23174 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect IdentificationPERMITNO.
Building Address: G , .23174
wners ea�(nte�_ cane:
CITY OF CUPERTINO-BUILDING DIVISION
` c°^tr er' Name: LI "°: APPLICATION / PERMIT
G 'dF S 7 3 BUILDING-ELECTMCAI nUMBING- CATEGORY CON'PtOI
ArcMten/Engt ae Lie.No: MLCI VsMCAL
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ITUNIT IT
❑ ❑
LICENSED CONTRACTOR'S DECLARATION LTJ
I hereby affirm that l am licensed under provisions of Chapter 9(comeneso, APPUANCESRESIDENTIA JOB DPSCRB'TIDN
ingwithSxaon7000)of Dlvislon3ofthe Businmand PrefessionsCode,and my 1 /�arte
license is in full filmsand affect. PANELS
License Chs — Conte 3 —
Dale a/ Contractorr� "T j v
ARCHITECrg DECLARATION
00 1 understand my plans shall be used at public records. PS SQ.Fr.FLOOR AREA $/SQ.Fr.
Licensed Professional SEL AL I
OWNER-BUILDER DECLARATION SPECIAL CRiCUIT/MIST
k, Zi IhereleyaffirrethatlamexemptfromtheContractor.LicenseLaw teethe TER
oo following reason.(Suction 7m1.5,Business and Professions Code:An cityor
Oz y TLMP.METER OR POLE INC
r4county which requlrcsapemdlreconstruct,
requir theaprovent fors ch,ormitto
qY any structureprior, tent that he Is also moseel pursuant
to the revisions of
te NiRL POWER DEVICES
Ei K 6 file a signed statement that he h licensed pursuant to the provisions of the
Wb Oi.., Contractor's License Law(Chapter 9(mmmencingwith Section 70W)afDivi.
H OS Mo03.fthe Buidnessand PrefessimuCode)orthat he h exemp"herefromand SWIMMING POOL ELECTRIC DA LUA'1]pNO
S^ the basis for the alleged exemption. Any violation of Benton 70315 by any OUTLE3SSWITCHESFlK'I'URFS Oy
�a applicant fora permit subjects ot the applicant to a civil penalty atom more than
QQ fivehund¢d dOilaq.rs(51s�wv
R u• NEW RESIDFMTAL ELECTR
�n ❑I,as owner,ll the property,ormyemployees with wages r their mak �'�' STORIES TYPE CONSTRUCTION
salqcompensation,Business weekandProfessions Codurehnotintended ar offered for
doe(net apply
Businessandof property
Cob:The uilds or Improves
U¢roelad
3� docs notsuchork owner ofprough hiswho
nemorimpprovied that
OCC.GROUP RFS.UNITS
who does su t.are c himself led orough his own employees,provided that such "7i
Improvementsarenotintended earofco !weak.th owner-pthebuildingve TO
Improvement beold within one ysarotcompldloM the owner-W Bderwlll have
t gW'denofpmvingthat hedid nabWldorimproveforpurposeof.1a.). QTY. PLUMBING PERMIT FEE --TE551) Nrg ApN
n L as owner of the property,am exclusively contracting wish licensed PERM777SSUANCE
comasclors
near the project(Sec.70K Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DEIN da VEN7-WATER(FA)
Wilds or improves;thereon, md
n,and who ntraa for such projects with a
rodor(s)u¢nwd pursuant to the Contradur's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LII am exempt under Sec. B k P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECEIPT p
WORKMAN COMPENSATION DECLARATION FIXTURE&PER TRAP SCHOOL TAX Y_ N_
❑m�ifl hereby ori that I have• l rturane of consent d spytheu or RFCETPr N
38W,Lab
of Workess'Compewadon lruurance eea¢dlfled copy thereof(Sec. GAS F.A.SYSf'FM-]INCA OUTLETS
Policy ab C.I PARK FIB Y_ N
Policy p CAS G,SYSTEMAVER d(FA) RFGPIIT M
Com any BUILDING DIVISION':ES
�Certlfied copy is heed with the
ted.city CREASE/INDUSML WASTE INTERCEPTOR PLANCHECKFEE
Certified copy la tiled with the city inspection division. U
GREASE TRAP a. y .
CERTIFICATEMPE EXEMPTION TIOIN FROM WORKERS' PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORMEA 20OFT Date eeel t#
(Tan need not W completed If the perMt h(or one hundrM dollars($]00).r l..) WATER HEATER W/VENT/ELCTR E F E Y N
I¢rtrtifytifythat In the per(omun¢af the work forwhich this permit is blued, WATER —
I shall not employ any person In any manner m as t me sub'a to the
Wmken'Cmn do we of I m . Date a - WATER SYSTEM/TREATING Ix
O Z Applicant ' —
ZO NU FILL[CAPPLICCAN 1:I,after nuking this Certificate of Exemption,you NEW RESIDENTIAL PLMB. BQ.Fr. Recei I#
Nshould become subjectto the Workars'Compensation provisions of the Labor OTAL:
W Code,you must forthwith comply with such provisions or this permit shall be
j deemed revoked. B G I
W G CONSTRUCTION LENDING ACFNCY S SMIC
a I herebyafflrm that there b a construction lending agency for the perform- EL• T
Oz sea.(the work for which this permit is issued(Sen.3097,Civ.CO TOTAL:
!, LenPL FEEder:Name
LL h- Lendar's Add reu QTY. MECHANICAL PERMIT FEEME NICAL FEB
O 111
UI cadify that have read thsappllcatlonand andethattheabove Information
Is correct,I agree to comply with all city and county ordinances and elate laws PERMIT ISSUANCE FEES PAID:
>. 1 relating to building construction,and hereby authorise representatives ofthls
Zcity to enter upon the above,mentioned property for inspection purposes. ALTER OR ADDTOMECH. Date R j [#
(We)agree to save,and emNfy an d keep harrNess the City of Cu pert W P
against lhbilittas,pdgmens,mass and expenses which may to any way accrue AIR HANDLING UNIT(TO 10,ODO CFM) SUBT TAL:
g.i City in rote ice of the grant Ing of this permit.
/ �j /"A AIR HANDUNG UNIT(OVER 10,0DOCFM) CONSTRUCTIONT X
nate re ofApApiplica tt//CConttractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION T X PAID:
HAZE R DOLS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant store or handle hazardous HEATING UNIT(TO 1(10,000 BTU) Date CCCi t#
material as defined by the Cupertino Municipal Cade,Chapter 9.1$and the
Health and Safety Code Seaton 75532(¢)? HEATING UNIT(OVER l00,0W BTU) OT
❑ Yea M No
Will the applicant¢form,building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANC ATE
which emit hazardous air consmlmns as defined by the Bay Area Air n D
Quality Management District? BOILER-COMP OM'OR 100,(100 BTU) W
I� Yee g No
h.VO read the bozo ous materials requircrnents under Chapler6.95 of MOILER-COMP(OVER 100,000 BTU)
the California Health kSafety Code,Sections 25SD5,25533and 25534.1 JAN 10 1992
understand that if the building does not correctly have.tenant,that it 6 my NEW RESIDENTIAL MEGA. IT
SQ. .
responsibility to net ify the occupant of the requirements which must be met
prior to Issuance of a Certificate of Occupancy. rtH I INV
wn
CI�I Y Uf �Ur.r..
Omer or authorized agent Data ISSUED BY: �+ �-a a'
y��
70TAL:
OFFICE COPY