24130 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY '
Building Pw ect Identl(Icnia" - PFRMITNO.
Building Address:
05 �ohna. .Ln . 24130 AL h
M 9
N.- Z.SS— Phone:
eCITY OF CUP ERTINO-BUILDING DIVISION �O _�, �j ^7
G°""adm°Na e' {�Na: APPLICATION / PERMIT / L
SO r Q✓ BUILDING-E.ECTRICAI PLUMBING-MECIIAMCAL CATEGORY CONTROL N
Arch ted/En ver. Lic.No:
/JJ T QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: -
r m(uuLIforce aOdCONTRACTOR'S
ONTRARODECLARATION
ARA�TIO.JN
9�
PEMTISSUANCE ❑ 1:1 El
Elherem'hat
I Hcenedundrrpr nsolChaptrr9(mAPPLIANCES-RESIDENTIAL
IngwlthSection700( 0DisNm3oftheBusnnsaited ProleWovCode,andicy PANELS )OB DSRBTON
urcn
90,gfA
License CWssLlep / i/"f 'I 0.1/
Date d[j�.[(a+7_ContractorUP 10 2N AMPS
✓er K( ��ARCHITECTBd m public
TION ,// OVER
AMPS
NZ OVER IOOO AMPS Ff.FLOOR AREA S/SQ.FT.
{Qq
00
I understand my plan shall be used u public rccoMe. SQ.
E Licensed SIGNS ELECTRICAL '
!6� OWNER-BUILDER DECLARATION SPECLALCBiCUIT/MISC
z ]a Ihembyaf@mtl tlamexemptfromthe Contradoh License Lawforthe
F�res qqqq ,following reaaon.(Seciton MIS,Business and Professions Code:My d or
county which requlrcsapermit rocomtwd,after,Improve,de=ibh,arrepair TEMP.METERORPOLEINST,
°'d anystmu mpdortoitsbaame,aLwrequlmtheappUmntformchper tto
]OWER DEVICES
file a actors statement that he lerlicensed(commencing
pursuant to the provisions of the -
COQOµ Contractors urines Law dPmester9(mmmendng with Section 7000)xampiherafof Diel- VALUATION
elon3of the guelnneand ProfesslovCode)orthat he lsexemptlhercfromand SWIMMING IDOL ELECTRIC
G the bash for the alleged exemption. Any violation of Stolon 7031.5 by any /IOD " "
//1/�/
applicant for a permit subjedsths aot m
pplicant to a civil penalty of nore than OUTLETSSWITCIiFSHXT[JRES s
five hundred dollars($500).
❑1 as owner of the property, NEW RESIDENTIAL ELECTRSQ.FT. STORIES TYPE CONSTRICTION
, p perry,or my employees with wages r there sok
70,
cc it lbe ad P sndlhesCde:Thure eout cho, dee Lt..Law -
O sale(Sec.78M,Bualvsa end Ikofessiona Code:The Contactors Llcerue Law
does not apply to an owner of property who builds or improves thermMand OCC.GROUP RES.UNITS
as whodue suchworkhimlfrthr ghhlsownemploymprovidedthatwch
Improvements are not Intended proffered for sale.IL however,thebuilding or TOTAL:
ImprovementhsoldwithlnoneyearofcmnplctloRtheowner-bullderwill have
the burden of proving that he did not build or improve for purpose of sale.).. QTY, „ PLUMBING PERMIT FEE , FLOOD ZONE APN
M L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec 7064,Businessand Professbna Code:
The Contractor.Llcenae Law don not apply to an owner of property who M,)Eg DRAW k VENT WATER(11A)
builds or Improves thereon,and who contracts for such pAojects with a FEE SUMMARY
c,5ador(s)Bernard pursuant to the Contradoes License Law.B k P C for this reBACK FLOW PROTECT.DEVICE
Ll I am exempt under Sec. »on
GRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECEIPT N
WORKMAN I have.COMPENSATION DECLARATION Ftt.N��.�r SCHOOL TAX Y_ N_
❑I hereby affirm that 1 have•certificate of conesnt to self-insure,or RECEIPT N
certificate C.Workeri Copmpevatlonlvurance ora certified mpythereo((Em. GAS EA.SYSTEM-1 INCAOITTHTS PARK FEE Y N
polis Lab C.) �O p�� _ RECEITN
Policy N 7 GAS LA.SYSITM-OVER 6(EA) —
Co�m.,y�nv ( -�A. BUILDING DIVISION FEES
�tJC dRied copy b herebytumb ed. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
rtHled copy V filed with/be city inspection division. -
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAII PAID
COMPENSATION INSURANCE
(Thissectionnaed not becomplded lithe permit lsforavhundred dollars SEWER-SANTTARY-SIORM FA.700FT. Date Rcc i t#
($1(10)orless.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I certify that In the performance of the work for which this permit is issued,
I shall not employ any person In any manner w es to become subject to the WATER SYSIEM/TREATING
Workers'Compeneation Laws of California. Date PAID
0 Z Applicant New RESIDENTIAL PLMB. SQFf. Date Recel t#
Z O NOTICETO APPLICANT:ILaBer ma king this CertRloteof Exemption,you
should become subject to the Workers'Compemation provision of the Labor TOTAL:
N Code,you must forthwith comply with such proislona orthb permit shall be
LU 7 deemed revoked. BUILDING FEE
..
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there IB a mvtrudion lending agency for the perform- ELECTRIC FEE
O ance aftheworkforwhlchthbpermltls Lasved(Sec.3097,CIv.C.) TOTAL:
lander.Name PLUMBING FEE
LL H Lander.Add.. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icacti(ythatlhavemadthsappHcationanddatethattheabovelnformation
lscomet.I agree to complywlth all city and county ordinances and Mate laws PERMIT ISSUANCE FEE$P�IeD:
). N relating Wbullding construction,and hereby authorlae representatives ofthb !p.
1— Z city to enter upon the abovo-mentloned property for Inspection purposes. ALTERORADDTOMECH. Dale ReCeI [#
— (We)agree to ever,Indemnify an d keep harmless the City of Cu pectin,
against liabilities,judgments,costs and expenses which may in any wayacaur AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agolvtuld Chyincon aryence t grantingefth permit.
AIRFUNDUNcUNIT(OVER lo,DBBCEM) CONSTRUCTION TAX
Signature of Applicant/Cont dp 94e EXHAusTHooD(w/DlJC7) CONSTRUCTION TAX PAID:
HAZARDOUS ATERIALSD SCLOSURE
Will the applicant orfuture building occupant store or handle haurdous HEATING UNIT(TO IOO,000 BTU) Date RCCeI t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and Safety Code Sedlon 75537(a)? HEATING UMT(OVER 100,000 BTU) TOTAL'
❑Yee MN.
Will the.pplinnt orfunmebuitding oompart use equipment ordaviass VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haardous air contaminants as defined by the Bay Area Air p
Qra lily Mavgerrent District? BOILFILCOMP Dp� AFP OR 100,DM BTU) IC I D
Yes nn No
have read the haar�ous materials requirement,u neer Cha pier&95 of BOILER-COMP(OVFR 700,000 BTU)
the California Health k SafetyCade,SMiov75505,25S33 and 75536. I OCT : 6 1992
understand that lithe building does not currently have a tenant,that it b my NEW RESIDENTIAL MECH. . SQ.FT.
responsibility to notify the occupa lit of the requirements which moat be ret
prior to Issuance of a Certificate of Occupancy.
C Y OF G rtes I uvv
Owner or authorised agent - [AteISSUE[) a
TOTAL:
OFFICE COPY