23642 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT.PEN ONLY
Building ProectIdentification PERMIT NO.
Building Adder�:e3S G J 9ios 23642
Uwner a Pismo Ponca:
_S46 *AQM) CITY OF CUPERTIN66UILDING DIVISION
1 2
"+ cmtnctora".me: ` Lk.No: APPLICATION / PERMIT u �IA
a M" CO. 31 CATEGORY CO L
BUfLDINGELECTRICAI.PLIJMBINGMEC
•a rchltect/Engineer. v Lk.No:
��• 's + KAaB 1 tBUILDING PERMIT INFO
QTY ELECTRIC PER Ff FEE
Address I.S`QS'(alOrcJlAa,aSMt�OSt 9SI1S" PERMITISSIIANCE
LICENSED CON ACTOR'S DECLARATION
I hereby affirm that l ace limsed under provWws of Chapter 9(commm APPLIANCES E L AJOB DE9CRQ'�QN
Ing with Sectlon7000)of Division 3 ofthe Business and ProfessionsCode,and myNI 1 uP
license Is In full jpme and effect. P Q i.{7{..�►
Ltmr.Clan %&-I LIq Y ctor 6,1 1
Date�l�A'_Contm �Aa w O�2
ARCHITECT'S DECLARATION 1-1000
NO ZO I understand my plans shall be used n public ermrda OVERI0#4" SQ.FT. FT.
AREA E/SQ.
Licensed Professional - SIGNS E AL 1
Q lniu OWNER-BUILDER DECLARATION SPECIA CIItCUf MLSC
IN
'ZI- a I herebyafOrm that lam exempt from the Contractor's License Law for the
following masmn.(Section 70315,Business and Pmf calors Code:My city or
FSI"' county which requires.permit to mnstruM alter improve,demolbh,arrcpair P. OR POLE
q��GG anysuucture prior to lot Wuance,also requires the applicant for such permit toPqWDEVICES ^�
fS o: file a signed rtateencot that he is licensed pursuant to the proWslons of the a j
(Qj O q 1I-� Contranoes License Law(Chapter 9(eommnnMg wRh Seabn 7000)of Divi- g�yplhgNG POOL ELECTRIC DATE
t,30J slon3ofthe Buslressand Prafmiom Cole)orthathe%emmptthemfromand _ — VALUATIONGay
a.•77 the basis for the alleged exemption. My violation of Section 7Q31S by!W OUTLET ES `� Q O�f �V
O appH..tf.r.perMtaubjdatheappUunttoadvilpemltymnat mor n YYY
five hundred doll..%50B. NEW RESIDENTIAL ELECTR .FT.
❑Lea owner of the property,m my employees with wag their suis STORIES TYPECONSTRUCTION
x mmpensatlon,willdolhe work andthestmeom is not intend aroffendfor
nla(Sec.70K Business and Professiom Code:The Contractors License Law
does not apply to an owner of property who builds or improves thereon,and OCC.CROIIIs RES.UNITS
EE: who doesmch work hlmselforthnasgh his own employees,provided that such
Improvements are not Intended proffered forsale.If,however,thebullding or TOTAL:
Improvement laaold withinoneyearofcomple ion,theowner-budderwlll have
t1giturden of proving that he did not build or lmpmve for purpose ofsale.). QTY, PLUMBING PERMIT FEE H.00DZONE APN
L j L as owner of the property,am exclusively contracting with licensed
contractors to mnstruct the projed(Sec 7006,Business and Professions Code: PERMIT ISSUANCE
The Contractors License Law does net apply to an owner of property who ALTER-DRAIN.&VEM-WATER[FA)
Wild.or Improves thereon, and who contracts for such plojerb with a FEE SUMMARY
cgp(la&or(.)ikensed pursuant to the Contractors License Law. BAIX FLOW PROTECT.DEVICE
LII am exempt under See B A P C for this mason
v" OUTS I DE FEE 5
OWNS FLOOR ROOF,AREA,CONE. SANITARY Y N_
Owner Date RECEBrf Y -
WORKMANCOMPENSATIONDECLARATION pyXTT)RES PER TRAP SCI{OOL TAX Y N
d I OI here of iren that I have a artfficate of consent to self-Insure,or RECEIVENY
'cemlllate of Worked Comperuatloo Insurance me motlfied copy thereoft5ec. GAS-EA.SYSTEM-1 INC4 OUTLETS PARK FEE Y N
`2 / 3800,Lab CJ RECF1IsTM
Go11ry Y GAS EA.SYSTEM-OVER 4(EA)
Com any BUILDING DI 151 FEES
ffCertlOed copy is hereby furnished. GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECKF
SCM ied copy It filed with the city impection division.
;` CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA XIOFf Re t
(This section need nut be completed if the permR hafmcme hundred dollars
(E10D)mless.) - WATER BEATER W/VFM/ELECTR E 'R EE Y N
I ceftlfy that In the performance ofthe work forwNcM1 this pemdt le based,
I shall not employ any perm%In any manner n as to become subject to the WATER SYSTEM/TREATINGWorkers'Compersation Lewsof Glifomb.Date PAID
OZ Appllmnt NEW RESIDENTIAL PLMB. SQF7. Date Recel t#
Z O NOTICE TO APPLICANT:If, her making this C.difesm of Exemption,you
should become subject to the Works.'Cmmpansatlon proubiter"the Labor TOTAL:
IrN Coda you most forthwith comply wltheuch provisions orthla permit shall be BUILDINGr
LU j deemed revoked.
d c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirmtlut there is a mmometlon lendingagenry for the peAorm TOTAL: ELECTRIC FEE
7 Z arm ofthe work for which this permit le;Issued(5m.3097,CIv.C.)
1.) O Lender.Name PLUMBING FEE
LL H Lender'sAddress QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
bW Icerifythat]have read thisapplkatWdand statethauhe above Information
O
1 correct.I agreeto comply with all dtyand murtyordlnances and slate laws PERMIT ISSUANCE FEES PAID:
> W relating tobullding construction,and hereby authorize representatives ofthls
F Z dtytoenterupon the above-mentioned property for inspection purposes. ALTERORADDTOMECH. Date Recei t#
(We)agree to save,Indemnify an d keep harmless the City of Cupertino
V agabut liabilities,Judgments,costnandesperses which may in anywayaceme AIR HANDLING UNIT(17010,000 CFM) SUBTOTAL:
agaimt said City 0 museque.of the granting of thla permit.
AIR HANDLING UNIT(OVER lO,OW CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAM RDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or hand Is hazardous I HEATING UNIT(TO 100,000 BTU) Date Recei
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Flcalth.nd Safety Col&JS 255320)7 HEATING UNIT 100,000 RW 'I'
M Yn No
_ Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESIDE issbA17d DATE
which emit havndous air contaminants as defined by the Bay Area Air
Quallly Management Dist ct7 BOILER-COMP DI-E'DR 1fX1,0(D BTU) MAY 21 1992
❑C Ya No
�t Y.
mad the hour pus materials requlremenH under Chapter 6.95 of HOMER-COMP(OVER 100,000 BTU) /.
[the California Health h Safety Coda Sections 25505,25533 and 25534.[ CfIY Uf (iUl"CI'1I IIVV
understand that lhhe ilding does not mrrently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.17.
respo : Ity to eoccvpant of the requirements which rtwst be met - mG
pd t oft ficateofO parry. ��++
Ovunarm.athaived.grm S -I Date -
TOTAL: ISSUED BY B��
OFFICE COPY