24212 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT N2 4 2 12
Building Address: L
D u '
nes - one: A
a� G, A CITY OF CUPERTINO-BUILDING DIVISION 1._ _ 1 _1>t n
Co tract sNar 1. W N APPLICATION /PERMIT- 6�y —'—v L+
AGM/ T BUfLDINGME TRICAL-PLUMBINGMECHANICAL CATEGORY CONTROL#
gi Mr. LI N
E BUILDING PERMIT INFO
QTY ELECTRIC PERMIT FEE
Address: PERWTISSUANCE ❑ 1:1LICENSED CONTRACT RS DECLARATI N
I hereby affirm that l am licensed under provisions of Chapler9(conunn APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwith Sec ..7000)ofD'Wsion3o(the Businnsand Pmfesd.nsCode,and my s,arr�
license Is In(uB( and effect. PANELS
LI¢�Ue#�
Dat Cmumetor �(LGOUP TO 2DOAMPS
ARCHITECT BCLA0. I rd OVERI0 AMP"'
qa0 7 I understand my plans sisal be sed es pubo rda OVER 1000 AMT'S SQ.FT.FLOOR AREA -B/SQ.FT.
q��++ O
k Fj Licensed Professional SIGNS ELECTRICAL - -
�n 6 OWNER-BUILDER DECLARATION SPECULCIRCNT/MISC
7 t, 7a Ihercbya(Orm thatlam examptfromthe Contractor's Licenxlaw(orthe
following reason.(Section 7001.5,Bunlness and Professions Cede My city or
O TEMP.METIR DIPOLE INSf.
K� anustmhmrequltoltsemNttommtequimer,Impmvgdemoibh,wr ttr
$ any at ruduretatemeltshatheis ahensed peatheat to the f¢auchperf to POWER DEVICES
file a signed statement that he h licensed pursuant to the provlelore of the _
3 w C.MraRar's Lice.law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
H OS sio0 ofthe Businessand Professlore Code)orthat he is exempt therthomand VALUATION
< the basis for the alleged exemption. Any violation of Section 7031.5 by any OIJTLETSSWITCIIF57lXTURES
O applicant for a permit subjects the applicant to a civil penalty afro[mmathan
five hundred dollars%W. STORIES TYPE CONSTRUCTION
C NEW RE9DENTfAL ELECTR SQ.FI.
W omeasowner of the property,or my employees withwage as offered
sok
m(Sec 7K wuldoth work arsions rode: hes ontractorsLtended or offered(or
O sok(Sec pply Busineto..owner
pmperty Code:The or Imp en License law
$ donwho not apply to an owner o!property whon builds or Improves thereon,and OCC.GROUP RES.UNITS
ionp.t eats am not
hisownemploowevesprovided that such or
improvementsarenot Intended earofc )¢sale.ILh er-bu UderwilI have TOTAI«
improvementhwld wlthinoneyearo(completion,theawner-bullderwlll have '
[burden of proving that he did not build or Improve for purpose ofsakJ. Q B PE I FEE
LJ L as owner of the property,am exclusively contracting with licensed HOOD ZONE APN
contractor to comlmct the Project(Sec.7066,Business and Pmtessloru Cade: � ,r C,."' ALJ
The Contractor's License Law don act apply to an owner of property who
c D -
builds or Improves thereon, and who contracts for such ;(pleats with a - FEE SUMMARY
gp(factorh)licensed pursucent to the Contnctoe.Lt..Law. BA FIA I'R T EVI
l_f I am exempt under Sec. B k P C for this reason
DRAIN ROOA, SANITARY Y N
Owner Data RECEIPT=
WORKMAN COMPENSATION DECLARATION
[:]I hereby.aHlrm that I have a certificate of Consent to eel(-InsureFRI•URFS PER TRAP SCHOOL TAX Y N
,or RECEIPT N
¢NlloteefWerkere'Comperealionlreuran¢me¢rtl(kd ropy thereof(Sec. GAS EA.SYSTEM-1 INC.4 OUTLETS PARR FEE Y - N
3#OD,Lab C.) RECEIPT#
a�� GAS EA.SYSTEM-OVER 6(FA)
Co a hf QC/ rt, LNJ• BUILDING DIVISION FEES
Certl ed copyh herebyturnlshed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANC1iECK FEE
•G}Ce.Hied copy h filed with the dty'repeat..division.
CERTIFICATE OF MUMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWERSAMT'ARY-STORM EA.HAFT. Date Recel t# .[.v
(This section need rad be completed I the permit tsfm one hundred dollars
($100)mine) WATERHEATER W/VENT./ET.ECTR ENERGY FEE Y N
I certify that In the performance of the work(orwhich this permit is Issued,
I shall not employ any person in any manner so u to become subject to the WATER SYSTEM/TREATING
Workar:Compernuo.Iasys o{ u(p#nla.Data
PAID
O Z Appuront /�J�IFY NEW RESIDENTIAL DUMB. sQ Fr. Date Recei t#
Z O NOTTCETOAPPLICANT:S atterma ng this Certificate l ,you
should become subject to the Workers Compensation provisions of the Labor TOTAL:
70 Code,you=atforthwith comply with such provision mills permit shall be .Cr BU E
W ] deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
d � Ihembyalflrm that there h a construction lending agency for the perform TOTAL: 3D0 ELECTRIC FEE
Z ancaofthewerkforwhichthhpermit h Issued(Sec.3097,Ci¢Q
() O lander.Name PLUMBING FEE •00
LLE Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W 1¢rtifythatl have redth applicationand starting theabove Information
1 iscorrect.Iagreeto comply with all cilyand ammyordinanm and state laws PERMITISSUANCE FEES PAID:
} N relating to building construction,and herebyauthoriserepresentativesofthis
Z city to enter upon the abov>mertkmed property for inspection purposes. ALTERORADDTOMECH. Date Recei f#
Z (We)agree to save,indemnify an d keep harmless the City of Cupertino
against llabWtkro,judgments,"sand expenses which may in anywaya¢rue AIR BUNDLING UNIT(TO 10,000CFM) SUBTOTAL'
ago Wt said City in consequence of the granting d this permit.
AIA HANDWNG UNIT(OVER 1g000CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Data IXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant atom or hand In h=rdous HEATING UNIT(TO 100,000 BM Date Recei t#
rwterlaI as defined by the Cupertino Municipal Code,Chapter 9.1$and the
Health and Safety Code Ion 25532(a)T HEATING UNIT(OVER 100,000 BTU) TOTAL: 1146
❑Yes
Will the applicants -future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit havardous air contaminants as defined by the Bay Area Air
Quality Management Da ct7 BOILER-COMP OHP OR 100,000 BTU) Bpy# pp pp��
n Yn P M I V
`Ehavc read the baz care materials requirements under Chapter 6.95 of. BOILER-COMP(OVER 100,000 BTU) -
theGllfomkHealth Safety Code,Sections 2550.5,25533 and 25536.1
understand that lithe building does not currently have a tenant,that It h my NEW RESIDENTIAL MECH' SQ'� OCT
7 1992
responsibility to notify the occupant of the requirements which moat be met
prior Issuance of a Certificate of Occupancy.
CITY ur T'
nerorautho a en Data ISSUEDBY: .#
TOTAL:
OFFICE COPY