22925 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project identification PF7(MITNO.
Building Address; 22925
► 0
wners aces: ane: A
3K L , CITY OF CUPERTINO-BUILDING DIVISION
co ra ora Name: T-DD2 Lk.No: APPLICATION I PERMIT
.7 G— O BUILDINC-ELECTRICALPLUMBINGMFLHAMCAL CATEGORY CONTROL#
Architect/Engineer. Lie No:
M �I QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:NIW TM` UL PERMITISSUANCE �U (dl ❑ El
CONTRACTOR'S DECLARATION El FM
I hereby affirm that l am Bcrosed under provisions of Chapmr9(commme APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwlth Section7000)of Dr talon3ofthe ButlnessanciProfessions Cede,and my
license le In full forceand dfect. - PANEIS ..w--��•• V '
clan #
LIe
Date
Date Lk.# er UP TO 2DO AMPS
ARCHITECTS DECLARATION 2074000 AMPS
9Z Iunderstand my plamehall be used as public remrea. OVERIOOOAMPS 'BBQ.err 001AREA. $/ Fr.
O C V N
Licensed Professional SIGNS ELECTRICAL T
6 OWNER-BUILDER DECLARATION 4 E R
res a SPECIALCIRCNT/#LSC /
zs, � Iheremn byafBthat lam exemptfmmthe Contractors LlceLaw wlm the
02po•'-9 following reason.(Section 70115,Business and Professions Code:Any city or / / ^
TEMP.METER OR POLE INSf. W
r4countywhkh requlrenapertNeromoaWtt,altep lmpmve,demolbh,orrcpalrDWA
< anystmctureprlortoih Wua.e,alwrequbestheappbantforsuchpermltto (OWER DEVICES
U IIIc a signed statement that he Is licensed pursuant to the provt,lons of the
3 ty� Contractors License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING TOOL ELECTRIC VALUATION
11F.... O sbn3ollhe Buslnessand Pr fenlom Code)orthat het,exempttherefromand
'u'O the bast,for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS-SWITCHES-FIXTURES
appBnnt for a parent,sub)aco the applicant to a civil penalty of not store than
$ five hundred dolhn(S50o). NEWRESIDENTIALELECTR
❑I,as owner of the property,or my employees with wagon as their sok SQA' STORIES TYPE CONSTRUCTION
compensation,will do the week and the structure is not intended or offered for
❑ .1.(1.70K Business and Prvfcelom Code:The Contractors License law
$ docs not apply to an owner of property who builds or improves lheremy and - OCC.GROUP RES UNITS
whodocssuchwmichimeelforthrough hisownemployees,provided thatsuch
Improvements arc not intended oroflered formic.If,however,thebulldlegor TOTAL:
Improvement t,sold withinoneyearofmmpldiomtheowner-buBderwill have
the burden of proving that hedid not build or Improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD TONE APN
111,an owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to mostruct the project(Sec.7074,Business and Professions Cade:
The Contractor's Llmnse Law does not apply to an owner of Property who ALTER-DRAIN&VEM-WATER(FA)
Wilds or Improves thereon,and who contracts for such pwjecta with a FEE SUMMARY
cgp(pctorE.)licensed pursuant to the Contractor'.License Law. BACK FLOW PROTECT.DEVICE 1_l1 am exempt under Sec. B k P C for this reason
DRAINS FLOR,OROOF,AREA,COND. SANITARY Y N
Owner Date RECEIPT❑ N#
WO that COMPENSATION DECLARATION pp(7URg5 PER TRAP SCHOOL TAX Y NI hereaffirm
by athat I have o Inmate of consent to opytherco or RECEIPT M
nrU/inteafWorYen'Comperoatlonlmuranm ore oertl(led copythereo!(Sec. GAEA.SYSTEM-1 INC.4 OUTLETS PARK FEE Y N_
Polis p Lab CJ S RECEIPT#
Policy GAS EA.SYSI M-OVER4(EA) BUILDING DIVISI ON FE CS
C. any
Certlfied copy is hereby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
U�Od` rtUed copy Is filed with the city Inspection division.
CERTIFICATE OF EXEM PFION FROM WOR KERS' CREASE-TRAP PAID
COMPENSATION INSURANCE SEW FR-SANRARY-STORM EA 2(IOFf Date Recei t#
(This section need not becompleted if tW permit him ons hundred dollars
($10a)oness.) wATeR HFwTER w/vENT/¢ECTR ENERGY FEE Y_ N_
I certlfythat In the performance of thdwW
ork forwhleh s pernot is Issued,
I shall not employ any person in any connote so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation laws of California.Date PAID'
O Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recel t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workars'Compa.tlon provisions of the GW r TOTAL:
N Code,you at forthwith comply with such provt,lom or thin permit shall he _ BUILDING FEE
LU > deemed revoked.
a CONSTRUCTION LENDING AGENCY SEISMIC FEE
Iherebyafllrmtluttheret,aco.tmcilon lending for perform TOTAL: ELECTRIC FEE
M Z anceofthe work for which this permit is Issued(Sec.3097,Civ.CJ
V Lender.Name PLUMBING FEE
LL F Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W ce
Irtlfythatl have readthlsappllcalbn.Mpalethatthe above lnfomalion
1 Is correct.i agree to comply with all city and county ordinance and nate laws PERMIT ISSUANCE FEES PAID
>. N relating tobuilding construction,and hereby authoree representatives oftht,
city to entero n the above-mentioned property for impaction u ALTER OR ADDTO MECH.
F Z ty P° P party Pect purposes. Date Receipt#
(Wo)agree to saw,Indemnifyan expenses which
the CityofCupertino AIR HANDLING UNIT 10,000 CFM)
V agalmtllabllltin,jadgments,cmtsand expenxs which may ioanyway accrue SUBTOTAL:
againstssl Ityloom enceofthegraotingefthispennit.
AI
R HANDLING uNrr(OVER Io,000cFki) CONSTRUCTION TAX
Slgranmaof Appli t/Contractor Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
i ZARDOUS MATERIALS DISCLOSURE
Will the applicant orfumm building occupant store or handle hazardous HEATING UNIT(TO 100,000 BU) Date Recel t#
material as defined by the Cupertino Municipal Code,Chapter 9.lZ and the -
Health and SafetyCode Section 25532(.)? HEATING UNIT(OVER 100,000 BTU) TOTAL: qq (J
RYea NN.
ill the applicant or future Wilding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISIVWIEBATE
which emit hazardous air contaminants an defined by the Bay Area Air
Iity Management District? BOILER-COMP OHPOR 100,000 3TU)
QuL_�Yen 1I��No OCT 3 1991
Ihave read the hazer�om materials requlmmenb under Chapter G95 of BOILER-COMP(DVER 1110,0011 BTU) O
the Californh Health A SafetyCode,5#7..25505,25533 and 2$37.I
�s understand that if the building does not currently have a tenant,that it is my NEW RESIDFNTIAL MECH. SQFf
responsibility to notify the ocau pant of the requiroments which must be met y/nv
1I1 Y,0F'(a1J1atK I INV
prior to Issuance ora Certificate of Onupamy.
Owner or authorized agent Data TOTAL: ISSUEDBY:4. vGe.l
OFFICE COPY