Ihercby a(flrm that]ace exemptfromthc Contractorb License Law for the
ZO following reason.(Section 7031.5,Business and Professions Code:Any city orr'
countywhkh rcqulraapermltlocoratruct,alien Improve,demolish,orrepair TEMP.M RI'QLE
anystructure pdorte,its Issuance.alsorequirestheappEmnt forsuch permit to
POWER DEVICES
V file a signed statement that M b licew d pursuant to the provisions of the
Contractors License taw(Cha(Chapter 9(commencin with Section 7000)of Divi- VAI UA
w Pt B SWIMMING IDOLCTRIC
F OS thesiobasis 3 of for
BuMncss end exemptProfession, AnyCode)or
hionat of exempt therefrom and
Yd�- the Wan for the alleged exemption. Any t to
of natty not o by any /s
<� OUTLETSSWITCHESFlXTURES Ov �•��
applicant for a permit subjects the applicant to a civil penalty d not mnrethan
p. five hundred dollars($SM. NEW RESIDENTIAL ELECTR .FT.
? M 1,as owner of the property,or my employees with wages as their sole STORES TYPL GDNSIRIX.TIDN
< compensation,will do the work,and the structure is rad intended or offered for
NO sale(Sec.701y Business and Professions Code:The Contractors License Law
j� does net apply to an owner of property who Wilds or improve thereon,and OCC.CROUP RES.UNITS
E whodoessuchworkMm B orthrough hisownemplmyees,provided that such
Improvements are not intended orof(ered forsals.If,howevegthe W ilding or TOTAL:
improvement bsold withinoneyearofcomplMbn theowner-buiMerwill have
thiSIZurEen of proving that he did net build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ E,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCEcontractors to construct the project(Sec.7061,Business and Professions Code:
The Contractors License Paw does net apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon,and who contracts for such pW"with a FEE SUMMARY
er(.)licensed pursuant to the Contractors Lkcme Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec B&P C for this mason
DRAINS A,FLOOR ROOF,ARECOND. SANITARY Y_ N_
. Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAIT SCHOOL TAX Y_ N_
M1 hereby affirm that I have a certificate of con.enl to self-Insure,ora RECEPT N
certificate ofWorkere Cnmpensationlreturance or a cenified copy thercof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
MOO,lab C.) EM —
Policy N RECEPT N
Com any _ GAS EA.SYSfFM-0OVER
� BUILDING DIVISION FEES
Cenified copy b hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
Certified copy is fled with the sty inspection division.
CERTIFICATE OF EXEM PTION FROM WORK ERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SAMTARY-STORM EA 200FT Date Recei O
(Thlsseition need not W completed tithe permit is forone hundred dollars
(8100)or le.eJ WATER HEATER W/VENT/Fd.ECTR ENERGY FEE Y_ N_
I mni(ythat in the performance ofthe work for which th permit is issued,
I shall not employ an person In ray manner ro u t b Y b', ty,IM WATER SYSTEM/TREATING PAID
I hall net
s Laws fomla.Dale YY.•
O Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
Z O NOTICE TO 1 1 ANT:I,afle makingthb Cenii of Exemption,you
should become subj cl to the Workers'Compensation provisions of the Labor TOTAL:
P
N Code,you=at forthwith comply with such provisions or this permit 0.11 be
deemed revoked. BUILDING FEE
IL devoted CONSTRUCTION LENDING AGENCY SEISMIC FEE
tl I hercbyaffirm that there Is a construction lending agency for the perform ELECTRIC FEE
7 Z ance of the work for which this permit is W (See Ensued 3097,Civ,C.) TOTAL:
UO Lender.Name PLUMBING FEE
LL I– Lander.Addreaa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O LEE Icertifythzt l have readthi.application and Matethat theabove Information
lamrred.I agree to comply with all city and county ordinances and pate laws PERMIT ISSUANCE FEES PAID:
} relating lobulldlng construction,and hereby authorize repmentatives of this
F N city to enter upon the above-mentioned property for inspection purposes. ALTERORADOTOMECH.
? (We)agree to save,Indemnify an it keep harmless the City of Cupertino Date Receipt#
V against liabilities,Ndgments,costs and expenses which may in anyway accrue AIR HANDLING UNIT(TO 10,000 CIM) SUBTOTAL:
ag.Wt said City In cons yuence of the granting of the.permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applicam/Cmdcartor Daze EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or forum to ilding occupant store or hand le hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino MuNctpal Code,Chapter 9.17,and the
Health and S.(My Codlon 75532(a)7 HEATING UNIT(OVER 100,00)BTU) TOTAL:
❑Yes 44No
Will the applicant orfutum building ocm pant use equipment or devices VENTILATION FAN(SINGLE BESIDE ISSUANCE DATE
which emit hazardous air contaminants as dented by the Bay Arca Air
Quality Management District? tel [l y Dict1FR
? BOILER-COMP O 'OR 100,000 BTU))have read the h �azainloNus materials requirements under Chapter 6.95 of BOILER-COMP(OVER1W,000BTU)
the California Health&SafetyCode,Sealons25505,25533and2S531. I na�s,� (] q
understand that lithe building does not mrrently have atcnanL that itbmy NEW RESIDENTIAL MECIi. SQ.FT. APR i7 1992
roponsibilitytondilytheocctt to(therequirements wIt hmustbe ret /s
prior to iss dtis a iOccu anry. d
/ � _ l*fY � •. f•I�.�'�il''-s'�VVQ,
Owner or authorized agent to
TOTAL ISSUED BY:
OFFICE COPY