24321 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMIT NQ 4 3 2 1
BuBding Address: Z
_ �oG S'9 K '�1Nwr=nP w�
n�v "cls%J CITY OF CUPERTINO-BUILDING DIVISION �O^ SUB-MCI I tI AL
L DA
Contnaors Nane: '"l sac.No: APPLICATION / PERMIT
1 333 BUILDING-ELECTRICAI PaUMBING-MECHANICAL CATEGORY C O�
Architat/Engineer. Lk.No:
QTY ELECTRIC ITE FEE BUILDING PERMIT INFO
Address: '��5 N L PERMITISSUANCE
LICENSEDCONT-A OR'S DEC RAT] N
Thereby alfirtn that lam Bcenazdu derproviN sof Chapter9(commec APPUANCES-RESIDENTfAll JOUDESCRIPTION
Ingwllh5ect1on7000)of Dlvislon3 ilthe8uslnesaand PrvfeslonsCode,and my
licenreialnful .deffect. PANELS ��
censeGb® L+eN 3007 3 Poo q-F>VCVsL
ateContractor 201-1111000 AM
ARCHITECT'S DECLARATION SQ.FT.FLOOR AREA $/SQ.FT.
Oro I understand my plans eha8 be used v public records
Professional
Profnssi. l S vF TRICAL
OWNER-BUILDER DECLARATION \ CIRCUIT/ �_-
7 F 7 owing reaffirson.
(halon 7 xempt(ro Business
a Contractor's License law fort ��+V 1,00►
pppp follectunyngrescan.irsea p7mIS,cosinessandProlesr,impi eCode:Any cttyor
FSP c.untywhich requbesa permittoconstroq ilter,bnprovemfora bh,or repair P.M ]NST.
anystma mpr rtolbbsaame,aL requlmtheappBcanl(onuch permitto PDWFR
Ho'
file a signed statement that he Is licensed pursuant to the provisions of the
Contractor's License Law(Cha er9(commencin withSeaton7000)ofDlvi-
Sl
Eb alon3o(the Business and ProfessionsCode)orthatt he b exemptthercfromand WIMtiQ LEL RIC VALUATION
O the basis for the alleged exemption. Any violation of Section 70315 by any ETS TC FIXTURES
applicant for a permit subjects the applicant to a civil penalty of not more than
56
five hundred dellee(&500).
NEW RESIDEAL ELECTR SQ.FI. STORIES TYPECONSTRUCTION
I,as owner.(the property,or my employee with wage as their sole
t7 compensation,will do the work and the structure is not intended or offend for -
$ O sale(Sec.7044.Business a rad Professions Code The Contractors License Law
gc$$ does not apply to an owner of property who builds or improves thereon,and OCC R(]ttl> IT
wh.doea such work himself or through his awn employees,provided that such i /` a iF II 1i�1
Improvements are not intended oroffered for sale.If,however,thebullding or
improvement bsoldwithlnoneyearofcomplalon,the owner-bullearwlll have
t1�s.Q�+,den of proving that he did not build or Improve for Purpose of sale.). QTY. PLUMBING PERMIT •L•
LJ L as owner o!the property,am exclusively contracting with licensed D.PiWDID N
contractors to covtmct the project(Sec.7044,Business and Professions Code: PERMIT ISSUANCE I1�1 CC
The Contractor's License Law does not apply to an owner of property who
ALTER-DRAIN k VENT-WATER(G)
bu8tls or Improves thereon, and who contracts for such ptojem with a
�ffic'02n exempt
under pu See, the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE
OUSUMMARY
EFEES
LJ I am exempt under Sec B h P C for this reason '
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECEIPT N
l,It', WORKMAN COMPENSATION DECLARATION pIXr*ppR TpAp �•� SCHOOL TAX Y_ N_
+❑I hereby affirm that I have a rertlBote of consent to sell-Insure,ora RECEIPT
N
icerti0cate of Workers'Cwnpewtlonlvurance oracertlfled ropy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
380,LbC.) —
RECEIPT N
Polity N GAS EA.SYSTEM-0VER 6(EA) BUILDING DI VI. ON FEES
cram ray
[PCertificd copy b hereby furnished. GREABE/WDUSIRL WASTE INTERCEPTOR PLANCHECK FEE a�
Certified ropy b filed with the city inspection division. 4 { 1�$
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID 116100
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.7(M)FT. Dale Recei
(Thlssea+on.eed not be completed Kthe permit b tonna hundred dollars
(51(0).aless.) WATER HEATER W/VENT/EECTR ENERGYFt Y N_
]certify that lnthe person In an ehe workmanner so as tobeca permit 1.subjec Issued,
tothe �s O
I shall not employ any peas In any manner w u to become abject to the WATERSYSTEM/TRfiAIING \\/lyryU[I`—
Workers'Compensation Gua of California.Date PAID
Z Z NOTICE TO APPLICANT;ILaKer making t his Certificate of Exemption,you cm N`�V RESIDENTIAL PLMB._SOFT. ate Recei [N
should berone subject to the W.,leen'C.mpensatlon pmvbl.ns ofthe Labor TOTAL:
F N Code,you must forthwith comply with sua provisions.,this perMtshall be
S j deemed revoked. BUILDING FE
IL — CONSTRUCTION LENDING AGENCY SEISMIC FEE _
[L Ihereby affirmthat there b a construction lending agency for the perform- ELECTRIC �-
Z arco.fthnw.rk for which this permit is Issued&c.3097,Cm.C.) 'PLUMBIN
V O Leader's Name
LL f Lendrea Adde, QTY. MECHANICAL PERMIT PEB MECHANf L FEE
OW I certify that l have readthbapplicalbnand statethat theab.ve int.rnutian iE
4 iscorrea,I agree tocomply with all city and county ordlnancesandwatelaws PERMITISSUANCE FEES PAID:
} relating tobulidingcom ualon,and hereby authorize rep rexntatives"this
F Z cityto enter upon the above-mentioned property for lnspectbnpurpoae. ALIERORADDTOMECH.
Date Receipt
(We)agree to save,Indemnify an d keep h.,ml the City of Cupome. a
V against Liabilities,7adgenents,reatsand expenseswhl.h mayln anywsyacaue AIR HANDLING UNIT GTO to"CFM) T L:
against deity in c.nsequene of. antingd this perordt.1 � CON X
R HANDLING UNIT(OVER 10,0()OCFM)
Sigvtvrc (ApplHAZA ontractor Date
IXHAUST HOOD(W/DUCT) CONS UCTIO TAX —
HA7AARD0 MA RIALSDISCLOSURE _ _
Willt cappllcant orfWu ngocmpantm.mmhandlcharardousIL
HEATING UNIT(TO 100,0)0 BTU) �• Date R [
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
1lealth and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU)
[]Yes M No
Will theappBcant.rfutumbuildugoccvPont..equipmentordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardoua air contaminants as defined by the Bay Area Air
Quality Management District?No BOILER-COMP(3FI'OR 100.000 BTU) kk��
❑'Ycs No L" a
-Ihavercad Health
of materialsChapter 2S534. I of BOILER-COMP(OV fiR 100,000BN)
tge.l.nd la Health building
Coda of Curr 75505,have
at and 25534. I
undersand that If the notify the occupant
does not currentlyyenarts which
that itbmy NEW RESIDENTIAL MECH. �.FT /I Q' {�O q(�
rriout.issu..rof.Cthe occvpantof the uparcyulrementswhich must be met PI eV /6 1993
prior to issuance of a Certificate.(Occupancy. /�'r
y In-
Owner or authorized agent Date — ISSUED BY:
OFFICE COPY