23534 APPLICANT TO FILL'IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
- Building Project Identification i - PERMIT NO.
BuBding Address,:
o ,: 23534
, I
CITY OF CUPERTINO-BUILDING DIVISION
contractor' Namc: Lic.Nx APPLICATION /PERMIT
D S d3 - CATEGORY CONTROL
Lic.No; M
Architect/Engineer. -BUILDING-ELECTRICALPLUMBLNG-MECIiAMCAL
QTr ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address' I S PERh9TISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Iherebyaf(irmlhatlamlRmsedunderprovWmsof Chapter9(mmmm APPLIANCESRESIDENFIAL p
ing with SecH0o7000)ofDivlslon3ofthe Bualmesand Profuaton.C-ode,andmy 1100 �. �/Pf , ^`d a0�
lirenselaln fullforce deffect.' PANELS . Le
License cmData c 4_ Lm« IO
,. ems. „ 5 P f� �v' Soo
J—UP TO 2DOANIPS
ARCHITECI•SDECLARArTree161919 AI-1000AMPS • 50
�q+DCO I unden[and my plan sha86e yged as pubBc s, OVER 100DAMPS SQ.FT.FLOOR AREA f/SQ.FC.
E zt, Licensed Pro.coal L} ,L-�n`Toc✓ pf1-L�'��� SIGNSELECTRICAL
<�6 4 OWNER-BUILDER DECLARATION SPECIALCIRCUIT/M1SC ate'
z p-.11 thereby offirmttut l am exempt fromthe Contradore License Law lorthe
r� following reason.(Section 7031.5,Business and Profession Code:My city or
O Fu"]Fq .aontywhlch requmapemtommhd,ater,mpme,denWh,urrepair TEMP.METRORPOLE INST.
4
'
mystmmmprlartoib WuancealmrequireatheappBanlforsud Permitto POWER DEVICES
E file a signed statement that he I,licensed pursuant to the providon of the
d3w�
Contractors Lt..Law(Chapter 9(mmmendngwilhSectlon7000)ofDivi- SWIMMING POOL ELECTRIC
ti�Os uon3 ofthe Businessand Pmfswlmu Code)arlhat he lsesempt therefromand VALUATION
O the basis for the alleged exemption. Any violation of Section 7031.5 by any O[TIT.ETSSW170FiFSF1X'1'ULIES
appllant fora permit subjects the applicant to a civil penalty of not morelhan
two hundred dollars($M. NEW RESIDENTIAL ELECTR SQ.FT.
�n 111,a.owner of the property,or my employees with wages as their role STORIES TYPE CONSTRUCTION
compensation,willdothe work andlhestrudure is not Intended or offered for
psale(Sec.704,E Business and Professions Code:The Contrsdoes License law
�$ does not apply to an owner of property who builds or improves t hereon,and OCC.CROUP RES.UNITS
who dcesaua work ht.1f.rthmugh his sawn employers,provided that such
improvements are not Intended oroffered forsale.IL however,thebullding or T
Improvement4wldwithinomycarofcompidloRtheowneo-bullderw111 have
the burden of proving that he did net bund orimprove for purposeofule.). QTY. PLUMBING PERMIT .FEE
4,_I L as owner of the property,am exclusively contracting with licensed ---fLOOD ZONE APN
contractors to construct the project(See 7044,Bu.i ...d Profession Code: PERMIT ISSUANCE
The Contractors License Law does net apply to an owner of property who ALTIItARAIN k VENT-WATER(EA)
builds or Improves thermn,and who contracts for such p�ejeu with a
optIador(s)Bcensed pursuant to the Contradoes License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under See B 4 P C for this reawn
Owner DRAINSFIIOOR ROOF,AREA,COND. SANITARY Y N
Date RECEIPT
«
WORKMANCOMPMSATION DECLARATION FIX,NRFS PER TRAP SCITOOL TAX Y N
❑I hereby affirm that I have a certWeate of consent to self-Inwn,ora RECEIPT«
certifJWa.fWorke Cempxmak.n ln.,shmma cedlftd cepythemof(Sec.
3800,Lab CJ GAS RA.SYSIAf-i WC.60IJII.EfS PARK FEE Y N
.Bry Y RECEIPT M
CGAS EA.SYSTEM-OVER«(EA) BUILDING DIV
ISION FEES
copy V hereby furnished.
❑Certified copy V filed with tlty CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
CERTIFICATE OF EXEMPTION FROM WORKERS C'RE'ASETRAP PAID _
COMPENSATION INSURANCE gE{VER-SAM7•ARy STURM EA.2tion Date Recel t#
(fMdb
seen need rad be completed lithe permit Maruse
hundred dollars
(f1I cemless.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
(certify hat employ
any p,he o in any heworknuome,for to bee le per bJecltls blued, —
I shag not employ any person]n any manner so u to become subject to the WATER SYSTEM/TREATING PAID
Worken'CompenuHan Laws of Calllomla.Date
O Z Applicant NEW RESIDENTIAL PLMB. :n.IT. Date Recel t#
Z 0 NOTICE TO APPLICANT:If,after making this Certiimeof Exemption,you
F should become subject to the Workers''Compewtbn provisions of the Labor TOTAL:
N Cade,you must forthwith comply with such provisions orthb permit shall be
j dermed revoked.
aG CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby a(Brmthat there V a construction lending agency for the perform ELECTRIC FEE
pe
Z ance of the work for which this permit In Loved 6ec.3097,Civ.C.) TOTAL:
u O Lmdee.Name PLUMBING FEE
LL H Lender.Addre„ QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icedifythatl have read this appliatio...d statethat theabove information -
1 Is correct.,I agree to complywlth all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
N relating to building construction,and hereby authotl representatives ofthis
j. city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH.
Z '
V Z (We)agree,to save,Indemnify an d keep harmless the City of Cupertino pate ROeeI t#
against Liabilities,judgments,cost,and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
again t said Ity en o!the granUn b permit
e
4 AIR HANDLING UNIT(OVER 10,000CrM) CONSTRUCTION TAX
Sliomh AppnoMt7C5ntmLTor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: ,
HAZARDOUS MATERIALS DISCLOSURE _ -
Willtheappllcantorfuture buildingoccupantstoreur handle harardou, HEATING UNIT(TO 100,000 BTU) Date Recce
material'as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health andSafetyCade Sedlon 25532(a)1 HEATING UNIT(OVER 100,000 BTO) TOTAL
you
�]Na
M the applicant or future building occupant use equipment or devices VWITLATION FAN(SINGLE RESID)
q ISSUANCE PATE
��asr which emit harardous air contaminantsa.defined bythe Bay Area Air '
ap.v lily Management Distdd7 BOILCR-COMPOHPOR 100,000 BTU) PAIID
I IYa. UoNo
-T alfforead the M1aaar fety Code,Se tioW255DS, 5533..hapter.1 of BOILGR•COMP,(OVER 100,000BN)
4ni the urs. dthaolut t fifth building
Code,Sedionntly h ve.tread2553d.I
understand that notify
the occupant
not a rrentlyhavea tenanq that It bony NEW RESIDENTIAL MEC]i. SQ.fI'. APR 20 1992
responsibility
to ndl(y theottvpant o(lhe requlremeniswhlch must be met /111��
priorto Lssu cee Ce i(late of pan CITY YU�
� ,� �-- �a
Owner or au lu a �TaTe
TOTAL: ISSUED BY•
OFFICE COPY