20693 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proent Identification k7g9- PIRMITNO.
Building Address: NL� ° 20693
Owner.Name:���71S ItCL�.
Phone:
M(,(Af )1k P( l ry73-0�C,)5- CITY OF CUPERTINO-BUILDING DIVISION _
' APPLICATION /PERMIT
DC^^ eTA k., C 4
BUILDING-EIECTRICAI PLUMBINGMECHAMCAL CA -=BY CONTROLN
Architect/Enginar. Llc.No:
QTY ELECTRICPERMIT FE1E� BUILDING PERMITINFO
Address: TPERMITISSUANCE a•(/� ❑ aT ❑
LICENSED CONTRACTOR'S DECLARATION �a—j
I hereby affirm that l am licensed under provisions of Chapter 9(comment APPLIANCES-RESIDENTIAL JOB DFBCRIPTION
ingwith Section 7000)0!Division 3.ftlicBusincssandProfcied.c.Code,indmy
license ie In ful T ayd dfort. UP TO 2DO AMM
//`— PAN[LS
LlanseCh —�LICN ( �a•S�
Date DComtractor d
J
ARCHITECPS DECLARATION 201-1000 AMPS
0]. I understand my plaresluBbe used as publicremrds OVERIODOAMPS SQ.FT.FLOOR AR $/SQ.FT.
O
�j Licensed Professional SIGNS ELECTRICAL
a6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MLSC
k'yd.7a flumbyafOrmlhatlimexempl from the Cont etor's License Law for the
o following reason.(Section 70315,Business and Professions Code:Any city or
O Z F., TEMP.METEROR POLE INS!.
� e.untywhich mprbaapertNt tomrotroct,ilter,Improve,demolbh,orrepalr s/
anyatrotture prior to ltaiswa nae,alsorequlrestheappBant for such permit to POWER DEVICES
I. file a signed statement that he is licensed pursuant to the provisions of the
Ow Contractor'sLicense Law(CMpter9(commencing with Section 7D00)of Divi- VALUATION
to SN.7MMING 7170E ELECTRIC
O the basis for
the
exemption.
Any
rlationthat f exempt therefrom and
the bean for the alleged exemption. Any violation of Section not room
m any OUTLETS-SWITCHESFf%TUR S
appBantfor a permit aubjMsthe applicant too civil penalty of net rtnretM1an
five hundred delta.($500). NEW RESIDENTIAL ELECIR SQFI'. SIOR[ TYPE CONSTRUCTION
.. ❑I,as owner of the property,or my employees with wages as their sole
comptine tiogwilldo the work and thestructure is not intended or offered for
psale(Sec.7064 Bushes.and Professlors Code:The Contractors License Law
�S$ does not apply to an owner ofproperty who Wilds or improves thereon,and Ulama
who doesauch work hhnself orlhr^ugh his own emples
oye ,provided that such
ITS
improvements are not Intended oroffered for sale.If,however,thebuilding or TOTAL: .Sa
improvement bmldwithln omyearofcompletloMtheavner-b Merwill have
tie Menof pmvmgthat he did not bund orlmprove for purpose ofsale.). OTY. PLUMBING PERMIT FEE FLODDZONE APN
"I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE /
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractor's License law does not apply to an owner d property who
Wilds or Improves thereon, and who contracts for such pUoj ts with a ALTER-DRAIN&VENT-WATER(EA)
owlifictr(s)licensed pursuant to the Conteador'a License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec B &P C for this reasonOUTSIDE FEES
DRAINS FLOORROOF,AREA,COND. SANITARY Y N
• Owner Date RECEIPT=
WORKMAN COMPENSATION DECLARATION SCI 1001,TAX Y N
F-11 hereby affirm that I have a cedlRcete of consent to self-InsureFIXTURES PER TRAP,or RECEIPT N
certificate of Wo/r�kers Comperscefied
ztlun Insurance ora rticopy thereaf(Sec. GAS EA.SYSTEM-1 INCA OUTL PARK FEE Y N
3800,La V2�1.(�C -3q—/) RECEIPT#
Policy# 1 h/ GAS EA.SYSTEM-OVER 4(EA) B UIL DING DI VISION FR BS
I Com ansa � 1 1 n �� _
Certified copy is h by furnished. CREASE/INDUSTRL WA M'FRCEPTOR PLANCHECIC FEE
CJI Certified copy is filed with the city inspection division.
Y-' CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANRARY- RM EA 2flOFT Date Recei Ili
(this section need not M complded lithe pcmdt is(otos hundred dollars
(81OD)m1essJ WATER HEAT W/VENT/ELECTR ENERGY FEE Y_ N_
I certify that In the performance of the work forwhich this Permit is hated,
I shall not employ any person In any manner n a to become wbject to the WATER SY , /TREATING
Workers'Compensation Law.of Callfornla.Date PAID
OZ Applicant NEW DENIAL PLMB. SQFT. Date Recei IN
'T:
Z O NOTTCETO APPLICANif,after making t his CertBiateom
f Exemption,you
should Wmme subject to the Worker' provisions prolaof the Labor TOTAL:
fA
Code,you=at forthwith comply with such provisions or this permit shall be BUILDING FEE
W > deemed revoked.CONSTRUCTION LENDING AGENCY SEISMIC FEE
d Ihembyaffime that there is a coretrudion lending agency for the perform- TOTAL: ELECTRIC FEE
M Z ance of the work which this permit is Issued(Sec.3097,C1v.C.)
U O 1'refer'.Name PLUMBING FEE
F I'naer.Aaarcaa QTY. MECHANICAL PERMIT FEE
LL
MECHANICAL FEE
U I mrtifythat I have rend this application and atatethat(hn above information �T
C' W is mord.I agree to comply with all city and county ordinances and state laws PE-RMITISSUANCE �a'D� FEES PAID:
} (L relating tobullding construction,and hereby authotlze representatives ofthis
F.. N city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH.
? (We)agree to save,indemnify an d kap harmiea the City of Cupertino Date Receipt#
U agairuthabilltim,pdgmenr, sand expenses which may in anywayacaue AIR HANDLING UNIT UO 10,000 CFM) SUBTOTAL:
ag.mst�ai�d�ty in segue (the granting of this Permit.
r/./12 �� 16 AIR HANDLING TT(OVER 10,0 OCFM) CONSTRUCTION TAX
SignatuYc of AppRant/Contractor D.4 IXHAUS7HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOS RE
Will the appBmtorfutum building occupant store or handle ha,candom HEATING UNIT 1fA,000BN) �� Date Reef IN
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I lealth and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yrs No
Will lheapplicant Sam building occupant use equipment or devices VENIILATION FAN(SINGLE RESID) IS3UM!-ZE DATE
which coil hauraous air contaminants as defined by the Bay Arca Air
Quality Management District? BO[LER-COMP QFI'DR IOD,OfD BTU) •Cv JUL 31 1990
Yes No
M1ave read the Mau sus modeiaisrequirements 5,2553under.Chapter&9i of BOILER-COMP(OVER 100,000 BTU)
the ersta d la Health&Sa fety Code,not
25505,ve at nan,that.I
undersand that if the notify the ing occupant oat a currentlyhavewhich
that its et NEW RESIDENTIAL MECFT. SQ.FT. Cit ('t Tomos Itln
responsibility to Issuance
notifytheic to of ofthercqulremnntswhich must be met
prior m Issuance of Certificate o(Occupanry.
Owner or authorised agent Date
TOTAL: ISSUEDB .
Q,
1
I OFFICE COPY