23753 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Build log Address 23753
:7 o w-
ame: one:
(I'ooL- 1,)A15,FR L-Z CITY OF CUPERTINO-BUILDING DIVISION
C.otmetn:.litme: Lic.No: APPLICATION /PERMIT lfl -l
` BUILDING-ELECTRECAL.PLUMBINC-MECHAMCAL CATEGORY CONTROL#
Arcrrhlten/En neeer�. /? Lk.No:
I Z� ;P" 5/ QTY ELECTRICPERMIT FEE BUILDING PERMITINFO
CAddress: 5—<954I C PERMITISSUANCE 1:1 1:1 ElLICENSED CONTRACTOR'S DECLARATION
Thereby afit=that l am licensed under provisions ofChapter9(comma APPLIANCMRESIDENTGL JOBDRBTI
ect)
ingwith Son7000)of Divbioe3°fthe B..I.ss nd Professions Code,and my n
license to In full fors end erfM. PANELS �U\ �
License Cbss mar I
Date Contactor ARCHITECT'S DECLARATION Ml-1030 AMPS
q�u aO zp I understand my plans shall be used as public records. OVERIOOOAMPS SQ.FT.FLOOR AREA It, S/SQ.FT.
d Licensed professional 9CN5 ELECTRICAL - D
<< OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC 1
IhercbyafRmn that l am exempt from the Contractor's License Law(arthe
pp IN
following reawn.(Seaton 7871.5,Business and Professions Code;M a or a p "'gam
y city TEMP.MECFA OR POLE INSf.
PRVY tl
p cnintywhich requlresa permit tocorstrucL alter,lenpeave,derrolth,oreepalr
anystroctom prior to Its Issuance,also requlresthe applicant for such permltto POWER DEVICES
5 file a signed statement that he b licensed pursuant to the provisions of the
COn, Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi-
OQ Non 3ofthe Business and ProfesionaCode)°rthal he is exempt lherefromand SWIMMING POOL ELECTRIC I DTE LUATI
a.•..1) the basis for the alleged exemption. Any violation of Section 7071.5 by any OUTLETS-SWITCHES FIX(URES
O appBcantforapermltwbic theapphcanttoacivllpemityofnd=mthan
five 1,as
demodollarhepr. NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
�n ❑I,as owner of the property,d he employees with wage Ter sok
compensation,(Sec.
70K Buldothe work and Professions Code:
is not Intended or coffered for
O does net vie(Sec. pply to Businessandof property
who
buildsThe Cimpreets License Law
$ who dose,such
torn owner ofporthrough who Wlmporimproovidedms eon,that and OCC.GROUP RES LMTTS
whoovements amnktinten ed or°ugh Neown le.Ifh we,providedthatsuch
improvementarenot Intended earofcedtarsale.I(h er.Atflderwdingm TOTAL•
improvement EwldwlthlnoMyearo(compldlory theowner-bu0derwill have
t"oden of proving that he did notbulldorimprove(orpurposeofwkJ. QTY, PLUMBING PERMIT FEE FLOOD ZONE APNr
LJ L as owner of the property,am exclusively contracting with licensed PERMIT]ISSUANCE
correctors to construct the pmject(Sec 7014,Business and Professions Code:
The Contncteri Licence Law don net apply to an owner of property who ALTER-DRAIN VENT-WATER ff�
Wilds or Improves thenen, and who contracts, for such pto)ects with a FEE SUMMARY
cge(paace
.r(Q licensed Fir to the Contradmi License Law. BACK FLOW PROTCCT.DEVICE
LII am exempt under Sec. B&P C for this reason
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
. Date RECEIPT#
WORKMAN COMPENSATION DECLARATION
❑I hereby affirmorken that I have a lmumne of concent to seR-inwre,ora FDCrUREca' TRAP S(Ti00L TAX Y N
rert0,ab of Workers'Compenutlon Insuranre ma certified copythemof(Sec, RECENT#
3800,Isis C.) CAS EA.SYSTEM-1 INCL OUTLETS PARK FEE Y— N
Polity Y GAS F.A.SYS;RM.OVER 4(EA) DING DI#
Com any BUILDING DIVISION FEES
�Certifed copy t herebyth the ed.city GREASE/INDUSERL WASTE INTERCEPTOR PLANCHECK FEE
❑
Certified copy t filed with the sty inspection division,
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(rhteseetlon need not becompleded BEWER-SANITARY-
lithe permit bforonehundred dollars STORM EA.200FT. Date Recei 1#
($100)1rent WATER HEATER W/VENT/E.FCTR ENERGY FEE Y N-
1.
Irertlfythat tithe performanceof the work forwhkw
h this permit ie issued, —
I shall not employ any person In any manner n as to become subject to the WATER SYSTIN/TREATING
Workers Compensation Laws of California. Date PAID
O Z Applicant
Z O NOTICE TO APPLICANT-.If,after making this Certificate of Exemption,you NEW RE9DENDALPLMB. SQ.Fr. Date RCCeI l#
Hshould became subject to the Workers Compersatlon provisions of the Lshor TOTAL:
CC N Code,you must forthwith comply with such pravbiors orthis permit shall be
deemed revoked. 'BUILDING
W G CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Thereby affirm that there t a on. uctio,lending agenry f°rm
for the pen - ELECTRIC FEE
7 Z an.of the workfor which this permit b Issued(Sec.3097,CIv.C.) TOTAL:
V O Lenders Name PLUMBING FEE
LL ~ Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Irertlfythat]haverealthniappliratlonand Natethattheabovelnformation
LU tcorted.I agree to comply with aB city and county ordinances and state laws PERMIT]ISSUANCE FEES PAID:
r W relating lobulldlng corenrudlon,and hereby authome repmsent0ves of this
I— U) city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH. Date Recei f#
(We)agree to save,IndemNfy an d,keep harmless the City of Cupertino
V against liabilities, hunts,"sand expenses which may in anywayaccruel AIRHANDLI IC UNIT(TO 10,000CFM) q ss` SUBTOTAL:
A gainst consequence of the granting of thiWreeR.
/ /-p AIR HANDLING UNTT(OVER 10,000CFM) CONSTRUCTION TAX
.SSignamrre of Appuan tactor/ (Date / EXHAUSTHOOD(W/DUC'D CONSTRUCTION TAX PAID:
HA7ARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.I2,and the _ Date Reeeivt#
Health and Safety Codo Section2M32(a)? HEATING UNIT(OVER 100,000 BTU) TOTA
E] Y. r]No
Will the applicant orfutum building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISISUOMATE
which Smit hazardous air contambants as deflned by the gay Area Air
Quality Management District? BOIIRR-COMP OHP OR 100,0(10 BTU)
q Yes P N° JUN -1 1992
haveread Health
a Tet Codeiaection rementunder Chapter a! BOILER-COMP 10D,B00 BTU)
theunderstan tHealth&Safety Code,Sections 25505,25S33 a Land,that I'
responsibility
that notifIf the y
the occupanting doe.of note equiyenson s hick that hIt tmy NEW RFSIDFN77AL MECH. SQ.FT ell
rnpomibsi nc of a Certificate
of Ocupancyulrcment which must be met CIt l Vr la(1rC
prior to issuance of a CertlRcatc of Occupancy.
Owner or authorized agent Date ISSUED BY:
OFFICE COPY