23351 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PIiRMITNO.
Building Address:
PX 23351
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ZS CITY OF CU PERTINO-BUILDING DIVISION p A
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Co IraetnraN /Z56 Lk.No: APPLICATION / PERMIT 4-L/f- Z %991—
IL
BUILDING-ELECTRICAf.PLUMBINC-MECITAMCAL CATEGORY CONTROL a
Archltee/Engineer: Lk.No:
a. ;QT;Y ,• EG CTRIG,PERMIT '.;:FCC BUILDING,PERMITINFD.
Adtlress:' - PERMITISSUANCE ❑ ❑ 1:1LICENSED CONTRACTOR'S DECLARATION
I hereby affirmthellamlimesed under powtslonsof Chapter9(comencne- APPLIANCFSRESIDENTIAL 1 JOB DESCRIPTION
ingwlth Section 70U3)of Dlvialon3ofthe Buslnessand ProfesslonsCode,and my
license la in full to andefee. PANELS /7G ax-/r 4{(,(ArlyiC,lAy.�
LlcenseC se Lk.B 310947 P /
Us.�Castraeor Aa r/ K r.Yl— /s
ARCHITECTSDECLARATION201-1000 AMPS TY FQ
qp❑O I understand my phos shall be used as public recurda. OVER1000AMPS � R1�js jSQ.FT.
tj Licensed Professional SIGNSELECTRICAL //—'1 V I
6 OWNEReBUILDERDECLARATION $PECIALCRCIRT/MISC P ,TSE
F, p Iherebyaffirmthatlam exemp[fromthe Contractors Llmnse Law forth¢ 3
ZO W following reason.(Section 7031.5,Business and Professors Code:Any sty or TEMP.METER ORPOLE INST. (}I�
W countywhich mquimsa peroutto construe,alter,Improve,demolish,orrepalr _ 7 G�
qq ."Ii anystm=mpdortoitsiseeancgalsomq iiestheapplluntforauchperMtto POWERDEVICES
t5 w file a signed statement that he Is llrens d pursuant to the provisions of the -
O w Contnotier's License law(Chapter 9(cemmencing with Section 7000)of Divi-
El
sion3 ofthe Businessand Profesabne Code)orthat hale exempttherefromand SWIMMING POOL ELECTRIC„ VALUATION
< the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSW[TCHFSFtJCMtES A'9
O applicant fora permit subjects the applicant to a civil penalty of not more than 3500
five hundred dollars(5500).
NEW RESIDENTIAL ELECTS SQ.FT.
❑e sa owner of the property,or my employees with wages r their dole STORKS TYPE CONSTRUCTION
compensation,will dothe e.and rfessor,Code:structure hnot
ontrandd orcense offered Lw
D sok(Sec.apply
to anteae and f property Code:The Contractors thereon Law
$ does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RES.UNITS
who does auchworkhimself dedoraughhisors employees,provided hebuilthat isuch
Improvementssold am intendneyearfemdforsaleIf,h ner-bunderildingve TOTAL: -
i provermnt lasold withinoneyearafcompletlon;lheowner-WBderwBlha e '
ttBE�udeno(proving that he did not Wild or Improve for purpose afs k). Qjy, l,:""�, " 'PLUM1fING,PER1�'IFF r•FEE"": FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed pp(MIT ISSUANCE
contractors to mretmct the project(Sec.7044,Boston.and Professions Code:
The Contractor's License law does not apply to an owner of property who ALTER-DRAIN&VEYL-WATER(EA)
Wilds or improves thereon,and who contracts for each pWjects with a
c,0t�'actor(.)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE "l `'-s'' 'FEE SUMMARY"`�
LII am exempt under See - B&PC for this reason -
DRAINSFT-DORROOF,AREA,COND. SANITARY Y N
Owner Date RECEIPTp
WORKMAN COMPENSATION DECLARATION PER TRAP SCI{ODL TAX Y N
[-]I hereby affirm that I have a certificate of consent to aelf-insure,ora FIXTURES RECEIPT k
mhiflcateofWorkers'Compemationir mnm6racertifWoDpythemcf(Sec.
380,lab C.) GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
Policy It /oS7!)b/^9 ''-- RECEIPTa
.Com 'S�, y,e a GAS FA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
L:fMCertlfled copy is hereby filedwthMshd. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
❑CertiBd copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWERSANITARYSTORM EA 200FT ' Date Recei t#
'(Thio section need natbecompleed if the perhatb(orone hundred dollars
(4100)nrleas3 WATER HEATER w/vENr/ELECTS ENERGY FEE Y N -
'I certifythat In the performance of the work forwMch this permit Is Issued, —
I shall not employ any person In any manner an as to becomi subject to the WATER SYSTEM/TREATING
Worked Compensation Laws of California. Date PAID
O Z Applicant NEW RESIDENTIAL FILMS. SQ.FT. Date Recei t#
Z O - NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers;Compensation provisions of the Labor IOTA .
N Code,you most forthwith comply with such provisions or this permit shall be FEE
> deemed revokd. - BUILDING
aCONSTRUCTION LENDING AGENCY SEISMIC FEE L
I hercbya(fime that there is a construction lending agency for the perform ELECTRIC FEE.
7 Z each ofthe me that
which this permit is issued(Sec.3097,Civ.C.) TOTAL:
V O Lender.Name - .•t PLUMBING FEE
ly F LedereAddmea QTY; MECHANIC,AL'PERMIT . FEE;'; MECHANICAL FEE
O W I chrtifythatl have read this applicationand stafethalthe above infornutwo
hcorrect.I agreeto comply with all city and county ordinances and state laws PERMITISSUANCE• FEES PAID:
>. 0 •reiL
lating to building mristruction,and hereby authorize representatives of this
f. city to enter upon the above-mentloned property for inspection purposes. ALTER OR ADD TO MECH.
(We)a e t save indemnify an d keep her ells t Ity of Cupertino Date Receipt#
V agalrut llab t4'
,judgts,casts and¢ n Ich y anywayacerve AIR HA NEEDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against sal In consequence o(th m 1 pe IL -
AIRHANDLINGUMT(OVER10,000CFM) CONSTRUCTION TAX
Appuv ontr r Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
H AD MATERIALS DISCLOSURE
r1lh.adS�fmyCadeS�c1Irx,2S532(.)?
applicant or futo buElding ompant store or handle hazardous HEATING UNIT 100,000 HTU) Date Recei t#
defined by the Cupertino Municipal Code,Chapter 9.12,and the '
HEATING UNIT(OVER 100,000 BTU) -TOTA
�]No
Will the applicant orfuture building occupant use equipment or devices VEMHLATION FAN(SINGLE RESID) ISSUANCE DATE..
which chat hazardous air contaminants as defined by the Bay Area Air,
Qua lity Management District? - BOILER-COMP(3F@OR 100,000 BTU) A ' D
❑Yea No
Ihavcread the haeandous rruterials requirements under Cha pier 6.95 of BOILER-COMP(OVER 100,000 BN) -
01,the Cal'fornh Health&Safety Code,Sections 25505,25S33 and 25534.I
unde aSid that lithe building does not currently ha tenant,that it is my NEWRESIDENTIALMECH. SQ.FT. ��� _
resp" ilitytonot ifytheoccupan the quire-� ichm�atbemet trine)
Ari Lssuance ofd Certificate at 1xa
ner or ized age t If
y (r Ti 111
ate ISSUED BY- ` [i'
TOTAL:
OFFICE COPY