22626 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Pro ed Identification PERMITNO.
ewmmg Aaareed: B r;;n7e— 22626 2 6 2 6
wnera aces: one: v
CITY OF CUPERTINO-BUILDING DIVISION ('] •�1sj
. Contra 'eNamc: ��,� ue.No: APPLICATION / PERMIT
� ArchitM/Fsglncer. LIr? BUILDNC ELECTWCAL-PLUMBINGRAS./,MMHAMCAL CATEGORY CONTq g-
p �/r QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addreae PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
Thereby afilrm that l am licensed under provisions of Chapter9(commnc APPLIANCMFTADENTIAL JOB OESC ON
ingwith5dbn7000)of Dlvidlon3oftheBuMb and ProfeaslonsCode,and my - /U' X1J
license le In full to and effect. (�j PANELS Aw I
License Cla Lie.# �'I'I���
Contractor f CGA+S%
ARCHITECTS DECLARATION 201-IOODAMPS
wN Zp I understand my plans shall be used u public records. OVER IOW AMPS SQ.FT.FLOOR AREA $/SQ.FL
z(0 Licensed Professional SIGNS ELECTRICAL
�6 OWNER.BUILDER DECLARATION ! SPECIAL CIRCUIT/MISCfoll ' l ♦ (�a �j
owing ason.(Srdle,7 eaemptfsumsea d Pttradols License lawforthe f •Z \a
ZO cmntingreasrequi aperR7tiocom13, sand Pmfeasve Cade Mydtyormpair Tpg(p MEfLR OR POLE INS?.
counlywhkh requlresapermitlocorstvd,ilter,improve,demollsh,orrcpalr
ate, anystrudure pdorto its Issuance,also requlresthe appllcanlfor such permit to [OWER DEVICES
1 file a signed statement that he Is licensed pursuant to the provisions of the
Oµ Contractor'sLicense Les,(Chapter 9(commencing with Section W)of Dist.
Et sion3ofthe Business and Profeselors Code)orthat he is emmpttherefmmVALUATIONanxi SWIMMING POOL ELECTRIC
the beets for the alleged exemption. Any violation of Section 7031.5 by any
pS
applicant fore permit subjects the applicant to a civil penalty of not more than OIIILEISSWITCIIF_SFUCfI1RES ` W.,
five hundred dollars($500).
I as owner of the ru NEW RESIDENTIAL ELECTR SQFI'. SfOWF5 TYPECONSTRUCTION
willdo�n ❑, p perry,or he employees with wages as thele dole
k <
sale&c.
Business
wmkandthes Cde:Thum not TnceMedo kens Law
O doe not
ply to an o e ami Professions who
builds or Imp does hence law
Q whoanot apply torn owner ofproperty who buildsorImprovesthertroryand OCC.GROIOP RFS.UNITS
EEE whodoessuch work himself or through his own employees,provided that such
Improvements are not Intended or offered for sale.If,however,the building m TOTAL,
Improvement Is sold within oneyearufcomplellon,the oweenimUderwlll have
tta,Zurden of proving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT ••E FLOOD ZONE APN
j j I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCEcontractors to cor aurid the project(Sec 7044,Business and Profeearom Cade:
The Contractor's License Law don not apply to an owner of property who L L
ALTERDRAIN 4 VENT-WATER(EA)
Wild.or Improvere
Improvers thereon,and who contracts for such pkojem -
with aFEE SUMMARY
ryp(T+dm(S)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ[am exempt under See B k P C for this reason
OUTSIDE FEI:c
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
Owner Date RECEIPT M
WORKMAN COMPENSATION DECLARATION FDMURF_S PER TRAP �/' SCHOOL TAX Y_ N_
❑1 hereby a((Irm That I have•certificate of consent to eel-Inwre,ora
RECEIPT N
certificate of WorkeraCompeneation Insurance are certifled mpythereof(Sec.
3800,1.bC.) CAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N_
Pol
REC
C.Icy GAS EA.SYSTEM-OVER 4IRA) BUILDING III VISION FE ES
ified copy is ed furnished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
PCert Wed is led
with the tltylmpectian divielon. ^ ���
CERTIFICATE OFH EMPTION FROM WORKERS' GREASE TRAP 'I PAO 2I
COMPENSATION INSURANCE Z
(Thlesectianneed fid be
COMPENSATION
Bmi
thepert CE carie hundred dollen SEWER-SANITARY STORM M"*7 Date Reef t#
I
pIidfees.)m (ythat In the pedarmanceofthe work(orwhkhthls pertNlls Issued, WATER HEATER W/VENT/ ENERGY FEE Y N�j�� p
I shall na employ any peeshn In any manner n fie to become subject to the S/2'� `o
WATIR SYSTEM/TREATf 1J may/
Worked Compensation Laws of California.mann Date PAI I✓b
ZZ Applicant NEW RE9DFNITAL I'IMB. FT. Date Recel t#
O NOlicant APPLICANT: after making this Certificate of Exemption,you
should bemns subject to the Workers'Comperaatlon proWlhm h(the Labor TOTAL:
M N Code,you moat forthwith comply with such provisions or this permit shall be BUILDING
FEE _tne Ind
deemed revoked,
IL _ CONSTRUCTION LENDING AGENCY SEISM •E t
CL Ihumbyaf0rm that them is.romtrudion lending agency for the pedorrm E C ••E _
Z anmofthe workfor which this permit er Issued(Sm.3097,Civ.C.) IOTA
V O Lender's Nano
LL t- Lender's Address QTY. MECHANICAL PERMIT FEE MEC AN E
U I certitythat I haveread this appilationand statethat theaboveleformatirm
O W Itmrred.I agree to comply with al city and countyordlnanmaoda ate laws PERMIT ISSUANCE �' FEES PAI
} U) relating to Wilding construction,and hereby authodu representatives of this
N city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
2 (We)agree to save,Indemnify an d keep harmless the City of Cupertino D R CI [#
V against liabilities,judgments,costs nd expenses which may In anyway accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBT IAL:
4y"
d " con once of the greening of this permit. AIR HANDLING UNIT(OVER 10,1300 CFM) CONSTRUCTION TAX
d 3/
Sigmtureof Appllcant/Contractor D e EXHAUST HOOD(W/DUCT) CONSTRUCTION TA PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HFATNG UNIT(TO 100,ODO BTU) Date R ei t#
material as defined by the Cupertino Me nidpal Code,Chapter 9.12 and the
I lealth and Safety Code Section25532(0? HEATING UNIT(OVER 100,000 BTU) '1' A
Yn ri No
Illthe appllant or(umre bvlldingompant sae equipment ordevlcea VENTILATION FAN(SINGLE RISID) Ipp�� ppI NCED
which rout hazardous air mntamieums as defined by the Bay Area Alr - If. pp 1
Quality Management District? BOILER-COMP OHP OR f 00,0(0 BTU)
I Yes 2 No
haveria the
ealth& our materials Se requl 25505, 5533under
and 255 6.95 of BOILER-COMP(OVQt 100,000 BIW OCT 3 1991
the Califhmla that
&Safety Code,Sections 25505,ve s hand 25536. I
undersibuityod 1.ifthe buie occupant
not erequire encs tenant that b mot NEW RESIDENTIAL MICA. SQ.IT
respoto Issace ofa theeicteof cfthecyWrementewhich must be mot CITY OF CUPEK 1114U
prior to Issuance a(a Certificate of Occupancy.
Owneror authorized agent Date -
70T
OFFICE COPY