23116 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Bulldin proved Identification PERMITNO.
Building � � v� 23116
Sme: °fie A
Q (O- CITY OF CUPERTINO�BUILDING DIVISION
C trado'6Name: LIc.Na APPLICATION /PERMIT - l�
BUILDING-ELIDCTRICAI PLUMBINC-MECHAMCAL CATEGORY CONTROL X
Architect/Engineer. Lie No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE ❑ ❑ j� ❑
LICENSED CONTRACTOR'S DECLARATION
[hereby hsedi.irmthat lamllcrosedunder provarul P feed er9(commene APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwith Sect1on7000)of DlWalon3oflhe Buelnnsand ProfeWonaCode,and my '
license la In fu (.m�es�a.�J died. 2 PANELS tk a - W,4+1(1. 1 ],,
Lice. Ch - ..'�J,f�,ic.N� w n
Date ContractorUP TO 2DQ AM
ARCHITECTS DECLARATION 301-1000 AMPS
$/
re0 ZO I understand my Pismo small be used u public records. 1000 AMI' SQ.IT.FLOOR AREA SQ.FT.
.d o Licensed professional SIGNSEIECTRICAL LED IN
OWNERexempt mmthe CARATION $pE-CIpLCItCU1T/ML9C ■ R�
71, Thereby a(flrm tOWNE OWNER-BOLDER
the DECLARATION
License lawforihe U ,�sr({
following reason.(Section 7031.5,Business and Profession.Code:Any dty or
O y:� TEMP.METER OR POLE INST.
F,� county which rnquimapermit tommway alter,improve,demoLLah,arrcpalr
anystructure pdorlo its Issuance,also requlresthe eppliant forsuch permit to
vl-
(�� file a signed statement that he is licensed pursuant to the provisions of the POWER DEVICES
H 30J son3ofthe Buiceineael ndPmfemlovCad er 9 orlhaBhewith
ln xemptlon Arefromod SWIMMINGPOOLMECTRIC VALUATION
.•$77 the basis for the alleged exemption. Any violation of Section 70G15 by any OUTLETBSWfICI IFSFl%TURES
6660 applicant fora permit subjects the applicant to a civil penalty of no name than
five hundred doth.(5500). '
$ NEWRISIDENTIALELECTR SQFT. STORIES TYPE CONSTRUCTION
..�n ❑I,as owner of the property,or my employees with wages as their sole
compensation,wBi do the work,and the structure h not Intended or offered for
Osal (Sec7014, .. oro and profession Cade:The Contractors Licerese Law
�$ don not apply to an owner of property who Wilds or improves thereon,and OCCGROUP RES.UNITS
who docssuch work hlmseifor through Msown employees,provided that such
Improvements are not Intended or offered for sale.If,however,the building or TOTAL:
bnpmvementls sold within one yearofcompletion,the owneebulldat will have
tbrtkorden of proving that he did out build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE
LI L as owner of the property,am exclusively=trading with Ilmnsed F7.00D ZONE AI'N
PERMIT I ISSUANCE
contractors to mnstrud the project(Sec.7094,Business and Professions Code:
The Contractor's License law does nor apply to an owner of property who
builds or Improves theme,and who contracts for such p(o)em with a ALTER-DRAIN A,VENT-WATER(EA)
ry➢If+dor(Ulicensed pursuant to the Coetradoes License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
[J I am exempt under Sec B k P C for this reason
Owner Date DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y_ N—
WORKMAN COMPENSATION DECLARATION RECEIPT p
he.by affirm that I have a certlMte of consent to self-insure,or a FIXNRES.PER TRAP SCHOOL TAX Y N
RECEIPTN
3800 Lab o(Worken'Compensatlonlnsunnco ora certified copythemf(Sx. GAS PA.SYSTEM-1 INCA OUTLETS PARKFTR Y N
3500,#6 C.1a ��sk 't
Com a C''�/ OL2— I GAS EA.SYSITTI-OVER OINRECEIPT N
Com any i BUILDING DIVISION FEES
Com
d copy b herebyth the city
d: CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
sniffed ropy h(Bed with the dty InspedWn division.
CERTIFICATE OF O(EMPFION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE ---SE'WF.R SANRARY
(ThissMionneed not becampleted BthepermR isforonehundrcd dollars STORM EA.200FT. Date RCtt'1 t#
(5100)orlm.) WATER HEATER W/VENT/ELECTRENERCYFEE Y N
mi
I certify that In the performance of the work for which this pert le Issued, S —
I shall not employ any person In any manner an,as to become subject to the WATER SYSTEM/TREATING
Worken'Compensatlon laws of California.Date PAID
pp SQ.FT, Date Recei t#
Applicant Z O NOTICE TO APPLICANT.IL after nuking this Certificate of Exemption,you NEW RESIDENTIAL
PLMB.
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
tll Code,you moat forthwith comply with such provisions or this permit shall be BUILDING
FEE
W G deemed revoked.
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there isa construdlon lendingagenry for the perform- ELECTRIC FEE
0 Z none ofthe workftr which this permit is Issued(Sec.3097,Civ,C.) TOTAL: X
Ver
O Lend 'sName PLUMBING FEE
I— Lender'sAdd. QTY. MECHANICAL PERMIT FEE
O W I ¢dlfythatl have read this appgm0onand statethal lheabove Information MECHANICAL FEE
G hempty comd.I agreeto cply with all ordinances and county ordinanand elate laws PERMfTISSUANCE FEES
>_ N relating to building construction,and hereby authodae representatives ofthh
H city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.? Date Reeei t#(We)a e to uve,Indemnify an d keep harmless the City of Cu pertina P
V ago Idea,jadgments,cops a nd expenses which may In any way amue AIR HANDLING UNIT ITO 10,000 CFM) SUBTOTAL:
t Pty In aryue of Ung ofMia pnmlt
/ D AIR HANDLING UNIT(OVER IO,OWCIM) CONSTRUCTION TAX
Signature of AppO / o odor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haramdous HEATING UNIT(TO 100,000 BTT) Date RCCCI t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 3,and the -
Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL-
[3 Yea M No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haardous air contaminants as defined by the Bay Area Air yy pp
YY
Quality Management District? BOILER-COMP DH'OR 100,000 BTU) 9� 1
Ya ❑No
01 Ihave read the b dausmaterialsrequirementsunderChapter6.95of BOILFA-COMP(OVER100,000BTU)
the California Health k Safety Cade,Sections 75505,25533 and 25539.1 JAN 10 1992
understand that if the building does not currently have a tenant.that It Is my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requirements which most be met
prior to lasuance of a Certificate of Occupancy. CITY Uh `Ureh 1114U
Ownermtrulhodaed agent Date ISSUEDBY:SL :Tb. )AU
TOTAL.:
OFFICE COPY