24106 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
-
Buildirol Project PERMIT N2
OOZ4 1 06
Building Adder.
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ane:
CITY OF CUPERTINO-BUILDING DIVISIONQ�
Contract. °N. L1c.No: APPLICATION / PERMIT T —[ ��
ftif
BUILDING-ELECTRICALPLUMBINGMFLHAMCAL CATEGORY CONTROLM
Architect/Enginar. Lie No:
' - - QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PLUMB mt�n
PERMITISSUANCE ❑ O ❑
LICENSED CONTRACTOR'S DECLARATION of ChON
IFthsy10.7000'hat lamlicensed 3.ftheunder
u.i...ndP f.hi er9(commrn API'LIANCESRE9DENCIAL �
Inense 1,1.fell force of d affen n3o(theguelmmand ProlendoneCodr,end my
license Is in full force and c,N PANELS
License Class Lka F
Date — UP TO 2DDAMPS 2z*A0RA-
Contntlor
ARCHITECT'S DECLARATION201-1 AMPS
q�v 9OZ I understand my plans shall be used m public recrdw OVER late AMPS SQ,Pr.FLOOR AREA S/SQ.prr.
!i Licensed Professional SIGNS ELECTRICAL
<< OWNER-BUILDER DECLARATION
SPECLILCD2CUIT/MIBC
t.., .a ]hereby aftlrm that[ase exempt from the Contractor's License
Mhwforthe
QQ following reason.(Section 7031.5,Business and Pro(easluns Code:Any city or
gas '� oauntywhich requlreea permit reconstruct,alter,bnprove,demollsh,orrepair TEMP.METER ORIOLE INST.SI
� anystrueture prlortolts Issuance,also requlrestheapplicent(msuch permit to POWER DEVICES
15 at file a signed statement that he V Bernard pursuant to the proeleloro of the
W63µ Contractors License Law(Chapter9(commencingwlth Section 7000)of Dlvl- SWIMMING POOL ELECTRIC VALUA
SOS slon3oftheBueNneand Pro(emlonsCode)arthat hebrxempttherefromadd OG
G 9 the basis for the alleged exemption. Any violation of Stolon 70315 by any OUILETSE9-
s%VncHFIXTURES
p applicant fora permit subjects the applicant to a civil penalty of net mare than
�;2 fiF11,as
red owner of thepr. NEW RESIDENTIAL ELECTR_SQ.FT. STORIES TYPE CONSTRUCTION
�n ❑I,ea owner of the property, i my employees with wage as (fere sole
com(Sr.70 n,wlldothe work andthe e C dare V not Intended or ca.L for
D sole(Sec.7064,BuslriessaM ProfemWns Code:The Contnctote Wame Law
�$ does not apply to an owner of property who builds or Improves thereoM and FQ 11 JAM IT
who doesnuch work himself orlhrough his own employees,provided that such
improvements are not Intended oroffered(create.If,howeveythebulldingor TOTAL: 1� n
Improvement Is.old withlnoneyearofcompletion,the owner-bullderwlll have a v' U Tr 11 R
t retenofproving that he did notbuildorimproveforpurposeofmis). QTY, PLUMBING PERMIT FEE 7n Apel
Lj L m owner of the property,am exclusively contractleg with licensed PERMITISSUANCE
contntlan to construct the project(Sm.7044,Business and Professions Code: DAT
The Contractors License Law dam not apply to an owner of property who ALTER-DRAIN&VENT.WATER(EA)
Wor Improves thereon, and who conenrts far such p(ojecus with
c9p1(+ctor(s)licensed Pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sm B A P C for this reason
DRAINS FLOOR ROOF,AREA,GOND. SANITARY V_ N Owner' RECEIPT0
WORKMAN COMPENSATION DECLARATION FIXT(JUF_S.PER TRAP SCHOOL TAX Y N
❑1 hereby afllrm that I have a l rtrune of consent to ael!-Ihemo ora RECEIPT I
certificate of Worken'Compenutionlnsurance ma artlflN mpythereof l5ec.
3gO3800,Lab C.) GAS EA.SYSTEM-1 INCA OUTLETS PARK PER Y N
Poliry p RECEIPT X
Com GAS FA.SYSTFMAVER 4(EA)ny BUILDING DI VISION FEES
CertWed copy b hercbyluMe city CREASE/WDUSML WASTE INTERCEPTOR PLANCHECK FEE
ed
CedBled copy V filed with the tlty inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWEWSANITARY•SIORM EA 200FT Date Reoei tN
(Thisseelon need not be completed If theperenit Warms hundred dollars
(FI 00)mfy that
WATER HEATER W/VENT/EL[CTR ENERGYFEE Y_ N—
I
thato the person
anymanofthe ner for whichthispermit Is issued,othe —
I°hall not empty any pears In any manner m m to become subject to the WATER SYSTEM/TREATING
Worlicant mpematWn Lawe of California.Date PAID
z Z NOTICE
Z 0 Nould b.OAPPLICAM:IL Workers
Compensation
og this CertniP.e,., emptb Labor
NEW RESIDENTIAL PLMB. SQ.ET. Date Recei tp
I" Code, ou=st ubjecitahe Workers'Comp rowasinproNeonsofthrall be TOTAL:
N deemed remketforthwith comply with each provlelons orth6 permit shall be
> domed revoked. BUILDING FEE
W G CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL I herebyaWrtnthat them is a construction lending agency for the perform- ELECTRIC FEE
M Z ance ofthe work for which this permit le Wued(Sec.3097,Civ.Q TOTAL:
V O )<ndc/.Name PLUMBING FEE
IL — Lendre.Addrem QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Ianlfythatl havereadthbapplimlionartd atatethatthe above Information
IL iscomet.I agreetocomplywlth al cityand coun
ntyordlnanoand.tatelaws PERMIT ISSUANCE FEES PAID:
>. W relating to building construction,and heerbyauthorize representative.o(thls
U) city to enter upon the above-mentioned property for Its mction purposes, ALTERORADDTOMECH, Date Recei tic
— (We)agree to save,indemnify an d keep harmless the City of Cupertino
Its net 11. ties, h-aft,cossandex neeswhic yinanywayamue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL'
againsleald Cloy co ¢prance o! tinting of •permit
r AIR HANDLING UNIT(OVER I0,000CFM) CONSTRUCTION TAX
S vture App o /Contractor Dat EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUSMATERIALS iSCLOSURE
Will the applicant or fulurebuddingoceop tstore or handle hazard... HEATING UNIT(TO I W,ODO BTU)
material as dellned by the Cupertino Municipal Code,Charter 9.1 7,and the Date Receiptib
I lealth and Safety Code Section25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTA
qY. NN.
II the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSIJAUCE DATE
which emit harardous air contaminants a°defined by the Bay Area Air
Qu lity Management District? BOILER-COMP DEEP OR I00,0(IO BTU)
Yea ❑❑No '^a 4
���
4hW.readtheEaudourmateabequlremenaunderChaper6.95of BOLER-COMP(OVER IW,000BTU) Ura
the California Health k Safety Code,Sections 25.50.5,5533 and 25534.I CITY
undenlandthat nlithe notify
the ing occupant
of the currently have n lenanq that it bony NEW RESIDENTIAL METH. SQ C
rssor to Issance not Certioate of oftheraqulremenb which mart be met
prior to Issuance cafe Certificate o(Oavpanry.
Owner or authorized agent Date I ISSUED BY:
TOTAL:
OFFICE COPY
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TO : PHONE NO. 14082855130 AUG. 4. 1992 2:57PM P 2
FROM : Monier Dural-ite PHONE NO. : 916 795 1378
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