19593 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm'ect Identification PF104T NO.
Building Address: 19593
6665 Clifford.
comers ante: FPhmv: AP111CATIONgUBMIlIALDAIE
Karen Garza" 257-7390 CITY OF CUPERTINOBUILDING DIVISION Z�� O
Contractor's Name: Lm.No: . APPLICATION / PERMIT
Tnhnqnn Air 485350 BUILDINGELECTRICALnUMBING-MECHANICAL" CATEGORY CONTROL N
Architect/Englneer. Lic.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO��//fl
Address: PERMITISSUANCE ❑ ��-/7L�_
LICENSED CONTRACTOR'S DECLARATION El1 41
I herebya(firce that l am heresed under provisions of Chapter9(commene- APPLIANCE5KESIUENTIAL JOB DESCRIPTION
ingwllhS oion7fllp)of Dlvlalon3ofthe Buslnesaand ProfestloneCode,and my -PANELS
licenm is in f t f and effed.
License Class $ Lm# 485350 C, /7—.
Date ontractor O 1-�R&OR m AMPS
ARCHITECT'S DECLARATION 201-1000 AMPS
Q
Z I understand my plans shag be weed as public mood. OVER1000AMPS SQ.FT.FLOOR AREA $/SQ.FL.
Q� Oq
E d(/ Licensed Professional SIGNS ELECTRICAL '
OWNER-BUILDER DECLARATION - gpECIAL CIl2CUIT/MIST N
Z Iherebya(0rm
that I.exempt ftom the Contractor's License Law forthe ' .
o fallowing reason.(Section 7031.5,Business and Professions Code:Any city or r
OZ TEMP.MECERORI'OLEI SC. OL'—.
cwnty structure
prqulrei spermute,coratmdiresth impmvent fors cher permit to
P any atmdure statement
temor ente that
he is licealso sed pursuant t lithe prnsuchpemNHe pOWERDEVICES^
1+ V file a alined statement that he t r 9(ceed pursuant it the tion 7000) of the '
3w Canlndthe Lisizes Lw(Chapter9(commencing with Section7000) Divi- SWLMMlNG POOL ELECTRIC VALUATION
O the basis
for
the alleged
d Professions Any virthathe f exempt therefrom and
G the baste for the illegsu exemption. Any tto acivi of Section no m by any OUTLETSSWIPCHESFIXTURES
ape hundred
pemNt subjects the applicant to a dull penalty of not mom than
o five 1,as
nrofdollarthe500). NEW RESIDENTIAL ELFGTR SQFr. STORIES TYPE CONSTRUCTION
GGGGGWIIIII Q e sa owner of the property,or my employees with wages r their sok t
col((Scc 0 K Businethess
and k endthestC dureh Contractor or ones dforLaw 1
O sok(Sec 704y Bueleess and Professloru Code:The Contractors Llceree law
$ does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RES.UNITS
EE who does suchwork himselforthmugh Meownemployees,provided thatsuch
improvements are not intended oroffered for sale.If,however,thebullding or TOTAL:
improvementiseoldwithinoneyearo(campldian,theowner-bu0derw011ave ,
tFiLburdes of proving that he did not build or Improve for purpose ofsaleJ. QTY; PLUMBING PERMIT FEE FLOOD ZONE APN
"I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
matradom to construct the project(Sec.7044,Business and Pro(essbra Code: - ,
The Contractors Licence Law does not apply to an owner of property who ALTER-DRAIN h VENT-WATER(EA)
builds or improves thereon, and who contracts for such plajects with a
� ador(s)licenced pursuant to the Contradors License Law. FEE SUMMARY
d�0t(I am exempt under Sec B&P C for this reason BACK FLOW PROTFOT,DEVICE
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RF)r NX
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP $p;OON
TAX Y_
. _
❑I hereby affirm that I have a certlBcete of consent roself-Insure,or"a RRCFIFT X
certificate ofWorkera'Compensation Insurance or a certified copy thereof(Sec. GAS EA.SYSTEM-1 INC.4011=S PARK FFR - Y_ N_
3800,Lab C.) - 5t: RECEE'CX
Po
i1ryX ji 335 GAS EA.SYSTEM-OVER4(EA) 'BUILDING DIV]SION FEES
Chereby Comp.rtrnlfed copy Is filed
the city GREASR/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
I-ZCerlNed copy b(fled with the tlty inspection division.49 CERTIFICATE OF EXEMPTION FROM WORK ERS' GRFASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date Recei IH
(Thissectlon nded nee be completed if the permit Is forom hundred dollars
(5100)orlessJ WATERHGTER W/VEM/ELECTR ENERGY FEE Y_ N_
Irerfifythat in the performance ofthe work forwhich this permit Is Issued,
I shall not employ any person in any manner so as to become subject to the WATPR SYSTEM/TREATING PAID
Workers'Compensation laws of California.Date
O Z Applicant - NEWRESIDENTIALPLMB. SO.FI'.
Z Dale Recei 9k
O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions ofthe Labor TOTAL:
I— y Code,you must forthwith comply with such provisions or this permit shall be U LDINGFEE
Uj j deemed revoked.CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Ihercby affirm that the.is a conatmctlon lending agency forthe perform- TOTAL: ELECTRIC FEE
D ance ofthe work for which this permit is Issued(Sec.3097,Civ.CJ " PLUMBING FEE
LL O Lender's Name.Adde MECHANICAL'PERMIT" FEE
LL U Lender's Address L MECHANICAL FEE X OO
U Irrxxt. thatHavemply this
with
aBcallonand dcounte that the yordinances ndgat stion
aws � EES PAID:
O W is t building complywo,all ndty and authorize ordinances and gate laws PERMIT ISSUANCE
} a city to Mating pont construction,and representatives of this - - -
(... N citytoto the,Indemnify
d propertyforInspection purposes, ALTEROR ADD TO METH.
? (We)agree la save, sgs, fy and keep es which
the in
of Cupertino Date ReOTAL
V ag Inst bNtkre,jadgmenb, and expenses which may In anywayamme AIR HANDLING UNIT(7010,000 CFM) � SUBTOTAL:
a i e m City In F.!&,grarding of this permit. CONSTRUCTION TAX
11/29/90 AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: o-
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 ETC), Dale Recei tff
material as defined by the Cupertino Municipal Cade,Chapter 912 and the
Mea lth and Safety Cod a�+.-Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
F] Y.. N No
Will the applicant or iuturebuildingoccupantusesqulpment ordevims VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contariinants as defined by the Bay Area AU
Qua lily Management District? OFE'DR 100,000 BTU) PAI®
Yea ❑No
l hYearead the hazardous matetlala requlrernents under Chapter 6.95 of BOILER-COMP(OVER 1fp,Ofp BTU) n y�
the Call(omia Health k Safety Code,Sections 25505,25533 and 25534.I
understand that tithe building does not currently have a tenant,that It is my NEWRMDENTIALMECH. SQ.FT. .
responsibility to nosily the occupant of the requirements which most be met . -
prior to Issuance of a Certificate of Occupancy. ow
Owner or authorized agentDate SSUED BY.-
TOTAL:
OFFICE COPY