23436 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buitdln Pro at ldenUllca'°n
Building Address: OF� PERMIT NO.
L5 la5rijtaa� 23436
neat oma:
'Zi CITY OF CUPERTINO-BUILDING DIVISION
.it due's ane' LIc.N. APPLICATION /PERMIT � Z
a BUILDING-ELECnUCAL-PLUMBINC-MECHANICAL CATEGORY COI•!>lR��
Arch eci/Fa neer. Lie No: CO ( m
4TY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addrcas O
PQNETISSUANCE 154 ElLICENS OCONTRACTOR'S DECLARATION If
79
I hereby aBlrm that l am Berated under provLdersa(Chapter 9(mmmenc APPUANCESRESIDENfIAL �nn
I]=.i i-lu 7000)ofd effeon Joftheauelneeand ProtesslonsCoae,and my �.(LLC–R��Rr Ire
license is In me and ic,N ,�! ppNpg ��+� �' �(�ivC{„✓�
LlcenseC LION
Data CHITS or_ ^
ARCHITECTS DECLARATION 201TO2D0MP5 i•�' 1 `
rs0CZlud
O SQFT
understand anmy plan sMBbe used upublicremrde. OVER 1000 AMPS .FT.FL RAREA S/��
Licensed Professlonl SIGNSELECTRICAL 2q Vr
6 kEa� OWNER-BUILDER DECLARATIONIhemSpp,CUL CIRCUIT/MLSC
OR– owing rafRrmlhatlamexampltro ossa d Praltors Li cense law tmthe
0 .. .—ntyngreh requl apernottocuainem aMr,impn lve, Code:Any city or
p,� caYstm hchPe t0iaperMt ,.Ilatrucyalter,improvgdersuchper ttlr TFMP'MEIER ORPOLE IN57. _I
anya signed statement
it�that
ane,alamsed pursuant
to thet revisions of t e POWER DEVICES
file a signed statement Mat ha le r 9(commencing
pursuant it 1Se provisions of Me
3w Con3 ofthe License Law(Chapter9(commencingwithxSection
mptherefofDivi.
G slon3ofthe Business and Professions Code)orthat hebesempttherefromarM SWBs1MINC IDOL ELECTRIC VALUATION
6
the basis fare a alleged exemption. Anyt tolacivi of Section nor IS re anyMALTMDR�&VENT.WATERCFA)
TSSWITCHESFIXTIJRES /sappkendreddollars subjtithe applMant tea dvllpaulty o(nat morethanGfive hundred tl r of thoS00). ESIDENTIAL ELECTRI,as owner ofthe properly,or my employers with wageasiMbwillBQ'FT STOHIFS TYPE CONSIRIX:TfON'compenaron,willclothe work andthertructure bnoHntendedor offered(or
Osale(Sec.7099,Business and Professions Code:The Contractors License Law
$ docs not apply to so owner of property who builds or Improve thereon,and
whudoessuchwork hlmselforthrough hlsownemployees,provided thatsuchOCC.CROUP RFS.UNI'15
improvements are not Intended or offered for sale.If,however,the building orTOTImprovement Ls acid within one rarofcomplettok the ownerbullderwBlhavetl�a,J2urden otpmving Mx Mdid not bund orimprove for purposeoteale.). pLUMBINC PERMIT FEE
L.j 1,as owner of the property,am exclusively contracting with licensed ISSUANCEcontractors to construct the projeci(Sec.7094 Business and Professions Code:Th Contractors License Law cion not apply to so owner of property whobu0ds or Improve thereon, and who contest(m such pjecnwithaDRAA'&VFM"WATFIRMgIlt(aCo ts)licensed pursuant to the Contractors License Law.
c L,JI am nempt under Sec. B&P C(or thio reasonLOW PROTECT.DEVICEOwner D .FTAOR ROOF,AREA.COND. SAIZftAkFWORKMANCOMPENSATION DECLARATIONRECEI T N❑Iherebyaffirmthat Ihaveamrtlfiefeofconsentto seB-inaureoraF_S.PER TRM artifinieofWOrkeWCampenationlnumnmmamrtifiedmpythereof(Sec. RECmaT3800,IabCJ .SYSTEM-]INCA OUTLETS PARKFEE Y N
Policy N R7xEB'T M
Co. ny CAS EA.SYSITM-OVER a(EA) BUIL DING DI VI EES
Pified ropy I.hereby th the cid. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCI-IECIC FEE
ertBicd copy V filed with the city inspection division. 1/7
CERTIFICATE OF EXEMPTION FROM WOR KERS' GREASE TRAP PAID 1IIIrr
COMPENSATION INSURANCE
ffhbsectlonneed not becompleted lithe permit isforon hundreddollars SEWER-SANITARY-STC)RM EA.HAFT Date Recei tk
($100). .)less.)
I mrt1(ythat in the perlorrunmof the work forwhich this permit is issued, WATER HFATERW/VENT/ELDM ENERGYFEE, N_
I shall not employ any person In any manner so as to become subjecito the
O Weaken Compensation laws of California.Date WATER SYSTEM/TREATING PAI
Z Applicant
Z O NOTICE TO APPLICANT:Bafier maWng this Certlfie/e of Exemption,you NEW RESIDENTIAL PLMB. SQFT, ate Recef t#
should become subject to the Warkers''Compemation provisions of the Labor TOTA
N
Code,You=at forthwith comply with such pmvisioroor this permit Asti he
W > deemed revoked. BUI IN
CL G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hembyaffirmthat there is a construction lending agency forth perform
7 Z ance of the work for which this permit is issued(Sec.3097,Civ.C.) ELECTRICFEE
(.� O Lender.Name PLUMBING FEE r-
LL r- Ianam.aaaren QTY. MECHANICAL PERMIT FEE
O W Icertllythall havereadthlaappllmtionandetatethattheaboveinforrution MECHANICAL E
6 Iscorreci.I agree tocomply with all city and county ordlnancos and state laws PERMITISSUANCE FEES PAID:
F N relating to building construction,and hereby authorize representatives of this
H Z city to enter upon the above.meatiomd property for too anpurposes. ALTER OR ADD TO MESH.
(We)agree to save,Indemnity an d keep harmless the City of Cupertino Date RCCCI t#
against liabilities,pdgmenm,mete and expenses which ruy In enywayactue AIR HANDLINGUNIT CTO 10,ODO CFM)
a SUBTOTAL:
Bald City in c of the granting of this permit.
AIRHANDLINCIINF(OVER I0,fe0CFTD CONSTRUCT] NTAX
Sigt Alpf, t/ incim Date EXHAUST HOOD(W/DLTCT) CONSTRU N TAX PAID:
HA RISOUSMATERIALS DISCLOSURE
Will the applicant or turc building ottupanbtore or handle hazardous HEATING UNIT(T0100,000 BTU) Date
material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the ReCCi the
Health and Safety Codra..S,ection 25537(.)7
Ye '_ HEATING UNIT(OVER 100,000 BTU) TO
❑ No
Will the applicant or turc building occupant use equipment or devices VENTILATION FAN(SINGLR miRESID) ISSU VE DATE
which et hazardous ah mntaMvats as defined by the Bay Area A4
Illy Management Dl9iritT BOILER-COMP OHP OR 100,000 BTU) not a
a tae nF�Na !r H
have read the hazarmateriaL requirements under Chapter 6.95 of BOILER-COMP(OVER 100,DW BTU)
the California Health 6 Safety Code,Se tion 2550.5,75533..d 25531.I
understand that if the building dues not currently have a tenant,that it is my NEW RESIDENTIAL MECH Fr MSR 30 1992
reponiblllty to notify the occupant of the remu
requirement.which sts M met
Prior to Issuanco of a Certificate ofOavpancy.
CIIY'i1i
OI
wner or authorized agent Date ISSUED hvcc BY. V\
TOTAL:
OFFICE COPY