24433 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification - PERMIT NO
Building Address: - 24433.
wners me: Fane:
Ron Q CITYOFCUPERTINO-BUILDING DIVISION .
C rsN : LIc.No: APPLICATION / PERMIT
BUILDING-ELECTMCAI.PLUMBINGMMHAMCAL CATEGORY CONTROL Y
Architect/Engineer: n Lie.N.
QTY ELECTRICPERMIT FEE, .BUILDING PERMIT INFOBLUG
,
'Addieea - ❑ -
PFRhITISSUANCE �� yLICENSED CONTRACTOR'S DECLARATION
I hereby afRrenthat l arelicensed under provbionsof Chapter9(mmmenc APPLIANCESRFSIDENTIAL JOBDFSCRIPTION
It...i i.f.117000)of Dlvfect. ofthe Buslnn,andPro(essionaCode,and my
license lslns force and effect.' - PANELS 11 ' • ,V
License Clan 1c.If � � '
Date ContractorIM TO 200ANTS
ARCHITECTS DECLARATION 201-IODO AMPS
9z I understand my pl..ehaR be uud u public records.' OVER]OW AMPS, /^,��SQ.Fr,FLOOR AREA $/SQ.Fr.
Fi [) Licensed Professional - SIGNSELECTRICAL FIVALE ® '. '
OWNER-BUILDER DECLARATION TIMP. LCIRCUIT/MLE /1 1�
f, Iherebyaffirm that am exempt from the Contractor',License Law for the J7 R
Z O following renin.(Section 7611.5,Business and Prolesslans Code:Any city p it _
O 7,e. TLMP.MLTTIR OR POLE INSf,
��ppp arystrcmntycture requiresaperMttomrutmutre.the applicant
forsuch Fermat
\
g � anya signed stapritement
that
he ii;licensed
sed pursuant t the fanuof itto POWER DEVICES AT v
�1 O Cie a signed statement that he lar 9(commencing
pursuant to the provisions7000) of the
G61 0,� sku.3Contrfthe Business
Gw(Cdessir9(mm)noting withxenlon7W0)of Dlvl- SWIMMING POOL ELECTRIC VALUATION
O0� sloes 3ofthe Business and exemption. Any orthaheb exempt therefrom and _
the basis for the alleged exemption. Any violation of Section 7031.5 by anyappOUTLETS-SWITCHESFIKTIR FS
live
five hunt fora permit subject the applicant to a civil penalty
m
of net ore than
R hundred dolowner
of the pr.
I,as owner of the NEW RESIDENTIAL ELECTR_SQ.Ff. 5fOI8E5 TYPE CONSTRUC'DON
�n ❑ properly,or my employees in with wages as thele sole
compensation,Buldessand a the Professions
Code;The
dractentended o License
Law
d for
q sale(Sec.apply
Business owner
fprope property
who
or Impttors Llceear hw
don not apply to rk owner of property who builds or improves thereon,and
who donsuchwork himself orthraugh his own employees,provided that such OCC.GROIRs RFS.I1NI75
ImprovementsamnoH tendedorofferedfors le.ILhowever,thebulldingor
Improvement bsold within ane yearofcompletloM the owner-builder will have
th,R.purden of proving that he did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD TONE APN
L1 L as owner of the property,am exclusively contracting with licensed ppTp ISSUANCE -
contractors to coralruct the project(Sec.7614,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who - x
builds or Improves thereon,and who contracts for such p(ojects with s ALTER-DRAIN&VENT-WATER EEA)
oRtractor(s)demand pursuant to the Contractors License Law. FEE SUMMARY
V I am exempt under Sec. 0&P C for this reason BACK PLOW PROTECT.DEVICE
Q.Met Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N�
• Date RECFJPfY
WORKMAN COMPENSATION DECLARATION FIXTURES-PER TRAP Sf]f001,TAX Y N
[:]Irm I hereby affithat I have a certlliate of consent to u -
self-Insure,or RECEIPT Y
mAifirateofWorkers•Compemaatlonlmumnceorarertifledmpythemof(Sec.
3800,1.6 C.) S CAEA,SYSTEM-1INCA 0UTLETS PARK FEE Y N
Policy Y RECEIPT Y
Vm
CAS FA.SYSTEM-0VER 4(PA)
y BUILDING DIVISION FEESdified copy b hereby fumlehed. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
_ CertNed mpYti(fled wlthlM tlty lrapettlon division.
CERTIFICATE OF EXEMPT ION FROM WORKERS' GRE'A'SE TRAP PAID
COMPENSATION INSURANCE SEWER-SAKETARY-STORM PA 210171. Date Rcmi t#
(This stolon need not be completed If the permit is forons hundred dollars
(E1I motify that
WATER HEATER w/VFFNT/ELECTR ENERGYFEE Y_* N
Innm that Intheperformanmofth nnerwo tohthispemdtis&auto,
I shall not emplay any person f any manner m u to become abjett to the WATER SYS.IFM/TREATING
Worlicant mpenutlon Laws o(Callfomb.Data PAID
O Z AppNOTICE
OTICE NEW RESIDENTIALPLMB._SQFT. Dale Recei t#
Z O NOTICEco esubjeAM:IL.her makinrs'Co pe sationCertifpro is Exemption,you
H Cadeshoulbe, at forthwith
Work with
such provisinprovbiomrmit of s Lab be TOTAL:
� RA Ceonedr vo etfMhwi(h comply with suchprovbloea orthb pertNl shall be
> dnrmd revoked. BUILDING FEE
d CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there b a meldrection tendingagency for the perform ELECTRIC FEE
D Z anmoftheworkforwhichthb permit is Issued(Sec 3097,CIv.C3 TOTAL:
U O Landers Name PLUMBING FEE
IL h Mndre.Aadren QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I.AifythatlhavereadthbappballonaMtlatethauheabovelnformatlon
1 Bmrrect.lagreetocomplywithaltltyandmuntyomdinana,anda.tclawa PERMIT ISSUANCE FEES PAID:
>_ W rebtingto Wildingmmtruction,and hereby authorim representatives ofths -
F Z citytoenterup.ntheabove-menti.n pmp"f.,Wpwianpurpo,n. ALTER OR ADDTO MECH.
(We)agree to save,IndemNfy an d keep harmless the City of Cupertino Date. Recei t#
V against lbbilltles,judgments,meband expenses which may In any way iform. AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agairatuInenn ceo the grantin his permit.'/ -
`' AIRHANDLlNGUNTI`(0VERIft0D0C M, CONSTRUCTION TAX
grocom of Applicant/Contractor to EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUSMATERIALS DISCLOSUR
Will thcappLLantor future budding occupant store or handle hazardous HEATING UNIT(70 100,000 BTU)
materials.defined by the Cupertino Municipal Code,Chapter 9.12,andthe Date Reeef t#
Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU' TOT
Fly. N No
Will the applicant or future building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit harardous air contamiunt.ate defined by the Bay Area Ab
Quality Management District? BDILFR-COMP OHP OR 100,000 BTU)
4 Yes No A f ^
haveread ealthhe h.9 ds Code, enforat2 5,2553 and255r.1 of BOILER-COMP(OVER lOD,000 BT11) P-7 9 D.
the California Health&Safety Code,Sectloos 25505,25533 and 75534.1 V
umid costs ad that if the building does not otmottly have a tenant,that it is my NEW RESI DFNTIAL MECH. SQXT Alol/
respoosibiu nc of aCeheaate of Oof nto
N eequlmrrenle which rtwst Merit 'NOV 1992 ��
prior loissuanm adiy the ate ofOttvpa racy. - ♦ s7s7C / \
ci l y �'J/
Owner or authorized agent Date : 1 v' Vr•
TOTAL: 155IlEU BY:�
OFFICE COPY