23675 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMITNO, 3675
Bull in Address: 2
�3 �2Gcj0d
rcs. Pieces:
o . CITY OF C-UPER-
TINO-BUILDING DIVISION
Name, APPLICATION / PERMITeBULDINGELECTCAUnUMBINGMECHAMCAL CATEGORY
'1#
cngineer:
- Lac.No:
QTY �{t ' •'•ELECTRIC PER,&fIT : `" :'.'�}"CC BUIODING PERMIT INFO',"
Address: PERMITISSUANCE ❑ ❑ ' ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirrethat l am licensed under provlsionsof Chapter9(commenc APPLIANCES-RESIDENTIAL we
J08 DESCRIPTION
ngwith Section 7000).(DiA.I..3ofthe Buslnessand PrefesalonsCede,and my a
lirenselsin full force aaqq effect PANELS �,{ j L'
Date Clap 1-' 1 Ic.M e l'1 1 f'/V 1 v x/'i
Date / ContractorUP TO 200 AMPS
ARCHITECPS DECLARATION 201-10110 AMPS •- -
oZ I understand myplaru shall be used as public records. OVER IWO AMPS S[/Q.FF.ILOORAREA $/ Q.F.
�(fOq 9 9 L E ® f
Licensed Profesaiowl SIGNSELECTRICAL
�¢
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC
owingrason (SectIa 70313, tfront
es he sad Professions
sLlcenu Law fort he _
p
following reason,(Section 70f1S,Business and Pro(eslons Code:Any city or -
O Z ticountyresuct, TE 11,
't'EMP.MECEROR POLE[NST.
F4 anystm kbps toiap aBe,alsotoomisquimsalter,impmvgdenslch,orr tto
any.signed
he
alcensed rersuant to the rovedhpermdte POWER DEVICES
file a dgned statement that he ra licensed pursuant to the provisioru of the �E
Oµ Contractor's License Law(Chapter 9(commencing with Section 7OW)of ONE-
�0 al.n VALUATION 3 of the Business and Profesdow Code)orthat he is exempt therchom and SWIMMING POOL ELECTRIC
Q the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHES-FIXTURES
applicant for a permit subjects the applicant to a civil penalty of not mare than
five hundred dollars 11111). - NEW RESIDENTIAL ELECTR
�n
F1 1,as owner of the property,or my employees with wages as their sole c'QPT. STORIES TYPE CONSTRUCTION
compensadon,veqll dothe work andthestructure isnot Intended or offered for
p sale(Sec.7044,B..I...and Profewtom Code:The Contradoea Liw.c Law
does not apply in an owner ofproperty who Wilds orimprovee thereon,and
whodoes suchwurkhimselforthrrugh hisownemployess,provided thatsuch OCC.GROUP RFS DNU'$
improvements are not intended cro(feredforsale.If,however,thebuildingar TOTAL: "
Zroveentne
hisold within oyearotcomplellon,theowner-bullderwlllhave
m
rden of provingthat he did notbulld or Improve forpurpose of sale.). QTY. l,'. Ilj,[JjyIBING PEILI�'�I�F .',i' 'SFEE'.:;; HOOD?ANE APN
u L as owner of the property,am exclusively contracting with Be need PCRMLI.ISSUANCE
C Qo
contractors to construct the project(Sec.7044,Business and Professions Code: J .
The Contractors Idrens Law does not apply to an owner of pioperty wha - ALTER-DRAIN&VENT-WATER(FA)
Wilda or Improves thereon,and who contracts for such p(ojeas with a 'FEE$UMMARY>
,,RRt{{actor(s)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Seo B&P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N
• Owner - Date - RECEIPT N
WOl]=that COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOL TAX Y_ N
hemby affirm that I have o certificate of consent m opy therno ora RECENT N
certificate ofWorkera Comperuation lsuuranre ora certified ropythereo((Sec. GAS-EA.SYSTEM-1 INCAOUTLETS PARR FEE 'y N
3BOQ lab C.) ll q
Pollry p' ,uc-9.�3'2i0`/Z RECEIPT
Com arY GAS-EA.SYSTM-OVER 4(EA) BUILDING DIVISION FEES
[�Ccrafied copy is hereby tthe cid. CREASE/INDUSTRL WASTE INTERCEPTOR PLANGHECKFEE
�C rafted copy is filed withh the city Inspection divider.
CERTIFICATE OF EXEMPTION FROM WORK ERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER SANITARY SCORN E4 211081. Date Recei t#
(Thor eneed rat becompleted if the permit iefor one hundred dollars
($100)oIns.)
certify that
WATER HEATER W/VENT/ELEc.I.R T6'0
ENERGYFEE Y N—
I shall not employ any person In any manner so s to become subject to the - WATER SYSH M/TREATING
Workcre'CompensaHon Laws of Callfornaa.
Data PAID
OZ Applicant - NEW RESIDENTIAL PLMB. SQ]rF. Date Recei t#
Z O NOTICE TO APPLICANT:If,after nuking this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
N CodGyourrwstfrrthwith comply with such Provisiow or this perrNtshallbc BUILDING deemed revoked. -
CL E3 CONSTRUCTION LENDING AGENCY SEISMIC FEE
S anon
that there is a coretructlon lending agency for the perform, ELECTRIC FEE
Z of she work or which this permit is asaued(Sec.3097,Civ.C.) TOTAL: 5
O O Lender's Name - D PLUMBING FEB G
IL I— Lender.Addres. QTS' MECHANICAG'PERMIT . "..'•IEE?i;` MECHANICAL FEE
O Wlwtifythalthavemadthlsapplimtbnand state thatiheabowin(omatlon
fsrorrect.lagreetocomplyithalldtyandmuntyordinanmsandaatelawe PERMIT ISSUANCE FEES PAID:
} IL relating to building construcw..,and herebyaWhma.representatives otthls
N city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TOMECH.
? (we)was,to save,indemnify an it keep harmless the City of Cupertino Date Receipt#
V
against]la little.,jedgmarei mets andez nxs whlchmayinanywayaceme AIR HANDLING UNIT(TO 10,000 CIM) SUBTOTAL: s
agai sYs B try to ronsequer th a ala .Initis Pon it. AIR HANDLING UNIT(OVER IIEWOC8M) CONSTRUCTION TAX
scat Appllcan Contra rn o/'/Date •� EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
If IR
SMATGRIALS DISCLOSURE -
Willtheapplies torfuture building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) ' Date ROCei [#.
material as defned.by the Cupertino Municipal Code,Chapter 9.1$and the - -
Ilealthand Safety Code'Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: s:
Yes ri No
Willlhe applicant or future building occupant use equipment ordevices VENTILATION PAN(SINGLE REBID) ISSUANCE DATE
which emit hazardous air contaminants as defirred by the Bay Area Air p
Ilitay Management District? ; BOILER-COMP DHP OR 100,OT BTU) P A4 D
Y.a No
Th veread the bazar us materials requirements undernd Chapter 2S534.I of BOILER-COMP(OVER 100,(100 BTU) spa
the
Caliandt Heahh&Safety Code,es Sect tons currently have a tenant,
that ] AUG -.- " 1992
u nderstandyto ifthe building
occupae.not currently haves tenant,that it is my NEW RESIDENTIAL MF.CH. SQ.FT
orwibility to nclify the occupant of she requirements which must be meE
r rto issuance cats rtifi nerd panty,
CITXUr �urrn-lutiV
ner.or authorize gent; Date -
IOTA?":1 ISSl1ED BY:�L
OFFICE COPY