24245 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building PmFd Idendflodon PMWT NO24245
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Building Address: \ 2 4 2 4 5
�o �Johe a,f IF\�r .
Mr'
APPL1C. A A
CITY OF CUPERTINO-BUILDING DIVISION
C° rano Name: `�APPLICATION / PERMIT ' 3 —
BUILDINGELECnUCA4ML BINGMECHAMCAL CATEGORY CONTROL
Architect/Eng/nttr. Lt.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add..
ITRMITISSUANCE o 0 0
LICENSED that ED CONTRACTOR'S DECLARATION
I herebythdtfflrmt0).fam.i..3 under Cssiami9(commmc APPLIANCFSRESIDENML JOB DESCRIPTION
ingwhFSectlon7(X)0)o(Divlslon3ofthc Buslnessand ProfeealonsCodc,and my
ttera is In s, semen. c q 3 rApms
License Class LkN / J e_ij'
Date�L[I/�C ARCHITECT'
r I 1 N (�� f`0
On'�
r ARCHITECT DECLARAT N X11ERICAMI'S
Q'L Iuedentand my pions shall be uxd upublicrtmrda. OVERICLO AMPS SQ,FT.FLOOR AREA 5/9Q.FT.
O
Licensed Professional SIGNS ELECTRICAL
< OWNTR-BUILDER DECLARATION SI'EC/ALCBiCU1T/M15C
t, I harebyafflrenthat l am exempt from the Contractor's License lawforthe
Z Q following mson.(Section 7Qi1S,Businessand Pmfesslom Code:Any city or
r,/�"� caantywhich mequbrm
a permit reconstruct,alter,improv,deolbh,or repair TEMP.METER ORIOLE INST.
qqq�g.a anystmcturc prlortoitsIssuance,also requlrestheapphunt for such permit to
O❑� file a signed statement that he Is licensed pursuant to the provisions of the IVWFR DEVICES
3 a G Contractors License law(Chapter 9(commencing with Section 70110)of Divi- SWIMMING R70L ELECTRIC,.SOS e.o3.fth1B.sInesaand rrolesslonsCode)orthathebeacmpuhere(mmand VALUATION
G5p1 the Gsb for the alleged exemplon. Any violation of Section 7Q715 by any
` 05 a OULLE
ppil.ntf.r.permitsubie theappUcantt.advilpc.Ilyanm.ro tHun lSSWIIC f 1
c. five hundred dollars(5500). NEW RESIDFN77A
7 I,as owner of the property,or my employee with wages s their.1, ES TYPE CONSIItUCTION
e- mmpena.U..wilId.thswrork andthestructure best Intended or offered for
� o diesSec.apply to abesand Professions who
or Improves
Lerem,and Pjsg does notsuch loan imserofprough who bulmporlmprovesthertoNand that such DATEOCGG OUT' RFS.UNITS
E whomwhod such are not msen intended
reoffered owne.If,ho ce however,the
provided or
Impmwerent%sold untendedyear
If,hnweve,lheer will have _ TOTAL:
Improvement prosng within he did r not Wild
or Improve
for pbul.ofsllhave
tt�urdmo neer of the Propewwtbuudorvely, contracting
with
license QTY. PLUMBING PERMIT FEE
LI 1,as owner of the ro FLOOD ZONE APN
p perry,am.7(hk Business
and
Pr.wOh Is Code: PERMIT ISSUANCE
mntracton to construct the project(Sec 7044,Busbess ami Ierpfembns Code:
The Contractor's License Law does not apply to an owner of property who
Wild. or Improves thereon,and who rontrscb for such prpjtiALTER-DRAIN k VENT WATFA(FA)ss with a
a tnRtrra tor(a)bcensed Pursuant to the Contractor's License Law. FEE SUMMARY
El 1 am exempt under Sec. B A P C for this mason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
DRAINS FLOG ROOF, SANITARY Y N
Owner Date R AREA, BECELPTN
WORKMAN COMPENSATION DECLARATION
t❑t hereby affirm that I have a ttniBote of consent to self4mene,or a FLXA7RES PER TRAP SCdiWL TAX Y N_
ttdifimte of Woren Compensation Isurana tta mnlflcd ropythereof'$tt. RECEIPT N
3800,I.b C.) la',yvJ--_ GAS G.SYSTEM-I INCA OUTLETS PARK FEE Y N_
Pahl y N RECEIPT N
GAS G.SYSTEM-OVER 4(FA)
Com ansa - BUILDING DIVISION FEES
�CenlRed ropyIshereby dished. GREASE/INDUSIRL WASTE W-fFRCFTTOR PLANCHECK FEE
TACertlfred copy u filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GST TRAP PAID
COMPENSATION INSURANCE SEWER-SANTTARYSIORM FA200FT pate Recd t#
(Thi section need rad W completed if the permit b for one hundred dollars
al00)orlms3 WATER HEATER W/VENT'/ELDM ENERGY FEE Y N
I certify thato thepeerson In aof ny manner
w as to
permit 1.Issued,the
I shall not employ any peas In any manner ao s to become subject to the WATER SYSTEM/TREATING
Workers Compensation Laws of California. Date PAID
Z NOTICE NEW RE9DFMIAL PI.MB. SQFT. Date ReOCI t#
Z O NOTICE APPLICANT:If,after coking this Certificate of acception,you
should become subject to the Workers'Compensation pmvisipns of the Labor TOTAL:
CC 0 Code,you must forthwith comply with such provisions orthis permit shall be
j deemed revoked. BUILDING FEE
W
O CONSTRUCTION LENDING AGENCY SEISMIC FEE I SPO
I hereby affirmthat there Is a construction lending agenry for the perform- ELECTRIC FEE
Z ance of the workfor which this permit Is Issued(Sec.3097,Civ.C.) TOTAL:
U O Lender's Nam PLUMBING FEE
LL I- Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
WIccertify that l have mad thhappecation and statethat theaboveInfornation
Is correct.l ague to comply with all city and county ordinances and state laws PERMITISSUANCE FEES PAID:
} (L rtlatingtobulldleg constructlea,and herebyauthomeceprexntativeso(this
V) city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADDIO MECH.
(We)agree to save,Indo.fy and ep harmiess the City of Cupertino Date Receipt#
V agaBatll tiegjrdgme ts,costsa apensswhlc yinanywayamue AIR FIANDUNGIMT pO 10,000CFM) SUBTOTAL'
Cit n e the granting spa TL,
AIA HANDLING UMT(OVQt 10,000 C}lf) CONSTRUCTION TAX
Signature of Applies tractor tc FXFiAl15'r HOOD(W/DUCE) CONSTRUCTION TAX PAID:
HA DOUS MATERIALS DISCLOS RE
Will the appllcan forum building oavpant store or handle haurdous HG77NC UNIT CIO 100,000 BTU) Date Reccl t#
materialasciefine y the Cupertino Municipal Code,Chapter 9.12,and the -
1Ic❑-1 yes SafV Cod,�`I�Noon 25532((.)7 HGTING UNIT(OVER 100,000 BT U) TOTAL:
Will the applicant rd future building occupant use equipment or devices VENTILATION rAN(SINGLE RESID) ISSUANCE DATE
which emit haeaNous air contaminants as defined by the Bay Area Air
QualitYManagementE�'7 BOILE2COMPOFB'ORIOO,mM)BTII) PAD
hava7eadtbehaz4/Iouaomaterials rcqulmments under Chapter G95 of BOMER-COMP(OVER 100,000 BTU)
the Gllfernla Health�4i Salcty Code,Sections 25505,25533 red 75531. I
understand that lithe building does not currently have a tenant,that it ismy NEWRFSIDENTIALMECH. SQ.FT SEP 18 1992
responsibility to notify the..Pac;,"c nyulrtmnenU which must be met
,prior ace ofaCe icateopanty.
9 d' cl CIl Y 1 r, 11�� l lrvv
err or authors ate ISSUED BY: VCl
TOTAL:
OFFICE COPY
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