23011 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildinK Project tlflotlon - PERMITNO.
Bulldmg Addres. - 23011
o - ti
k 7 ITY OF CUPERTINO-BUILDING DIVISION
Contracto'a Name: Uc.No: APPLICATION / PERMIT
1" CA'Ir RY CONTROL x ry
BUILDINGFLECTRICAL I1MB G-MEC}IAM AL /
_ ArchB EnRi r. Lk.No: 6 C 3
QTY ELECTR�CIVIERMIT FEE BUILDING PERMIT INFO
Address: f _ U1. P[Ith9T155(IANCE - .
❑ ❑
LiCENIIED CONTRACTOR'S DECLARATIO
Thereby affirm thatI son siolicensed 3.fthcunder provisloresofChapteril my AI'1'1-IA C DEM7AL JOB DGSCRB'f10NL
Ing with force
effect.
License
Buslnessand ProlesslonaCode,and my
license is Ia full force ana ic.0
License class Lk.N
Date Contractor 1000AM1S
ARCHITECTS DECLARATION
pWpW uO(Gj Z l understand my plam shag be u.ed m public records VER 1000 AMPS SQ�R AREA $/SQ.FT.
E z Licensed Professional
6, OWNER-BUILDER DECLARATION SPECIAL CIRCUIT
l hereby affirm that am exempt from the Cont ractor's Lkense law for the
following reason.(Section 70315,Bwiness and Professions Code:Any cityor
Kzl"'v9 county which requbna permit tomrotruct,alter,improve,derechah,orrepair TEMr.ME RI'OLE INST. .5
��� anystrammpriortoitsi ance,aborequireatheappBmntforauchpermitto POWER CES
file a signed statement that he is licensed pursuant to the provisions of the
�$ Contractor.License (ChapterLaw 9(commencin with Section AW)of Divl-
F OS skm3 ofthe Business and ProflomiCede)orthatt he is exempt therefromand S NG POOL ELECTRIC VALUATION
Y.' the basis for the alleged exemptrmn. Any violation of Section 7001.5 by anyG q
Q <5 UTLETSSWITCHESFIXTURES l ( � 60
�
applicant permit aubjMsthe applicant penalty of more than ! I
five hundred dolUm(SM. ��.
$ NEW RESIDE
MIALELECTR SNRT ® TYPECONSIRUC'1'ION
Zy ❑e saowner or the property,or my employees with wage as there sale'
C ¢
compensation,wiliclothe Business and k.andthes Cdtim In e:TheC ContraIntenctor's
Law
- '
55 O sale(Sec.apply
to
oanow andProfessions
property who
Wilds Contractors Llmnse law
whodim not such roan imserofprough his wnemsorfmprwested or,that and O .UNTfS
CC wuch am not msende Nrwgh hlsow d oroffered for ale.Ultowevravidedthargar
such
Improvementsissuld lnlendneyearfcomplelo theh er-builderwilI have 7 AL:
Improvement proving
within he eye notbuildorion,theeforp rposcrwillhave
tf`r�kurden owner
of the property,
na exclusively,
xclor lmprovefacting osth licensed
QTY. PLUMBING PERMIT
u L as owner tr the property,am emluaiv sines contracting Pr with B¢nsed PERMIT ISSUANCE
The Comm en construct the project(Sec.apply
Business and Professions pro om Code:
Ila Contractors License Lw does not apply tct an owner p property who
builds or improves thereon,and who contracts fm such PtojeM with a ALTER-DRAIN&VENT-WATER(EA) -
FEE SUMMARY
co 31 am exempt order
Sec tothe ContractorsLicense Law. BACK FLOW PROTECT.DEVICE
` LII am exempt under Sec. B&P C for this mason
OUTSIDE FLES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N `
Owner Date DRAINS. N
WORKMAN COMPENSATION DECLARATION FIXilR2ES PER?.RAP SCHOOL TAX Y_ N
E31 hereby affirm that 1 have a certificate of consent to self-Insure,ora - RECF]I'1'x
ceniflcate of Workers Compemation Insurance Ora certified copy thereof(SeG GAS EA.SYSTEat-1 WC.l OUTLET'S PARK FEE Y N
MOO,Lab Q RECFR'f N
cc M y GAS EA.SYSTEM-OVER 6(FA) BUILDING DIVISION FEES
cum an '
MotlBed copy 6 hereby famished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCI
❑CertBied copy is filed with the city inspection division. ,
CERTIFICATEPE EXEMPTION N PROMWORKERS' GREASE?RAI' PAI ( brz�a
COMPENSATION ATIONINSURANGE SEWER-SANITARY-STORM EA.2WFT. Date Rccei t#
(Thlssectlon need na be complacd B the permit isforom hundred dollars
($100)or less) WATER I fFATER W/VENT/ELECTRJB
ER 'EE Y N
I mrUfy that in the perfornance of the work for which this permit b issued,
I dull not employ any person N any manner so as to become subject to the WATER SYSTEM/TREATIN'G
Worker'Compensation laws of California. Date D
z Z Applicant NEWRESIDE1ITIALPLMIL TIQFT. Date Recef t#
Z U NOTICE TO APPLICANT:It after making this Certificate of Exemption,you
should become subject to the Worker:Cnmpemat ion provisiara of the Labor TOTAL: 6-0
cc Vl Cod,you rrwat forthwith comply with such provi9fon or this permit shall be W > deemed revoked. SMIC PEE a OCONSTRUCTION LENDING AGENCY tI hereby affirm that there Is a comtructfon lending agency for the perform- TOTAL: ECTRIC FEE
Z sure of the workfor which this permit is Issued(Sec.3097,Civ.Q UO )enders Name UMBING FEE
F- lender.Addrew - QTY. .MECHANICAL PERMIT FEE
LL U 1 certilythat l haveread this application and statethatthe above Information MECHANICAL FEE'
O is correct.I agree to comply with all city and county ordinances and gate laws i'FRMITISSUANCE FEES PAID:
} 11 relzeng tobullding construction,and hereby authorac representatives of this
N city to enter upon the above-mentioned property,for Inspection purposes. - ALTFRORADDTOMECH.
Z (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt# l,'j(^
V aga Inst liabilities,judgments,cotasnd expenses which may inanyway accrue AIR HA NDLING UNIT(TO 10,000 CFM) SUBTOTAL:
aga imt said City In consequence of the grading of this permit
• - NR HANDLING UNIT(OVER 10,030 CFM) CONSTRUCTION TAX •'
Signature of Applicant/Contractor Dace IXITAIJS'T HOOD ml DUCT) CQNSTRUCTION�T/IXP� D-
HAZA R DOLS MATERIALS DISCLOSURE G �=y__z -fy ;��,{"�(y
Will the applicant or future building occupant store or hand In havardous HEATING UNIT(TO 100,000 BTU) Date ReccI t#
moods as defined by the Cupertino Municipal Code,Chapter 9.12 and the
Hca lth and Safety Cod a Section 25532(a)? • HEATING UNIT(OVER 100,OW BTU) TOTA
❑ Yen , ON.
Wflltheapplimrt or future Wilding occupant use equipment mdevim VENTILATIONFAN(SINCLE RESID) ISSU{,NpjF Qct E- -
whichemlthazardousaircontaminantsasdefinedbytheBayAreaAir -
QualityManagementDistrict? - BOILER-COMPOHPOR100,OW BTU) 1.
Yes rcad ❑No ^
Ihavethehazardousmaterials requlrerrenlsunder Chapter 6.95of BORER-COMP(OVER 100,000 BTU) JUN 12 1992
the California Health&Safety Code,Sections 25505,75533 and 25531.1
understand that if thebullding don nor currently have a tenant,that it is my NEWRMSDENTIALMECA. SQ.FT
rnpomibdaylo maty the occupant oa regaemaMx
eemwrn mast .;,et CxIJY Ur laUrl:.
mpm
prior to Issuance of a Certificate of Occupancy.
Owner or authomed agent Date ISSUED BY_�/W� -
TOTAL:
OFFICE COPY