23902 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro cc,Identification PERMITNO.
Building Address: 0PrKC�-e S1. 23902
nems_time: one: - A A
LU CITYOFCUPERTINO-BUILDI G IVISION
""' cnntano:aNa[�e Lie.N. APPLICATION / MIT
a' N a BUILDINGELECTRICA 1 C-MECHA CAL CATEGORY CONTROL N
Architect/Engireser. Lic No:
L_ A BUILDING PERMIT INFO
} Z2962 C1QwtT� 'a—A qtr No-
QT" ELECFR CP RMIT FEE .
Address PERMIT ISSUAN ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby
ectionaffirm").f mBcensedunder heBusiemandMofChapter C(rommme- MI'LIANCES ENTUL JOB DESCRR'iTON
Ingwlth 1 fon 7000)of Dl effect oftheguslnessand Pro(ndoneCmde,and my � ��/)
Bcenu'�In fulWr�E aerreat. & t ./ PA //
07 8-j-11
Lim CC for
I_Lic.N 7 1y
Date_ ( Contractor
ARCHITECPS C ORATION 1-1 AM
MCO lunderstand myplaresshallbe used as publierecords. ER1000 SQ.IT.FLOOR AREA S/SQ.FT.
Ztj Licensed Professional SEL - -
6 OWNER-BUILDER DECLARATION SPECIALC T/MI
t.., 7 Ihcmhyaffirm that am exempt from the Contractor's License Law(or the
OOO,9 following reason. 9031.5,Business and Professions Code:Anycityor TEMP.MEIPROR LEINST.
county which requiresa pemdttocorotruct,alter,impm re,demolish,orrepair
q;4V'6 anystrmture priorto its Issuance.alsomquirestheappliant forsuch permit to POWER DEVI
E I V file a signed stater not that he is licensed pursuant to the provisions of the
3q
Contractor's License Law(Chapter 9(commencing with Section 7000)of Dwl- SWIMMI ' IpOL ELECTRIC VALUATION
O Mon3 ofthe Buslnessadl ProfesilonsCode)orthat hers exemnt therefmmand aO a 00
p S"$ tM1e baste far the alleged exemption. Any violaBon of Sxtio7lli15 by any SWI.ICHESFIXTTJRFS
4S� appBantfora permit subjects the applicant to a civil penalty a not more than O
five hundred dollars($500). RESIDENTIAL ELECTR SQFT.
$ STORIES TYPE CONSTR(1CTION'
.-�n ❑I,as owner of the property,or my employees with wages as their suis
mm(Sm.7 K Be,[o and Pr.and Neswcwrehe Contractor.o License
��p vie LFc.7064,BuaineM.s and Profeviov Cade:The Contractor's Llcertc law
�S$ does not apply to an owner of property who Wilds or improves thereon,and OCC.GROUP RFS.UMTS
whodoessuchworkhkrsseBorlhmugh hisownemployess,providedthats ch
Improvements are not Intended oroffered formic.I(however,thebulle ing or TOTAL:
improvement issold withinoneyearofcompleiogtbeowner-W Bderwiilhave
tbalt+rdenofpmving that he did not Wild or improve for purpose ofsals.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
comrstow to construct the project(Sec.7014,Business and Professions Code:
The Contractor's Licens law does not apply to an owner of property who AL RAIN&VENT-WATER(EA)
Wilds or Improves thereon,and who contracts for such prajets with a
egtt ador(a)licensed pursuant to the Contrador's License Law. BA .D c FEE SUMMARY
LJ I am exempt under Sec. B&P C for this reason
Owner Date -
DRAINS. R:ROOF,`A"C9ND.1 SANITARY RECEfPI'N
• _ 1 J
WORK MAN COMPENSATION DECLARATION FD(TURES PER TRAP SCI OOLTAK Y_ N
711 hereby affirm that I have a certl0ate of consent to eel!-Inwre,ora RECENT N
certRicme of Workeri Compensation Insurance ora certified copy thereof(Sec.
3800,Lab C.) GAS•EA.SYSi&kbsll BYC.40ITIL PA FEE Y_ N_
Policy N .. —_ RECEIPT N
Com any GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION F.ES
ffCertNed copy is hereby furnished. CRGASC/INDUSIRL WASTE INTERCEPTOR PLANCI IECK PE
❑Certified copy Is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANRARY-STORM EA.2(IOF I'. Dot 1 (#
((hisseetion need not be completed tithe pewrit is forone hundred dollen
($100)or I.) WATER HEATER W/VENT/ELECTR ENGRCYFE N_
1 esnily that N the performanceof the wmk for which this permit is issued,
I shall not employ any person in any manner ao as to become subject to the WAT R 5YS EM/TREATING
Workers'Compensation Laws of California. Date PAID_
O Z Applicant NEW RESIDENTIAL I LMB. �F. Rete] t#
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
should become subjed to the Workers'Compereuticn provisions of the Labor TOTAL:
P: U) Code,you most forthwith comply with such provisions orthis permit shall be BU 'D .J
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEI 'E
d I hereby affirm that there is a construction lend ing agency for the perform- TOTAL: ELE GFEE
Z anceofthe work for which this permit is exceed(Sec.3097,Civ.C.) PLUMBINGP
(� O 1<nder'o Name
H Lender's nddrcsa QTY. MECHANICAL PERMIT FEE MECHANICFEE
OW 1cortifythat i have read this application and Rate thatthe above information
1 iscorred.l agree to comply with all city and county ordinances and state laws PERMITISMIANCE FEES PAI[}
} relating to building moutmeion,and herebyauthcoluerepresentativesofthis
H W city to enter upon the above-mentioned property for Inspection purposes. ALTTRORADDTOMECH.
_ Zpcni. Date Receipt#
(We)agree to save,lents cosy and keep es whibaronch
the City of syaceme AIR HANDLING UNIT(TO 10,000 CFM)
V agalrut llabllltks,judgmentM costs and expenses which may In anywayaceme SUBTOTAL:
agalm sea Cityl mnsaR�pxeofthegranth ofthlspem,B. CONSTRU ION TAX
!_1LJ\y AIR HANDLING UNH(OVER 10,000 CFM)
Igvturc of Appllant/Contra ate
EXHAUST HOOD(W/DUCT) CONSTRUCFVTAX :
HAZARDO MATERIALS DISCLOSUREWill the applicant orfutum bulldingomupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Datematerial as defined by the Cupertino Municipal Code,Chapter 9.12,and theHealthandSaldyCodeSetion25532007 HEATING UNIT(OVER 100,000 BTU)
❑ Yes D No
Will the applicant or future building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE D
1111'.
which emit hazardous air contaminants as defined by the Bay Area Air
Qu a lily Mawgemcnt DkWt7 BOILER-COMP pFR'pR 100,IXq BTU) P\ q
4Yo g No li- PSI
havercadthe havrsuusmaterials requimmentsunder Chapter 6.95o! MOILER-COMP(OVER 100,0(DBTU)
the California Health&Safety Code,Sections 25505,25533 and 25536. I
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL METH. SQ.FT JUN 26 1992
responsibility to notify the occupant of the requirements which most be met
prior m Lssuance of a Certiflate of Ocmpanry.
CI I Y LIr I/Lif LII I IHV
Owner or authotved agent Date ISSUIiD BY _
TOTAL:
OFFICE COPY