23545 iAPPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project identification =T NO.
R4liing Actdre..: 23545
C x'13 S� ice cr i
Kama:
ne:
A
CITY OF CUPERTIN0.8UILDING DIVISION Q"
contrachAsName: tic.Na: APPLICATION I PERMIT �
B(RLDING-ELECTRICALPLUMBING-MECIIANICAL CATEGORY CONTROL#
Archil /Fagineer. Lie.No:
' ZZo� 0Y ELECTRICPERMIT `' FEE BUILDING PERMIT INFO
Adtlrcu: 146' - PERMFLISSUANCE L I� ❑
LICENSF,D CONTRACTOR'S DECLARATION'S `�
I hereby afftrm that l are licensed under provbioes of Chapter9(commene- APPLIANCESRFSIDENTIAL �'� JOg Of mo
Ingwlth Section 70D0)of DAudcm3ofthe Busfauand ProfessionsCode,and m /a� .0 �/�
license is In run force and effect, PANELS ., \/Ja�:L /111 ]�y�
License Clam Lie# - , 1`T�'��`a'1/
Data LM TO 200 AMPSARCHITECTSDECLARATION 201-I000 AMPS
Z 1 understand my plansshall be used as public records. OVER IODO AMPS SQ.FT.FLOOR AREA S/SQ.FT.
GOC
U Licensed Professional SIGNSELECTRICAL
OWNER-BUILDER DECLARATION SPECIALCRCUfT/MLSC
a 1herebyafBrmtlut9am exempt fromthe Contractor's Licanse Lawferthe
Zo following reason.(Section 7031.5,Business and Professions Code:Any city or -
KZI" cauntywhlchmqur aperrNtWmmu ct,alter,impmve,de=lWh,ormpalr T�P.M E ST. '
'SI anystmmmpr rtoltelewance,alcorequimatheappUmntfonuchperMtta
0IL file a signed statement that he Is licenced pursuant to the proves idof the POWER DEV C S
wfn Contractor's Lkense law(Chapter 9(commencing with Section 7000)of Divi- y •- I-^
SOS slon3oflge Business and ProfessionsCode)orthat he b exempttherefromand SWIMMING 1, Cl` 7 / VALUATI(6O '
O_ the boob for the alleged exemption. Any violation o(Sedbn 7N1S by any OLI LETSSWITCHESI
'Sri?f
applicant for a permit subjects the applicant to a civil penalty of not room than - J('fURES
five hundred dollars(S5M. Fill
NEWR D
�n ❑1,as owner of the property,or my employees with wages as their sola EMIR ELRT RIES TYPE COIASTRUCTION
compensation,willdolhe work and thestmeture is not intended or offered for
O ale(Sec 7044,Buebieu and Professions Cade:The Contractors License Iaw
$ dos not apply to an owner of property,who builds or Improves thereon,and OCC.GROUP RFS.UNITS
whodees such work himselfor though Ms own employee,provided that such
improvements are not intended oroffered forsale.If,however,the building or T .�
Improvement b.oldwlthnoneyearufcompletlogtheowner-bugderw111 have -
tINbunlenof proving that he did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensor
contractors to construct the project(Sec.7044,Business and Professions Code: PERMIT ISSUANCE
The Contractor',License law does not apply to an owner of property who ALTER-DRAM kVENT-WATER(EA)
builds or Improve thereon,and who contracts for such p(ajed&with a
cgn(pctor(s)Licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY.
UI am exempt under See. B k P C for this meson
DRAINS FLOOR ROOF,AREA,CONTI. SANITARY Y_ Nr r
EES
Owner Date RECEIPT#
WORKMAN rm COMPENSATION DECLARATION 01 SCHOOLTAX Y N
01 hereby affithat I have a certificate of consent to self-InFIXTURES.PER TRA
self-Inure,ora RECEIPT M
oertlflate ofWorka Compensation Iran rance or a cartBled ropy thereof(Sec.
3800,Lab C.). GAS EA SYSTFMIMC4OUTLETS PARK FEE Y N
Policy Y GAS EA,SYSTPM-0VER d(EA) RECEIPT#
Com any BUILDING DI VI SION FEES
[�Certifled cupy is heed with the
GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE'
OIahcd
CertNed copy billed with ted city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Remi tq
Ohbm
slon need nm[be completed If the permit b for one hundred dollars
(5100)orlessJ WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
[certify thatInthe person
any ork
An which as tobthispermitb[sassed,
Work not employ any pesos In any manner at as to become subject to the WATER SYSTEM/TREATING
Workers Compensation Laws of California, Data. PAID
O Applicant
Z rZ1 NOTICE TO APPLICANT-.If,after making this CeMfiateof Exemption,you NEW RESIDENTIAL PIMB. SQFT. Dale Remi tN
'J. should become subject to the Workers'Compensation provisions ofthe Leber TOTAL:
W' Code,you=at forthwith comply with such peavotions or this perrut shall be �e
W j deemed revoked.
a � CONSTRUCTION LENDING AGENCYSEISMIC FEE
^µ Ihereby affirm that there b a construction lending agency for the perform- TOTAL: ELECTRIC FEE
once ache work for which this permit b issued(Sec.3097,Clv.C.I
UO Lender's Name - PLUMBING FEE
IL f— Lender's Address - QTY. MECHANICALPERMIT.. - FEE MECHANICAL FEE
U I rertifythat l have read thbYppllati.nand utamthetheabove information
O WIs correct.I agmeto comp) ith all cityand county ordinances and state laws \ PERMRISSUANCE ( FEES PAID:
>. CL W relating to buil ops ctton,a reby authorize represent--this
F.. Z city to an pontN ve-meriib property,for Wpedlon pas ms. ALTER OR ADD TO MRCH.
V _ (We) gee t6 e,In mm(y d keep harmieu the Clty of pertinm Date RCeeiptq
agalnstll is, and expenses which may inany ayaccrue AIRHANDLING IIMT(fOI0,000CFM) SUBTOTAL'
agolnst uld s an ofthe Small ng hie permit
AIR HANDLING UNIT(OVER 10,00OCI•M) CONSTRUCTIONTAX
Sign rem( ppllmnt/C tactor Data EXHAUST HOOD M/DUCT) CONSTRUCTION TAX PAID:
HAZ DOUSMATERIALSDISCLOSURE
Will thcappgan rfuturebullding oaupantstoreor handle hazardous HEATING UNIT(TO 10,000 BTU) Date IReceipt
materialaa de0ned y the Cupertino Municipal Code,Chapter 9.12,andthe
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTA �t
Rill
M No
Ill the applicant orfutumbulleing occupant useequipment ordevlces 1 VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haveldous atr contaminnts as defined by the Bay Arca Air
Quality Management District? BOILER-COMP QHPOR 100,IX0 BTU) p pM ' D
Y. n❑No
have read the hazards..maP terials requirements under Chapter 6.95 of BOILER-COMP(OVIR 100,000 BN)
the GliforNa l lealth k SafetyCode,Sealons 75505,25533 and 25534. I
understand that if the building time not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT APR 21 1992
resccunt
responsibility to notify the opaof the requirements which must be met
prior to Issuance of a Certificate ofOcmpa racy.
CI Y u CIuptHlIAD
Owner or authorized agent Data
' 7.0 , ISSUED BY:
OFFICE COPY