22941 APPLICANTTO FILL IN INFORMATION WITHIN.RED LINES— USE BALL POINT PEN ONLY
Building Procct Identification PERMIT NO.
Building Address:
Cis-
22941
' weer. aces: J / on
CITY OF CUPERTINO-BUILDING DIVISION
'C lo•N APPLICATION I PERMIT
PLUMBIN -ME
CATEGORY CONTROL N
A Ite /Eneer. BURDINGFIECTRICALc
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add. - PERMITISSUANCE QO ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby Affirm that l am licensed under provWons of Chapter 9(cousummu, APPLIANCES RESIDENTIAL JOB DFSCRIIPf10N
ingwithScdhm7000)of Divlsfon3 ofthe BusinesemdProfeWonsCode,and m `
licenaele In full f and Affect. y PANELS
License CWee,/�Lk.N' ?D� Z- I signs
Date Contractors
•'ARCHITECPS DECLARATION 201-IODOAMPS
X2 iundent.Admry'plsnssh.BbeuwdupubUcrecorda OVER1000AMPS (((���SQ.FT.FLOORAREA I $/SQ.FT.
I1 o Licensed I'mfeularal I-
SIGNS ELECTRICAL p L E D ,
<<
OWNER-BUILDER Ism exempt
fm DECLARATION SPECIAL CIRCUIT/MISC M
2s, 4 Ihembyaffl"n that lam-BUILDER the DECLARATION
License Law for the
following rcuon.(Section 7031.5,Business and Professions Code:An ci or
Ip"'�q'{ countywhlchmquimsaper ttocoutruc4later,lmpmvgdemoibh,orrepalr - T�']P.METER ORIOLE INSf. q
'�5❑ anystmeture prlorto its Issuance,also requlrestheapplicant foreuch permit to /1 f
/ /7
file a signed statement that he is Licensed pursuant to the provisions of the POWER DEVICES d.
O u, Cena License Law(Chapter 9(commencing with Sectio"7000)
30�r' abn3ofthfthe BuMneaeand Profesalons Code)orthat helsettmpttherefromand SWIMMING POOL ELECTRIC VALUATION
the bush for the alleged exemption. Any violation of Section 70113 by any
< applicant for a permit subjects the applicant to a civil penalty c(nst more than OUTLETSSWITCHESFIXTURES
o
two hundred della"( .
�A ❑L as owner of the ro NEW RFSIDPNTTAL ELECTR_SQFr. STORIES TYPECONSTRUC11OR
p petty,or my employee with wage as their sole
compensation,will do the work and the structure la sot Wended or offered for
q .Is&c.70K BuaUass and Profeubns Code:The Contractors Llcerae Law
docs not apply to an owner of property who builds or improve mhereen,and
EE whodaresuch work himself w through Neown employee,provided that such OCC.GROUP RES.KNITS
bnprovement.am rentintended oroffemd forsale.If,however,the Wildingor TOTAL: 5a '
Improvement bsold withinonnyearofcompletbn,theowner-WUderwlll have
Trdenofp.vJcgth.t he dW rad build ar Mprove for puryo.e o(ule3. QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
L as owner of the pmpelty,am exclusively contracting with licensed ntractors to construct the pmjed(Ser.7044,Business and Prn(esdans Code: ppRMpp ISSUANCE
he Contractors Liaise Law does no apply to an owner of property who ALTER-DRAIN 4 VENT-WATER(EA)
Wilds or Improves thereon,and who contracts fee such pRejects with a
cgnjractor(s)licensed pursuant to the Contractors License law. BACK FLOW PROTECT,DEVICE - FEE SUMMARY
L�I am exempt under Sec. B k P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
• Owner OUTSIDEFFTS
Date RECEIPT
WORK MAN COMPENSATION DECLARATION FDnIrRF&PER TRAP 5CIt00L TAX Y N
Of ho by'affirmo(Workem that 1 have• jm n n of convent to opythemof ora RECEIPT N
cert?(Ia"ofWorken'Cempensationlnsuranceora certified copythemof(Sec. GAS EA.SYSTEM-1 INCAOUTLET5 PARK FEE Y N
Polis Lab C.)
Policy N RECEIPT'M
Company I GAS EA.SYSTEM-OVER d'(EA) BUILDING DIVISION FE IS
I—'
Certified copy le herebyth the city GREASE/INDUSfRL WASTE INTERCEPTOR PLANCHECK FEE
crtified copy I.(lend with the city inspection division.
CERTIFICATE OF EXEMITION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 2DOFr, Dale Revel t#
R)m I..on need nam h compined lithe permit ls(stone hundred dollars
($100)orfy that
WATER HEATER W/VFNT/ELECTR ENERGY FEE Y N
I certify thato the person
forwhich astob co permit is issued, —
I shall m' employ any person I"any manner at u to become subject mo the WATER SYSIIM/TREATING
Worker?CompewtlonGsnatGlllomla.Date PAID
O Z Applicant
ZG NOTICE TO APPLICANT: aker making tide Certificate.4 Exemption,you NEW RESIDENTIAL PLMe, SQFf. Date RecA f#
(• N should becoresubjeettothe Workem'Compensation previsions,oflhe Labor TOTAL:
Code,You nwat forthwith comply with such provisions orthls permit shall be
LU > deemed revoked. BUILDING FEE
LU
G CONSTRUCTION LENDING AGENCY SEISMIC FEE
IherebyafBrm that there Is a aulmdIon lendingagency for the perform. TOTAL: ELECTRIC FEE
Z anaoftheworkforwyr�ythis perm"bLwed(See3097,CIv.C.)
U O Lander.Name '(/O/1�{... PLUMBING FEE
ILS ' Lendees Addresa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I cerlilythat l have read mhlsappUcetionand statethattheaboveinm
foutlon
S lsconect.I agree to comply with all city and county ordinances and Cate laws PERMITLuUANCE FEES PAID:
} Mrelating to building construction,and hereby aumhorlu representatives of this
r Z city to enter upon the above-mentioned property for inspection purposes. ALTIRORADDTOMSCH. Dale Revel t#
L) — (We)agree to save,Indemnify an d keep harmless the City of Cupertino
against ties,�udgnenle,ma/s antl expenses which may In any wayattroe AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL:
aga eat City inconuqu n fthajrantingof thlspe It.
21/ AIR HANDLING UNIT(OVER 10,000CPM) CONSTRUCTION TAX
4 2z
mtumo Appllant Contra or Date EXHAUSTHOOD(W/DUC'D CONSTRUCTION TAX PAID:,
HA7ARDOUSMATERIALSDIS LOS RB
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(10 100,ODO BN) Date RCCCI t#
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the -
Iiealthand Safety CcdeSen, 1S%aASS33W7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yeao
Will the applicants ture building occupant use equipment or devices VWITLATION PAN(SINGLE RESID) ISSUANCE DATE
which emit haaardous air contaminants as dented by the Bay Area Air
Ilty Management District? BOILER-COMP DIIPOR 100,000 BTU) P A I D
Yes Q No
have read the h., ors materials mqulrernents under Chapter Q95 of BOILER-COMP(OVER100,000 BN)
the California Health k Safety Code,Sections 25505,75533 and 75534.I NOV = 1991.
understand that It the building don not arrently haves me..AIL that it ls my NEWRESIDENTIALMECH. SQFT
rep ora to nq Ely the occupant of the requi"rre"te which must be mot •T
PH o nceofaCey+I cotocupanry. IN GUNERTINO
r or authorized agent to
TOTAL: ISSUED B
OFFICE COPY