23444 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Addreu: (0 19' 1100%. LIP 23444
date: one: q A
0064 .- CITYOFCUPERTINO-BUILDING DIVISION � 1} �y
cant dor. aces: L+c.Na: APPLICATION 1 PERMIT `i 6—lZ
(C BUILDING-ELECTRICAL-FLUMBINCMECHAMCAL CATEGORY CO (�In7
A Itect/Enginer. Lie.N. —`0
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
AddressA;?5yrel a✓ ` RMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby aairmthat l am licensed under provisions of Chapter 9(mmmenc. APPLIANCES-RESIDENTIAL ly
JOB DFSCRBIION
ingwith5 dion7000)ofDivision3ofthe Businessand PwfsssionsCode,and my Q
limns Is in full( and d(e I. _ I PANELS F�
License Las+ Contractor • 9 ` L ��
Date a"tT611 1
Ins hall DECLARATION Ml-jOVER00)() PIIAM PT{„/�i I Z G..1v
a'CJ. lundentand my place shall be used upublic remrds. OVERIWO AMPS �,FT,FLOOR AREA $/
ZO Licensed Professional SIGNSELECTRICAL L+�V
OWNER-BUILDER DECLARATION SI'FGALCIItCUfT/MIST
7E' er I hembyaffirmthat lamexempe fronethe Contractor's License Lawforthe
po following reason.(Section 70315,Businessand Professions Code:Any city or
F k' cwntywhichrequirnapermltmromtmd,alteglmprove,dermlish,orrepair �MP.METTRORPOI.EINST.
a nystm=mpdortaits WuamealsorequirestheappBmntforsuchper tto
�o.F Ole a signed statement that he is licensed pursuant to the provisions of the POWER DEVICES
1..,�O� Contractor's License Law(Chapter 9(commencing with Section 7000)ofDivi.
05 sion3ofthe Buvnmsand ProfsiomCode)orthathebexemptthemfmmand SWIMMING POOL ELECTRIC VALUATI
5 the baso far the alleged exemption. Any violation of Section 7031.5 by any
applicantforaperaatsubjedstheapplicanttoadvilpemityofnotrnrethen
OUTLETS-SWITCHES-FIXTURES —eFIXTURES Z
❑ Z
five hundred dollars($SM. NEW� RESIDENTIAL ELECTR j � ❑I,as owner of the property,or my employees with wages as their sole SQFr. STORIES TYPE CONSTRUCTION
compensation,willdothe work and thestrudum is not Intended or offered for E p I N
❑
sole&c(See 70K Business and Professions Code:The Contractors License Law
� $ donot apply to an owner of property who Wilds or improves thereon,and i
who does such work himself orthrough his own employees,provided that such - NUNITS
WITS
improvements are not intended oroffered for sale.If,however,the building or Jf� U ' 1F[.
Improvement exuld within one yearofcompidion,the owner-builderwlll have
t e Nen or proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FE APN
Lj L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
mntracton to construct the project(Sec.700 Business and Professbm Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN kVENT-WATER Wilda or improves thunder,and who contrafor such EimjeRs with a (EA) awa —
m-p(Tactor(s)licensed Pursuant to the Contractors Lima Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B k P C for this reason
OUTSIDE FLL�
Owner DateDRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION RECEIPT 9
hereby affirm that 1 have a cart+f este or consent to elf-insure,m a FIXTURES PER TRV' SCHOOL TAX Y_ N_
mnif+ate of Worker Compemat+on Imunnm ora mniflcd mpy thereof(Sec. RECEIPT p
3800,Lab C.) GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N_
Poli Y
�- Cam anv_ 7- / a GAS EA.SYSTEM-OVER4 MAI tlUIL RDC DIVISION FEES
[�C rimed mpy la herebyfurnished.the
GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
I�Cenifiea mpy b mini Alin ted tlry wpeRmn division. ^ ^ yY
CREASE TRP / t
CERTIFICATE EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE PAID
(fhbsess.) need ria be completed lftW permit is(Drone hundred dollar SEWER-SANTIARY-STORM EA.200FT. Date ReCCI t41
($1(I cart less.) WATER HEATER W/VENT/ELEC7R ENERGY FEE Y N
I cent that in the person
he work forwh+ch this pernit is issued, —
I shall not employ any person m any manner so ns to become subject to the
Worket%Compensation Gws or Uliforma.Data WATER SYSTEM/TREATING PAID
z Z Applicant
Z NOTICETOAPPLICANT:If,after making this Certificate of Fm ption,you NEW RESIDENTIAL PLMB. SQ.FT. Date Re-
2 t#
should becom iu,bp&to the Worker'Compematon provisions ofthe Labor TOTAL:
Code,you rtwat forthwith complyns with such provlaloorthis permit shall be
W > deemed revoked. nFEE
EE
S p CONSTRUCTION LENDING AGENCY E
1 hereby afTiren that there b a comtmction lending agency for the perform- ELECTRIC EE
Z ance of the work for which this permit is Issued(Sec.3097,Civ.C.) TO
U O I. oder',Name FEE LL I- I<naer'sAddress - QTY. MECHANICAL PERMIT FEEAL FEEOW Icertifythatl have read thisappllmtionand statethattheaboveinformationiscorrect.I agree to comply with all dryand county ordinances and state laws PERMIT ISSUANCE �} W relating to building mnstrection,and hereby authorlu reprdxm ativaa ofthis
city to enter upon the abovnmentloned propertyforinspectionpurpoes. ALTERORADDTOMECH.(We)agree to save,indemnify an d keep har less the City of Cupertino Receiptq
against liabilities,judgments, sand expenses which may in anywayaccrus AIR HANDLING UNIT(to 10,000 CFM) SUBTOTAL:
against sal C in c segue oft granting of this permit.
�. 'aL9 r� r� AIR HANDLING UNIT(OVER I0,000CFM) CONSTRUCTION TAX
Sigwture of Applies 4'
Date EXHAUST HOOD(N/DUCT) CONST CTION AX PAID:
HAZ.A R DOUS MATER MALS DISCLOSURE _.W
_/ —� G_ �
Will the applicant or future building occupant store or ha ad le hazardous HEATING UNIT(TO 100,ODO B 4 �/ /1
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the Date RCCeI tH
Health dna Safety Cede,Scayan 2i532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: .6
❑Yes 'G���7vo
Will the zpplimnt rtuturc Wilding occupant use equipment ordevlces VENIILATIONrAN(SINGLE RESIDI 1$�IIA�Ni PATE
which emit hazardous air mnlaMmnbasdeRned by the Bay Arca Ab If- M U
Qu I+ty Management Distrkt BORER-COMP(3HE'GR IW,IXq OTU)
LY, -the hazy materials requlremenbunder Chapter6.95 of BOILER-COMP(OVER I OQOW BTU)iealthkSofetyCode,Sedions2S505,25533aed2S534.1JUN - 5 1992
tifthe building does not currently have a tenant,that it is my NEWRESID!2 HALMECH. SQFTo notify the ompant of the requirements which must be metprice to iss
��� too! mvpancy. CII Y Vf Va11fCT411140
onzed agent Date
7 �� ,•^'4�/)�fI t
ISSUED BY:
OFFICE COPY