19832 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
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Building Pr^Icn IJentlfkatimt //''Tk /� • r, PERMITNO.
Building Address: �� 7 ul a�L'/} .E
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E f1JR? ✓ 1Q Eiyb"S�� CITY OF CUPERTINO-BUILDING DIVISION
ceno-a#era Name: Lic.Ne: APPLICATION / PERMIT 3-9--90
I'L'K BUILDINGELECTRTCALPLUMBING-MECHAMCAL CATEGORY CONTROL
Architect/Engineer. Lic.No:
QIY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PIRMITISSUANCE ❑ ❑ [1LICENSED CONTRACTOR'S DECLARATION
IhthSyion7OOO) fDiAsiI am en3ofthe ur ne rslonsof Chapter9(mmmmc APri]ANCESRESIDEMIAL Og pp�c Rpry3pN OW`
InenseISe#ion 7000)of Di effect o(thegualnenand l'rv(essionsCode,and my ^r'� V. �'L50 �(
license b in ruB force ane erre#. PANELS
I
License Clan Lie#
Date Contractor or UP TO 2DOAMPS
201 IOOO AMTS /Y
ARCHITECT'S usedDECLARATION OVERIOOOAMPS SQ.FT.FLOOR AREA E/SQ.FT.
(�rc0 7O I understand my plea shag be used u public recwda
a d o Licensed Professional SIGNS ELECTRICAL
Qaw OWNER-BUILDER DECLARATION I
In Z FA SPECIALCIRCUIT/MISC
Ihercby affirm that Iam exempt from the Contractor's License law for the
7 0..'- following reason.(Section 7 31.5,Business and Professions Code:Any city or r"'\
OZI.e TEMP.METER OR POLE INST.
county which requires a permit to construct,alley improve,dernolish,or repair
E [B< any strumare prtorto ib tswance,also rcqulrcslheappBceN(w such pertNt to POWER DEVICES t 1
E 4l Ole a signed sumenrm that he is;licensed pursuant to the provVlom of the
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Contractor's Llcere,Law(Chapter 9(commencing with Section 7000)of Divi- -
30r slon3ofthe Buss and Pro .W.Code)orthathebexem themfmmand gWBdMING POOL ELECTRIC _J� I VALUATION v
the bas's for the alleged exemption. Any violation of Seetlon 7031.5 by any OUTLETSSWITCHFSFTXTURES
O
applicant fora permit subjects the applicant to a civil penalty dna rnorethan r
five hundred dollars($SD0L i 1
pq I,as owner of the roe or m employees with wa es as their sole NEW RESIDENTIAL ELECTR SQR. A` S DRIES MISCONSTRUCTION
W^ ❑ e property, YB -'
Q, compensation,Businewill do ss
I' essimnd the atructere Is de:The ot intendedContactor orceremLaw
� p
to(See.apply
to alnowner property Code The or improves
themone Law / \` 1 f fes/
g whodossuchtoanownerapropertywho Wtidsorimprovvided soRand �� 1Y V 6f OCC.GROI/l' RIS.I1NIl5
c-$^ wpro, csasam khimsededorough hlsowne.If,hoevrovidedthatsu or 7
Impeovemenbsold withinomyo offered for rofcompleto l(hower-WWerwilI have TOTAL:
Improvement bsoid within one ycarofcompletloMtheowner-builderwill have
tl)Ljirden of proving that he did nor build or improve for purpose ofsale.). QTy, PLUM TNG PERMIT FEE FLOOD ZONE APN
u L as owner of the property,am exclusively,contracting with licensed rFRMI.T.ESUAN
contractors to construct the project(Sec.7074,Busmen and Profession Code:
The Contractor's License Law don not apply to an owner or property whoALTER-DRAIN kVENT-WATER(EA)
build&or Improve thereon, and who coarsens for such piejecb with a FEE SUMMARY
cBernardi+ctor(s)Bernardi
pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
L j I am exempt under Sec B k P C fee this reason
Owner Date OUT SIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
RECEQT#
WORKMAN COMPENSATIONDECLARATION FIX'NItES PER TRAP SCHOOL TAX Y_ N_
❑i hereby affirm that I have a certificate of consent to self-Insure,ora RECEB'T#
3800,llAb C.Workers C^mpewtionlnsunnce oracertified ropy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,lab C.)
RING DI#
i'ollq p CAS FA.SYSITTf-OVER d(Fit) BUILDING DI VIS ION Fii ES
Com any
�Certl copy b herebyth the city GREASE/INDUSI'RL WASTE INI'FRCEPTOR PLANCI-HICK FEE
Certified copy b filed with the#t4,lnspetion division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date Remi t#
(fhb section need not be completed if the penNt b fer one hundred dollars
($100)orless.) WATER HFATERW/VENT/ELrCTR ENERGYFEE Y_ N_
1 certify that in the performance of the work farwNch this pennB Is timed,
I shall not employ any person In any manner w as to become subject to theWATER SYSTEM/TREATING
Wwkcri Compensation Gws o(Call(ornla.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ.FI. Date Recei t#
Z O NOTICE TO APPLICANT:If,ofter making this Certificate of Exemption,you
h' should become subject to the Workers'Compensation provisions of the Labor - TOTAL:
N Code,you most forthwith comply with such provision or this permit shall be BUILDING FEE
LU j deemed Invoiced.CONSTRUCTION LENDING AGENCY SEISMIC FEEAm
tL Ihercbyaffirmthat there is a construction lending agency for the perforce. ELECTRIC FEE
Z ante of the work for which this permit is Lssaed(See.3097,Civ.C.)
V TOTAL:
O lander.Name PLUMBING FEE _
14, f tender's Add rues QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U I cert ify that T have read this application a rad state that the above Information
O W .correct.I agree to comply with all city and munry ordinances and state laws PERMIT ISSUANCE FEES PAID:
0. relating to building construction,and hereby authorize representatives of th is
I— I) city to enter upon the above.mentioned property for inspection purposes. ALTERORAODTOMECH.
Z (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Recel t#
V
against liabilities,Judgments,mks and expenses which may In any way accrue ATR HMA I)LING UNIT CFO 10,"GEM) SUBTOTAL:
against said City In consequence of the granting of this permit. CONSTRUCTION TAX
Elft IiANDWNG UNIT(OVER I 0,01)(I CFM)
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applies nt orfuture building occupant store or ha rad le hazardous HEATING UNIT(TO 100,=BTI!) Date Reeel t#
material as deo ned by the Cupertino Munl#pal Code,Chapter 9.12 and the
Iieallh and Safe ode Section 25532(a)i HEATING UNIT(OVER 100,W0 BTI) TOTAL: L-t 1
❑Yn No
Will the appllesnt or re building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSIATE
which emit havrdous air conlamlnsnls as defined by the Bay Area At,
Quality mgen
Maralrirt7 BOILER-COMP OLE'OR 100,000 BTI)
W7 Yea ���No 0 g 1990
the cmadtheha ous materials requirements under Chapter 6.95 of BOILER-COMP(OVQt1013,000BIV)
e California Health k Safety Code,Sediore 75505,25533 and 75534.1
understand that lithe building does not currently have a meant,that it is my NEW RESIDENTIAL MECH. SQ.Fr.
responsibility to natty the occupant of the requirements which most be met
prior to issuance of a Certificate of Occupancy. ''oo e�
Owner or authorized agent Date TOTAL: ISSUED BY: U Ve—
'HOZ V is-a+aZ
OFFICE COPY