23853 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building project identification PERMNO.
BuBuildingA�3z� ���� y� IT23853
els aide: A A A
/LS l�iG/l �fllic%q/N1 'f`!o s� CITY OF CUPERTINO-BUILDING DIVISION
Cnntmetn.sName: ///�_J Lie.No: APPLICATION / PERMIT "� Z
BUILDINC-ELECTRICALI'LUMBINC-MECFIAMCAL CATEGORY CONTROL N
• Architect/Engineer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDINGPERMIT IPLUMUNFO
Add.
PERMITISSUANCE I y 1:1LICENSED CONTRACTORS DECLARATION RATION L�] �0
Thereby af(Irm that lam licensed under provisions of Chapter9(commec- APPL[ANCESRESIDENTIAL )Oq
license I,in fullforceandttat dfeR,3olthe Byq dPq rofexslpnaCode,and my PANELS �y\ 0./1��{ cW�•`Y!J` C
161._1 s'
CHI 5'CL (_IOON�'(b-
Date ' Contrado, UP TO
DAMPS
AIashall CTSDECLARATION OVER1000AMPS SQ.FT.FLOOR AREA S/SQ.FT.
06
7 )understand my plan ahaB be used a public recomdx
ww SIGNS ELECTRICAL
a V� Licensed Professional
<Cw OWNER-BUILDER DECLARATION
1n E$ SPE WLCIRCNT/M15C
F, Thereby afRnn that lam exemptfromthe Contractor's License Law for the
Z O following reason.(Sec4lon 7m1.5,Buslnex and Pv(eviona Code:Any dry or
02t'u9 =ntywhichrequiresaper ttommtmd; ter,Impro demlBh,ormpair TEMP.METER OR IOLEINS!.
anystrucure priorto its Leuance,abo requirestheappllant forsuch permitto POWER DEVICES
6 V file a signed statement that he is licensed pursuant to the provisions of the
�WW�55 Contractor'sLicenselusices Law nd Prof erii eCod0ondn Its Section
mp"he00)of DWI AL Mid
Con3olthe Bushes.and(ChaptovCommemcinghebexem tberefromand SVsEs MING IDOL ELECTRIC
p y.'S the basis for the alleged exemption. Any violation of Section 7MIS by any OUTLETSSWITCHESF'IXTURES
{r�, <� appiartfora pemutsubjects the applicant to a civil penalty of not more than
A. five hundred dolWa(g5111p. hEW RESIDENTIAL ELECTR
c Q I,a ower of the property,or my employee with wages a their sok e�'�' SI'ORIF5 TYPECONSTRUCTION
compensation wllldothe work andthe structure best intended or offered for
Osale(Svc.7044,Business and Pmofeeloes Code:The Contractors Linrue Law
tj$$ does not apply to an owner of property who Wilda or improves thereon,and OCC.CROUP RFS.UNITS
CC.. who does such work himself orthrough his own employees,provided thatsuch
Impmve,ments are not intended orolfered for sale.ILhmveveethr WJIdingor TOT L.
Improvement easold witMnoneyearofcompletlon,the owner-builderwill have
fiqL,f rden of proving that he did not Wild or improve for purpose of vie.). QTY. PLUMBING PERMIT FEE FLOOD LANE APN
L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
Ile Cor tmeo conatcansc Law does not apply to an owner
of prop
The Coor i.p b Llonx Law aces not apply to an owner M property who .
i
Wild,or Improve thereon, and who contracts for such pnoFcv with a ALTER-DRAW k VEM-WATER(FA)
dor(.)licensed pursuant to the Contractor:License Law. FEE SUMMARY
tJ I BACK FLOW PROTECTDEVICE
am exempt under Sec. B 6 P C for this reason .
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
' Owner Date RECEIPT N
WORKMAN COMPENSATION DECRATION pLXTURETRAP �PER TRAP SCITOOL 7AX Y_ N_
❑1 hereby affirm that I have a cemrl(laLAte of consent to self-insure,ora RECEIPT If
certificate ofWorken Compensation lnsumemora unified copy thereof(Sec. GAS EA.SY57-EM-]INC.40L17LE15 PARK FFR Y N
3800,Lab C.)
Policyp RECEIPT N
any GAS EA.SYSFEMd OVER 4(EA) BUILDING DIVISION FEES
freified copy Is hereby furnished. 'TT)R PLANCHECIC FEE
Certified copy b filed with the city Impedisn division. GREASE/INDUSIRL WASTE INTERCF]
CERTIFICATE OF"EMPION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCESEWER-SANITARY-S'IURM FA.200F1'. Date Recei IM
(This section need not be,completed lithe permit Is furore hundred dollars
($1W)orless.) WATER HEATER W/VENT/ELPCTR ENERGY FEE Y_ N_
I cerUfythat in the performance of the work for which this permit is issued,
1 shall not employ any person In any manner so as to become subject to the WATTR SYSTEM/TREATIN'G
Workers'Compensation Laws of California.Date PAID
O Z Applicant NEW RFS DEV AL PLMB. SQFf. Date Recei tN
Z Q NOTICETO APPLICANT:1 after ma king this CertBlale of Exemption,you
Pshould become subject to the Worker?Compensation provisions ofthe Labor TOTAL:
CC N; Code,you most forthwith comply with such provisions orthb permit shall W BUILDING FEE
deemed revoked.
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE __ U
CL M G I herebyaffirmthat then b a construction lendingagency for the perform T L ELECTRIC FEE
7 Z anceof the work for which this permit is issued(Sec.3097,Civ.C.)
0 O Lendcr'a Name PLUMBING FEE E OQ
IL F Urde:Addrvss QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U I cedirythatl have read thisappllationand etatethat theabove information
O W bcorrcd.I agreeto comply with all etyand county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} 1 relating to Wilding covtrudlsn,and hereby authorlu representatives o(this
Z city to enter upon the aWve-mentlomdl property for inspection purposes. ALTER ORADDTO MECH.
(We)agree to save,Indemnify an it keep harmless the City of Cupertino Date Receipt#
L.)
against lbbililes,judgments,copsand expenses which may In anyway seems AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
ogulnstsaid City f the granting of this permit.
G�y� AIR HANDLING UNI"1'(OVER IO,OW CFM) CONSTRUCTION TAX
wm
Igre of App�can nvador Date FXFIAUS'r HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wil l the applies est orfutum building occupant store or ha od In harardous HEATING UNIT(TO I OD,ODO BTU) Date Receip U
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Ilallh and Safety Code Sedlon 25532(Q? HEATING UNIT(OVER 100,00)BTU) TOTA
❑Yo rl No
Wllltheappliant orlutum building occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit havrdous air contaminants as defined by the Bay Arca Air RR�� pp
' Qua lity Ma nagement District? BOILER-COMP OHP OR 100,!X10 BTU) A pp) Il" N D
4eNo
hYsaveread the h.9 us materials requireronts under Cha pier 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health A Safety Code,Sectiona 75505,25533 and 25534.1 JUN 18 1992
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECIT, SQ.FT
responsibility to notify the occupant of the requirements which most be met /�
prior to Issuance of a Certificate of Occupancy. Cllr U
Ownerorauthorirad agent Date ISSUED BY: L
TOTAL:
\ OFFICE COPY
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