23597 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
'Building Project Identification PERMITNO.
Building Address: - 23597.
wners anti: one: -
CITY OFCUPERTINOQBUILDING DIVISION
rady\sName: Lk.Ng: APPLICATION / PERMIT 'l G•
BUR.DING-ELECTMCAL-PLUMBINGMFLHAMCAL CATEGORY CONTROL If
Architect/Englseer. Lie.Na
G _ QTY ELECTRIC PERMIT FEE
BUILDING PERMIT IFLUM6NFO
Address:/ , 2lr S nLt PERMITISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATI N �O6
IMreby Actionr7DOModamlltmudunder inessadPrcfehapler9(mmmmc- APPLIANCFSREgIDENIALIngwit - _LOPD Klll`l ION _ -w
)1...hSection to.
the BuAwsand PmlesUonsCade,and ` ,AfirU�Y
Lima 12
In full form and Affect. PANELS
License Cka Llc.tl 4
Date Contractor 201I000AMPS 1 �+
ARCHITECPS DECLARATION
uQ�IXO z I understand my plane shag be used as public rectrda OVER IODO AMPS SQ.F7.FLOOR EA f/SQ.FI'.
E od 0 Licensed ProfeaWnal SIGNSELECTRICAL
OWNER-BUILDER DECLARATION SPECIALCIRCNT/MISC
Zs, a Ihcrebyaffirmthat l am exempt from the Contrador's License Law for the
O�
following rtawn.(Section 7m15,Business and Professions Code:Any city or ti TEMP.MEITROR POLE INST.
E cguntywhkh requimapemNt to mrutrucL alters improm,demoWh,orrtpalr
qqq anystmdure pdorto its tsmance,Worequirestheapplicantfw such permitto POWER DEVICES
rEv file a signed statement that he is licensed pursuant to the protuore of the
3w� Cgnlramm's License Law(Clapter9(mmmencingwllh Section 7000).f Divi- SWIMMING POOL ELECTRIC VALUATION
SOSO
sion3ofthe Butlnessand ProfemkroCode)orthat hekexempitherefromand S the basis for the alleged exemption. Any violation of Section 70315 by any OUTIETSSWITCHESTIXTURES
applicant fora pare dl subjedathe applicant to a civil penalty of not more than
five hundred dollars(f.500). NEW RESIDENTIAL ELECTR SQ.FT. SfON1E5 TYPE CONSfRI1CT10N
7 I,as owner of the property,or my employees with wages as their ink
compensation,will do the work and thealrudure knot Intended or offered for
Osale(Sec.7046,Buskea and Professions Code:The Contactors Llmnu Law
$ does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RES UNITS
who dose such work himself ornhrough his own employees,provided that such
Improvements are not Intended oroffered for sale.If,however,thebuliding or
Improvement kwidwithlnomyearofmmpletkgtheowner-buBderwill have
t"rden of proving that he did not build or Improve for purpose of sal..). QTY. PLUMBING PERMIT FEE
LI L as owner of the property,am exclusively contracting with licensed FLOOD TONE APN
contractors to mnsWd the project(Sm 7044,Busimaa and Prdealom Code: PERMIT ISSUANCE
The Contractor's Llmose law does net apply to an owner a properly who ALTERDRAIN&VENT-WATER(EA)
Wilda or Improve thereon,and who contracts for such p(ojeci -
s with a FEE SUMMARY
cgRtfador(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE LII am exempt under gee. B k P C for this reason
DRAINS FLOOR ROOF,AREA,CONI. SANITARY Y_ N
Owner - Data - d gEC�g
WORKMAN COMPENSATION DECLARATION n n
Xhereby affirm that I have a mdiflone of consent to self-Insure,or a FIXTURES'PEVR I 1 LTA Y N
mi rote ofWorkeri Compeaatlanlaunnceora certl(kN mpythereof(Sec. - r RECm•1'Y
3800,Lab C.) - GAS EA.SYSTEM-] C.4OUTLOS 8 Y_ N—
Policy Y RECEIPT A
CAS EA.gYSIFM 9<(EA)
Com any UILDING DIVISION FEES
ffCe allied copy k hereby furnished. CREASE/IND S1RL Wy�ry:It�m EPToIi CH CK PEE
Certified copy k filed with the city Inspection division. D/T,"aa—K
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SLWER-SANITARY-S]ORM EA 2(IOFf Date Remi t#
(I'hls section need cad be completed If the permit k foram hundred dollars
(f10(Emless3 WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I certify that In the performance of the work for which this permit is issued,
I shall not employ any person In any manner An As to become subject to the WATER SYSTEM/,TREATING
Workers'Compensation laws of California.Date PAID
ZZ Applicant NEW RESIDENTIAL PLMB. SQFI. Dalt: Reset t#
O NOTICE 70 APPLICANT:If,after making this Certificate of Exemption,you
Fshould become subject to the Wmrken'Comperuation provisions of the Labor TOTAL:
N Code,ym oust fmthwlth mmplywllhauch provklmu orthk pemNt shallbe
W dmmcd revoked. 13UILDING FEE
IL CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyaffirm that there is a coatmctlon lending agency forth,perform TOTAL: ELECTRIC FEE
O
D Z anmafthe work forwhich this permit k ismed(Sec.3097,CIv.C.)
fJ _ Lenders Name PLUMBING FEE
/- Lenders Addrea QTY. , MECHANICAL PERMIT FEE
LL MECHANICAL FEE
O W onect.I cert that
agerethave
mply this with
allcatbnendpnle that yordiheces and ate[am
-
1 re mired.buildingmmplywilh andtyand auhort.rnunms and rtahlaws I'ERMITLSSTIANCE FEES PAID:
rektlngtobu pont eabo dloryendhereby mthor terepresenpurposgf this
H N cit(Wenter
ee to iheabndemnify an
pmpedrrades the Cit purposes, ALTLR ORADD'R7 MECH.
? (Wet)agree to ave,indemnify an d keep harmieu the City of Cupen lnoDate Reeel t#
V against liabilities,Judgments,mks and expenseswhlch may In anyway Accrue AIR HANDLING UNIT(O 10,ODO CFM) /� SUBTOTAL:
against said City in consequence of the granting of this permit.
NR HANDLING UNIT(OVER IO,OW CFM) CONSTRUCTION TAX
Sigmmm of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a ppllcacat orfutore Wilding occupant store or handle hazardous HFA11NG UNIT(TO t 00,0DO BTU) Date ReceI t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I Health and Safety Code Section 25532(A)I HEATING UNIT(OVER 100,000 BW TOTAL:152
n Yes q No
IIIIM1eapplicant or Lure building occupant equipment mdevima VENTILATION RESID) ISSUANCE DATE
which emit harardgus air contaminants as defined by the Bay Area Air
ality Management District? BOILER-COMP IHR'DR 100,IX1)BTU)
Yes ❑No
have read the hazardous materials re"hemenb under Chapter6.95 of BOILER-COMP(OVER 100,000 BTT!) T AA ' D
the California Health&Safety Code,SM Ions 25505,25533 and 25534.I Ir
understand that if the building doenot currently have.tenant,that it k my NEW RESIDENTIAL MECH. SQ.Ff
responsibility to nes fly the occupydthe ice tswhichmustbernet APR 29 1992 d�^�
seance •/ neo Pa
Owner or auth gent
Dafe
OFFICE COPY