23364 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Bulidlex Prom Identification - PERMITNO.
Building Address:
oLA C--A y - G QJP0 .I N0 C44 233
64
ante: me:
{V1V(INLQy S(+Mn Q,5!5 CITY OF CUPERTINOtBUILDING DIVISION
Contractors Name: LIc.No: APPLICATION /PERMIT
BUILDINC•ELECnUCALPLUMBING- 1CAL, CATEGORY CONTROL M
Architect/Engftuer. Lie.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE D5 $e ILUMB MELEE
1:1 F-1LICENSED CONTRACTOR'S DECLARATION
[hereby
ion 700 of Wision3 ofthe er usines sions ofand Pro Chapter
setim.9(commm APPI]ANCESRESLDE OB DFSCRR'1'tDN
Ingwith esInfull force and effect. (the Budnesand ProfeWonvCode,and my , ^��^
Licer bin tuft force and effect. PANELS V L.–rJ
License Chss Limp
Date Contactor
ARCHITECPS DECLARATION 20
a0 O I understand my phru shag be used u public records. OVER 1 AREA S/SQ._FT�'
Licensed Professional SIGNSE G ��//OO
OWNER-BUILDER DECLARATION SPECIALCRCUI /
7 s.,�a Thereby afOrmthatlam exemptfromthe CoNranor'e Licens law for the
qqq followingreason.(Section7mlS,BuAI..And Pmf.1mu Code:Anycityor
rsy emntywhlchrcquimaperrrdtmmmtmd,altenimpmve,demolbh,orrepair TEMP'METEROR E ST.
`'0 3 any stmtlure pnortolb lautance,aW requlnslheappunntfar each permit to POWER DEVICES
(ilea signed statement that he is linmeed pursuant to the provisions of the
3m Contractors License Law(Cho pier 9(commencing with Section 7000)of Divi- SWIMEWNG[VOL ELECTRIC VALUATq�IJ„J
BOJ elon3o(the Business.cid ProessimuCode)orthat he b exempt therefromand I &
•77 the basis for the alleged exemption. My violation of Section 70)15 by any OUTLETSSMT'CIiESFI%I1IRE5
a05
applicant for.permit subjects the applicant to a civil penalty of net more than
Bve undmd dollar(f50N. SQFT, STORIES TYPE CONSTRUCTION
A NEW RES[DENTIAL ELFGTR
I, downer o(tFe property,or my employees with wage as their cote
zQ nsatfon,wllldo the work and thestmcture Is not intended or offered for
6 sle(Sec.7040 Businessand Profenfom Code:The Contractors License Law
$ does net apply to an owner of property who builds or improves thereon,and OCC.GROUP RFS UNITS
who does such work himself re through hisown employee.,provided that such
Improvements are not intended oro(fered for sale.If,however,the building or TO
Improvement issold within oneyearofcompletion,the ownenbullderwlll have .
tfLI,tiurden of proving that he did not build or improve for purpose of sale.). QTy. PLUMBING PERMIT FEE
UL as owner of the property,am exclusively contracting with 1—aed WOOD ZONE APN
mntndon to construct the pmj&((Sec.7064,BusinenaM Perfmioru Cade: PERMIT `LSUANCE
The Contractors Llrenss Law does not apply to an owner of property who ALTgIF-D
Wilds or Improves thereon,and who contracts for such ptom jewith a PI FEE SUMMARY
cgR((anorW licensed pursuant to the Contractor's License Law. BACX
LJ I am exempt under Sec II k P C for thio reason
DRAINS R SA ARY Y N
Avner Date RECEBrr 0
WORKMAN COMPENSATION DECLARATION I7X PER TRAP SCI OOL TAX Y N
❑1 hereby&(firm that 1 have a certificate of consent to seR-Inaure,ora RECEIPT-el(Icate of Workers Compensation WuranceoranrtlMdcopy thereo((Sne. C EA.SY P FEE Y N
polis IabCJ RECEIPT N
cff'R GAS EA.SYSTEM-OVER 6(EA)
Com any BUILDING DIVISION FEES
"
-edified copy is hereby furnished. GREASE/WDUSIRL WASTE INTERCEPTOR PLANCFIECKFEE /
Certified copy b filed with the city inspection division.
CERTIFICATE OF Et(EMPnON FROM WORKERS' GREASE7RAP PAID
COMPENSATION INSURANCE ghWElt- STORM EA.200F1'. Date RCCCI t#
(Dusan
,tion need not be completed If the permR b(orom hundred dollars
(SI00)orles.) WATER HEATER W/VENT/Q.ECTA ENERGY FEE Y N
I certify that In the performance of the work for which this permit is bound,
I h.11 not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workers Crmpe uaec.Laws of C.lffomia.Date PAID
ZApplicant
Z -
Q NOTICE TO APPLICANT-.If,after makingthio CertRbale o(Fxemptlon,you NEW RESIDENTIAL PLMB. SQFP. Date Rece1 t#
F should become subjectns
to the Workers'Compeation provisions ofthe Labor TOTAL:
CC N Code,you=at forthwith complywlth such provisions or this permit shall be BUILDING
W > rimmed revoked.
a G CONSTRUCTION LENDING AGENCY SEISMIC FEE
Ihereby affbmthat there ba metmceon lendingagenry(orthe performELECTRIC FEE •�•
Z ance oftheworkforwhichthts permit bhwed(Sec.3097,Cly.C.) TOTAL
(, O Lander:his PLUMBING FEE
'LL F Lender's Address QTY, MECHANICAL PERMIT FEE MECHANICAL FEE
OW I cedlfythmI luveread thbapplicatfonand smtethattheaboveinformatlrn
,a bcorrect.I agreeto comply with all city and county ordinances and state laws PERMITISSUANCE FEES PAID
r W rdatingtobufidingmmtmdimacid Mmbymthodxerepmwntativesofthb
I.- city to enter upon the above,mentioned property for inspectlon purposes. ALTERORADDTDMECH.
? (We)agree to save,Indemnity an d keep harmlessthe City of Cupertino Date Reeel t#
V .gainsabNtles,Iidgmenb rets and expenses which may In Anywayaceme AIR HANDLING UNIT(TO 10,010 CFM) SUBTOTAL:
s d City In con sequ ce of the granting of this permit.
AIR HANDLINGT'roFR
NC UNIT ]B,BBBCFkt) CONSTRUCTION TAX
x.
Signature pin o traitor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
H ZA US MATERIALS DISCLOSURE
Will the applicantDILL
building cocupantstore or handle hazardous HEATING UNIT(10 IM,000 BTU) Date Recei
• materulasdAned by the- pertlno Municipal Code,Chapter 9.17,and the
Health and Safety Code Stolon 25532(x)2 HEATING UNIT(OVER 100,000 BTU) TOTAIOW—
RYea No
ill the applicant ar Nre building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) P1AgABCE DATE
which runt bacardous ab connmlranta as defined by the Bay Area Air
Quality Managcrrcnt DlaMn7 BOILEIFCOMP OHF OR IOO.Oq BTU)
❑Yes
No MAR 9 1992
Ihaveread Health
Safety
mode, erequirementsun33 And
255rti.95 of BOILER-COMP(OVER 100,000 BTU). y O
the Ca understand
h Heatth building Safety Cade,Sections 75505,ve a t and 25534.1
undentandyto If nthe theoccupant
of therequir haves tenant,that it Is my NEW RESIDENTIAL METH. �.R
responsibility issuance
c notify the requirements which must be rrct CITY Ut Cllrtnluru
prior to lsuance cats Certllicate of Occupancy.
Owner or authod>ad agent Date ISSUED B =/�-
TDTAL:
OFFICE COPY