24033 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALLPOINT PEN ONLY
ewlmn Pro sect Identification I PELWT
BaN(y 4 0 3 3 '
nning naaredd: /o/7S IR2C4 c QCC--
nere anis. one:
, A
CITY OF CUPERTINO-BUILDING DIVISION ^ 2 •�
c°n ectal."anis: Lie•No; APPLICATION / PERMIT ( C
BUfLDING-ELECTRICALI'LUMBING-MDCFLANICAL CATEGORY CONTROL N
Anhltetl/Gg/nnr. Lie.No:
QTY•- ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby
octlonaffirm that l Division
oftheunder inessaprmisoms dPro Gaptsr9(commn APPLIANCES-RESIDENTIAL JOB DESCRIPITON
Ingwhh Section force at Divfect. fthe Butlnessandlarofaselona Code,and my
license le In full force and effect. PANELS ^ ,
Lirense Clam Lic.Y N ,..a*'t4e ,�
Date__so
UP TO 2DOAMPS
ARCHITECT S DECLARATION X11-1000AMP5
Q�u 0 CZCO I understand my piers shall be used m public rerords. OVER 1000 AMPS I Sq w.tR E#1 §/SQ,FT,
S Z U Licensed Professional - SIGNS ELECTRICAL O
R 6 OWNER-BUILDER DECLARATION SPD21ALCIRCUIT/MISC
yt., ? Iherebyaf(Irmlhat lamexempt fromthe Contractor's License[Awforthe
ppt- folho leg...(Setion 7R31S,fl ketasand Proio
fessns Code:Anor ' �r
UTER
OZw9 EMP.MEI'IROR POLE INST. b
F� � cauntywhlch requirena permit tocorutruq a]ter,lmprove,demoWh,o tlty TEMP.
g .a any structure prior to its Issuance,also requires the applicant for such permit to POWER DEVICES
E5 0 file a signed statement that he Is licensed pursuant to the provisions of the
3w� Contractor's License Leve(Chapter 9(mmmendng with Section 7000)of Divi-
SWIMMING]i70L ELECTRIC
�01 Ann 3ofthe BukeouandPrefemlonCode)mthatheis exempt therefromand VALUATION
g} �" the bash far the alleged exemption. Any violation of Section 70315an —"
«Q applicant fora permit subjedsthe applicant to a civil penalty of net room than ES
OUTLETSSWITCHFIXTURES {
p�R roL° flue hundred dollars he pr. NEW RESIDENTIAL ELECTR SQ.F. STORIES TYPE CONSTRUCTION
QQ
compensation,
as owner of the properly,or my employees In with wags as their outs
PE- M sale&e 700 willdess and work,Pr and the ssion, udurehe Contactor o icense offered Law
p dale(Sec. pply to Business and Prdessbv Code:The uilds or improves Limes law
( 5$ don not loan owner ofproperty
rough who nemporees,Eructed that such
OCC.GROUP ftES.UNITS
0.
who doessuchwork hlmssQorlhrough his ownemployns,provided thateuch
improvements are not intended oroffered forsate.IL however,lhebuilding or TOTAL:
improvementissoldwithln oneyearofcnmpletWrythe ownentoulderwlli have
the lacolen of proving that he did notbundorimproveforpurpossofsale.). QTY. ` :`.'t .PLUMBIN&PERMIT •a�FEE HppD7y7Ng APN
F1 Lea owner of the property,am exclusively contracting with Ileensed PERMIT ISSUANCE / l
rontractors to construct the pmjed(Sec.7016,Business and Professions Code: a DY
no Contractors License Law don net apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or Improves thereon,and who comment for such prefects with a
coLJI ctor(s)licensed prsua
untto the ContratFEE SUMMARY
o's License Law. BACK FLOW PROTECT DEVICE
am exempt under Sec. B& P C for this reason
ser DRAINS-FLOOR ROOF,AREA,COND. SANEARY Y N
Oats RECEF T M
WORKMAN I have.COMPENSATION DECLARATION FIXTURES.PER LRM _QO SCI{ODL TAX Y_ N
7 nereorf m that I have o lmumne of consent to opyth urc,ora RECEIPT N
«00,La sof Workers'Compersatlonlrsunnceararerti(kd rwpythercof(Sea GAS EA.SYSTEM-1 INCA OUTLETS PARK FIE Y N
380D,Isis C.)
poi Y
RECEIPT p
MC
Com any GAS EA.SYSTEMOVER6(EA) BUILDING DIVISION FEES
trifled copy is heed with the
CREASE/INDUSTRL WASTE INTERCEPTOR PLANC14ECK FEE
'�Certlfled copy V filed with RM city inspection division,
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
Cot be ecom
COMPENSATION INSURANCE SEWER-SANITARY-STORM F.A.XIOFT. Date RCCYI tN
(This section need not completed lithe permit V(Drone hundred dollars
($1
I orcertltytha N
WATER HEATER W/VENT/E,ECTR ENERGYFEE Y N
• that the pedortrenreaf the work lorwNch this permit is leered,
I shall not employ any person In any manner m as to become subject to the WATER SYSTEM/TREATING
Workers'Compensationlaws of California.Date DU PAID
O Z Appilcant
Z teofxemloMyou
ERESIDENTIAL PIMBO NOTICE TO APPLICANT.If,after making this Certifies W SQ}7. Date Reeei to
Hshould becoreesubpct,to the WorkersCompensation provisions of the Labor TOTAL: .
L
Code,you must forthwith comply with such provisions orthle permit shall be
W > deemed revoked. BUILDING ,•,
d c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affrtrnthat there Is a commoction lending agency for the perform
Z anceoftho workforwhichthb permit is Issued(Sec.3097,Civ,C.) TOTAL: Vp ELECTRIC FEE
V O Lender9Name • PLUMBING FEE - - CQ
U. F Isndere Address (2TY: MECHANICAL PERMIT FEE . MECHANICAL FEE
O W l rertifythat l have readthla application and mate thattheabove informatin
C Ismrrect.I agreeto comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} U) relating to building comtrudlon,and hereby authorlu representatives ofthis
1" Z _ city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
— Me)agree to save,Indemnify an d keep harmless the City of Cupertino Date RCCCipt)1
agairstlabillties,rydgreents,mks and expenses which may In any way same AIR HANDLING UNIT ITO co10,000 CFM) SUBTOTAL:
agal aid City in consequence (the g0000g of this permit.
AIR HANDLING UNIT(OVER IQOWCFM) CONSTRUCTION TAX
granum of Applicant/contractor Date EQIAUST HOOD(W/DUCE CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building Occupant store or handle hazardous HEATING UNIT(TO 100,00D BTU) Date Recef tM
material as defined by the Cupertino Municipal Cade,Chapter 9.12,and the -
Irealth and Safety Code Section 25532(a)I HEATING UNIT(OVER 100,000 ITEM TOTAL .OD
71 Y. No
Will the applicant or No
building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit havNous air contaminants as defined by the Bay Area Air /�
alRy Management D❑0Mct7 BOILER-COMP OIL'OR 100,IXq BTU) P A
Yes N No
ave mad the Fara ma ma
terialss requirements under Chapter 6.95 of BOILER-COMP(OVER 100,D00 BTU)
/
the CallfomisHealth&Safety Code,Sections 25505,25533and 25534.1
understand that it the building does not currently have a tenant,that it is my NEWRFSIDENTIALMECH. SQ.Ff JUL 29 1992
- meponslSillty to notify the occupant ofthe requirementswhlch must be met .,
prior to Issuance of a Certificate of oompancy. C11 Y UF' r UPI:n i Ii4Q
Owner or authorized agent Date -
ISSIIHD BY
TOTAL:
OFFICE COPY