23032 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pmjc t Identification PERMIT NO.
But in Ad J`. mQXI I 23032
Ovals..NJ
m: one: A A
lEbAZ� CITY OF CUPERTINO-BUILDING DIVISION � t
tra a aN.me: LIc.No: APPLICATION I PERMIT ly L
BUILDING-ELECIRICALI'LUMBINGMECHANICAL CATEGORY CONTROL N
rchitect/ neer. Lic.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
BLOU
PERMITiSSUANCE ❑ {� ❑ Tom.
LICENSED CONTRACTOR'S DECLARATION Lel L�
[hereby a Bum that l am licensed under provisions of Chapter9(comment APPLIANCESRESIDENTIAL JOB DESCRETION
ingwith Section 7000)of Dlvlslon3ofthe Businessand ProfesdonsCode,and my �a
I racial. f deffect. 1 PANELS y,P1 As.ai t'
Lice
Lc'.'.-
cX
Dat Contract InV
ARCNITECPS DECLARA ON 201.1000 AMPS
07 [undn erstand my plane shag aOVER
be used
public records. OVER 1000 AMPS SQ.FT.FLOOR AREA 5/SQ.FT.
�y O
OF Licensed Profe.iovl SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION
tn` FnSPECIAL CIRCUIT/MIST
L., G 1herebyafRrenthat l aexempt from the Centractorb Llmnx law(or the
m
O 0 following reason.(Section 7031.5,Business and Professions Code:Any city or TEMP.METER OR POLE INST.
rcountywhichrequimsapermittomnstmd,altegimpmve,dcn lbh,ormpalr
g$'��`r3 anystmc mpr rtaibbauanceaborequlrestheapphcantforsuchpert tto OWER DEVICES
6 I U file a signed statement that hs Is licensed pursuant to the provisions of the
Contrachm'�30� slan3oftheBulcense sinesslnd(Pro(eviovCoder 9 e)orthatthencing lth Section 6exemptherefrofmM SWAMINGPOOL ELECTRIC VALUATION
<5 the basis for the alleged exemption. Any violation of Section 7MIS by any OUTLETS-SWITCHES-FIXTURES
applicant fora permit subjects the applicant to a civil penalty M net more than
p� SQ�FT. STORIESTYI'ECONSTRIX:TION'
five hundred della.($500). NEW RESIDENTIAL ELECTR
t] �n ❑I,as owner of the property,or my employes with wags as their sole
7Q
compensation,Business and k,anathestmctureheis ot Coetendr's Limme La r
O
sale es not apply 014,to alneas ana f prope ons Code:The Contractors License Law
S$ whodesessuch torn owner ofpropghhisobuilds nemorlmproovided.ogand OCC.GROUP RES.UNITS
whodoessuch work Mmtended through hlsowne.If,hoes,provided thatsaor
Improvementsare not Intended earofco for nab.IShower-I thebuulder ill have TOTAL:
Improvement bsold within oneyearo(chid r the Improveownfor p rpose ofsahave
tt�r ameno neerprovingof t to t bc propeld nat exd orvely==trading
with
o(cen a QTY, PLUMBING PERMIT FEE FLOODZONE APN
Ltr S as owner of the property,am exclusively lBusi contracting with llcenxd pFRh11T ISSUANCE
The
contractors construct thew doe nee apply
to an o and of pro ons Code:
The Contractor's Licenx Law aces net apply ct f owner of property who
Wild. or Improvm thereon,and who commas for such pkajeM with a ALTER-DRAIN 6:VENT-WATER(EA)
cgNTanar(.)B...d pursuant m the Ca.tracter'.License Law. FEE SUMMARY
�l l am BAER FLOW PROTECT.DEVICE
exempt under Sec. B k P C for this mason OUTSIDE FEES
DRAINS FLOOR,ROOF,AREA,GOND. SANITARY Y_ N_
. Owner Date - RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES PER[RAI' SCHOOL TAX Y_ N_
I hereby a((Irm that I have a certificate of consent to self-Imre,ora IRECEIPT N
ceHfirate of Workers'Compevatlon Insurance ora certified copy thereof(Sec. GAS FA.SYSTEM-1 INCA OUTLETS PARKFEE Y_ N_
3801 lab CJJ �('� RECEI'Cp
Po11ryX IJ RSI Is� GAS EA.SYSTEM-OVER BUILDING DIV]SION HE ES
Gay _ —
�rtlRedcopybherebyththecid. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
erttfied ropy b filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWERSANIZARY-STORM F.A.200FT Date Reml t#
(Thbsectlon need net be completed lithe permit b forov hundred dollars
($10))orlen.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
1 certify that In the performance of thework for which this permit b burned,
I shall not employ any person In any manner so ns to become subject to the WATER SYSTEM/TREATING PAID
Workere'Compenmlon lawn o(UII(omla. Date
0Z Applicant NEWRESIDENTIALPLMB. SQ-FT. Date Remi t#
Z O NOHCETOAITLICANT:ISaftermakingthb Cediii.teof Fsemption,you
rs
should become subject to the Worke 'Compensation provisions of the Labor TOTAL:
N Code,you must forthwith comply with such provblons orthb permit shall be
CC j deemed revekea. 6 IL ..
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL IherebyafRrmthat there is a construction Lending agency for the perform- TOTAL: ELECTRIC FEE act
7 Z ante of the work for which this permit is Issued(Sec.3097,Civ.C.) PLUMBING FEE
() O 1<nder's Name
TL Lenders Addersi QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U Icertifythatl have readthbapplicatlonand statethetheabove lnfierrvtlon �p
0 W bcorect.l agree tocomply with all eltyand county ordinance and state laws PERMIT ISSUANCE FEES PAID:
} N relating to building construction,and herebyauthomm representativesofthb
1-" citytoenterupon the above-mentlDned propertyfarinspectlon purposes. ALTERORADDTOMECH.
Z (We)agree to save,Indemnify an it keep harmless the City of Cupealno Date Receipt#
V against liabilities,judgments,costsand expenses which maylnanywayaccrue AIR HANDLING UNIT(r010,000 CFM) SUBTOTAL:
agal s City in ronaRplence the ant thl mat.
AIRHANDLINGUNTT(OVERIA(lis M) CONSTRUCTION TAX
14
g to eof Applicant/Contractor EXHAUST HOOD(W/DUC'D CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS D. SURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT CTO IKWO BTU) Date Rowel1#
at
merial as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER IDQOOD BTU) TOTAL:
❑ Y. M No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
hlch ems hazardous air contaminants..defined by the Bay Arca Air
llty Management Dlstd97 BOILER-COM? 1W,OlU BTU) A B
Yes nn No
Lr'bave read the has r�iO mmerlab requirements under Chapter 6.95 of BOILER-COMP(OVER100,000111V)
the California Health k Safety Code,Sections 255D5,25533 and 75534.1 JUN 5 1992
undersm tand that if the building not currently have atenam,that itbmy NEW RESIDENTIAL METH. SQ.IT.
responsibility to notify the occupant of the requirements which most be met
prior to bsua nee of a Certificate of Oaupa nry. CITY (JY 1,
Owner or authorleed agent Date TOTAL: ISSUED BY:
OFFICE COPY