19911 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Protect Identification . PERMIT NO. 1
Building Address:'
w' Phone: A DALE
d _ /YIA' pU CITY OF CUPERTINO-BUILDING DIVISION J b
I'
=Name: Lic.No: APPLICATION I PERMIT a
BUILDINGELFCTRICALPLUMBING-MECHANICAL CATEEGOR Y CONTROL#
Ammosa/En neer. Lic.No:
Qtr ELECTRIC PERMIT Fgg BUILDING PERMIT INFO `
Address; - PERMITISSUANCE - ❑ " ❑ ❑
affirmLICENSED CONTRACTOR'S DECLARATION
I herebyion70 that lamliceved underprovisionssofChapter9(rommen APPLIANCESRESIDEMIAL JOB DESCRIPTION
lice..ingwit
Lull farma00) nDivifect. (the Buelnessand PeafestlonsUnne,andmy
license is in full force and it,# PANELS -/
Disuses Chea .Cont /�! /ml 7(xQ7�
Date ContnRor v
ARCHITECTS DECLARATION 701-1000 AMPS"
q�v ceOz I understand my plans shall be used as public reads. OVFR1000AMPS SQ.FI.FLOOR AREA -S/SQ.FT.
-
k U Limned Professional SIGNS ELECTRICAL ,
dfn 6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/
z1„ � thereby affirm that l am exempt from the Contractor's License Law for the
oo following reason.(Section 7031.5,Business and Professions Code:Any city or
O , TEMP.�1TfC[t OR PO ST. .
r� countywhlch requlresa permktocoratruq alter,improve,demolish,or repair
g anystruaure prior W its Issuance,also requires the applicant for such permit to ]OWER ICES
�a file a signed statement that he Is licensed pursuant to the provisions of the
Comead.l.License Law(Chapter 9(commencing with Section 7000)of Divi-
alon3mf1he Bueinessand Pmfessloru Ccde)orthat he is exemplihandromand SWIMMIN EI'ECfAfC VALUATION '
Gthe basis for the alleged exemption. Any violation of Section 70315 by any OUTL HBSFI
O applicant for a permit subjects the applicant to a civil penalty of not more than /
five hundred dollars($500).
�n ❑[,as owner of the o e NFW RESIDENTIAL ELEC FT. STO ES. TYPE ONIS RUCTION
pr p k,a or my employees with wages r thele dale _
compensation,will dotes work,and the b.C dere h noHnhnded or offered for
2 sae(Sen appy to art ow ami Prooperty Code:The Contractor;License Law
rag does whodot applyse.ch torn owner ofpropertywhin emorimprovvthereoryand OChat such C.GROUP RES.UNITS
whowork Mmae dedoroughed for owns.If,hoes,p howevideder,
building
or
improvements intendeeyearoBredplatlonlLhower-builderwdl have TOTAL;
Improvement heals wllhinoneyeerofCompletion,tbe owner-bulderwlll have - -
tllilIlurdenofprovingthathedidnot build or Improve for purpose ofsak). QTY, PLUMBING PERMIT FEE FLOOD TONE APN
L j L as owner of the property,am exclusively=trading with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.709y Business and Professions Code: '
The Contractor's License Law does not apply to en owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or improves thereon,and who contracts for each pe
to)es with a FEE SU_MMARY
tIador(d)licensed pursuant to the Contractor'.Llcenss Law. BACK FLOW PROTECT,DEVICE
LJ I am exempt under Sec. B A P C for this reason
FEES
DRAINS FLOOR ROOIFAREA,COND.' SANITARY Y N�
• Owner Date RECEIVE p -
WORKMAN COMPENSATION FIXTURES. TRAP SCHOOL TA% Y N
❑I herelry af(Irm that 1 have a certificate of consent to self-insure,ora RECEIPT p
certificate of Workers'Compensation imunnm or a certified copythereof(Sec. GAS EA, PARKFEE •Y N
3800 Lab C? , _ -
Pmllry# W O C - RECEIPT#
GAS EA.SYSTEM-OVER 4(FA)
Com env ,oyJaY� BUILDING DIVISION FEES
Lj C.hile m h herebyfurnished.the city GREASE/INDUSTRL WASTE INTERCEPTOR PLAN CHECK FEE
❑Ccrtl(Id copy h filed with the tlty Inspection division.
CERTDTCATE OF EXEMPTION FROM WORKERS' GRE'A'SE TRAP PAID '
COMPENSATION INSURANCE SEWER-SANTTARY-S30RM EA 7Wh7 'Date Recei I#
(Thossectlon need not be completed of the permit h forms,hundred dollars
($100)otifyth WATER HEATER W/VENT/ELECTR - ENERGY FEE Y_ N_ '
I certify that Inthe peHomunce of the work forwhich this permit is issued,
I shall not employ any person In any manner.o as to became subject to the WATER SYSTEM/TREATING
Workers'Compa matlon Lswsof California• Data
- PAID ,
O Z Applicant - NEW RESIDENTIAL PCMB. SQFp. Date Revel t#
Z O NOTICE TO APPLICANT;If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions oflhe Labor - TOTAL:
N Cade,you must forthwith comply with such provhioruorthh permit shall be - BUILDINGcite
md r
W > deeeevokd. .
CONSTRUCTION LENDING AGENCY - SEISMIC FEE
CL Iherebyaflrmthat there he a construction lendingagenry for the perform- ELECTRIC FEE,
D Z a are ofthe work for which this permit is hooted(Ser.3097,Civ.C) TOTAL: '
O O ]enders Nam PLUMBING FEE
LL 1- Lend,r.Addm. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertitythatl have read this application and state that the above Information -
C hmrrect.I agmsto complywith all cityand countymre
dlnansand state laws PERMIT ISSUANCE FEES PAI .
^
>- relating to building covstmctlon,and herebyauthorize representativedo(this ^ ^ 6
N )
m
city to enter upon the above-motioned property for Inspection purpose.. ALTER OR ADDTO MECHt .
""'Date - Revel f#
V ally an d keep harmless the City of Cupertino a
, "
ag.l billtim,judgments, d pensee hich may i.mywayaccnm AIR HANDLING UNIT CTO 10,000CFM) SUBTOTAL:
94..t a d City In conseryen o h gra U of this permit
2 AIR HANDLING UNIT(OVER IB,000GFM)'' CONSTRUCTION TAX
St mmof Appilant/Cont cmr' to E%tv+UST IioDD(W/DUCT) ' CONSTRUCTION TAX PAID:
/ HAZA 01 US MATERIALS DISCLOSURE
Will the applicant orfamm building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date - RCCeI t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and Safety Cde Sec 25537(.)7 HEATING UNIT(OVER 700,00)BTU) TOTAL: '
❑Yes o '
Will the applicant orfuture building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSj�•�jfF•/TE' `
which emit haradous air coma rants as defined by the Bay Area Air - u" '
Quality Management Dl Irl BOILER-COMP OHP OR 100,0(0 BTU)
Yca m
averead the haze mus mode,le requiremenh5533 aChapter. 1 of BOILER-COMP(OVER 100,000 BTU) NPR
3 1990
the CaliforniatHealth building
Code, currently
have
ate and 25534. I T l�
understandbility to if the buil occupant of t the
menta which
that It met NEW RESIDENTIAL MECH. SQ.FT. pp - }.
;n�ccrorauthori
onsibility to notify occupant of the requirements which mustbecot - - 'Wys�
o lasuance o(a rt ice o(O parry. yy,of, It
m"7'
fT"
ae gent, Date - - ISSUGDRY:Vy�WV`�y n
. ' . ,TOTAL:
FFI P
O CE COPY