23317 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildinX Project Identification PERMITNO.
Building Addicts—^ LW 23317
tl�—
Jilhone: q A
neV amaA12.116 CITY OF CUPERTINO-BUILDING DIVISION
Contractor's Name: L N : APPLICATION if PERMIT
S C.R21/ L O 6 k BUILDINGELECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL#
Architect/Engineer. Lie No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE �' Ly is � ❑
LICENSED CONTRACTOR'S DECLARATION i�J
affirrin a licensed Wonsoffmaimsr9(commove. APPLIANCES-RESIDENTIAL JOB DESCRIPTION
It. .i in
Di vislmn3oHheguslnessand PmfnalonaCode,and my
license is In fun(o end erred. y PANELS
Lire Cls Lictl 52IO a�fe R
Date Contractor UP 201 TO 2DOAMN
MP5 "'� '� •�
ARCHITECTS DECLARATION AVER 1fA0 AMPS E/SQ.FL
^Z W e understand my plansahaB be used as public records. J A'L ly
�2rv1�i�j Licensed Pmfemloml SIGNS ELECTRICAL p /l
C POT F1
OWNER-BUILDER DECLARATION \/'-..--�-
{-n SPECIAL CIRCUIT/M1SC V
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason.(Section 7031.5,Business and Profealons Code:Any cityor 'TEMP,METIX ORPOLE INST. 3 1�
O Ep'u� cauntywhichmquiresapemattocomtmdaiteglmpmvedemlRh,orrepalr E
4,`S
-U,
anyatndu priorroiu ismancgals0 quireatheappenntforsuchpen ito
EEY RAWER DEVICES
a0 U file a signed statement that het emceed pursuant it the provisions of the
�a Con3oftheLicense Lwrodeseer9(commencing)orthathatexSection
mptthe00of Dtvi-mandIQ�TY.
SWpiMNG]OOLELECTRC VALUA�ON
O eian3of the Buelnevmd Pro(eml0m C0de)ortha[hely exam ihercfromand �
Sn the basis for the alleged exemption. Any violation of Section 70315 by anyOUTLETSSWHCHFSFIXTURFS 0 O�
<$ appewnt fora pemutsubjectsthe applicanitoa civil penaltyofnot morethan
five hundred dollars(5500). NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
nI,as owner of the property,or my employees with wages as their sok
t compensation,will do the work and the structure is not intended or offered for
5 O sale(See.7064,Business and Professions Code:The Contractors License Law
pj $ does not apply to an owner of property who Wilds or improves thereon,and OCC.GROUP RIS,UNITS
EE who doessuchworkhlmselforthrough hisownemplcyees,provided that such
Improvements are not Intended oroffered forsale.If,however,thebuilding or TO
Improvement hisold withinomyearofcwnplet Ntheowner.WMerwlll have
I"rienofpmving that he did not build or improve for purpose ofuk.). PLUMBING PERMIT FEE FLppDZONE APN
LI I,as owner of the property,am exclusively contracting with licensed t PERMIT ISSUANCE
contractors to mnawct the project(See 7064,Business and Professiosu Code:
The Contractor's License Raw does net apply to an owner of property who
Wilds or Improves thereon,and who contracts for such projMs with a ALTER-DRAIN&VENT-WATER(EA)
,,ntI)�fIactor(s)licensed pursuant to the Contractor's License Law, FEE SUMMARY
LJ I am exempt under Sec. B &P C for this reason BACK FLOW PROTECT.DEVICE,
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N .-
Owner Data RECEIcI"p
WORKMAN COMPENSATION DECLARATION FIXTURES-PER TRAP SCHOOL TAX Y_ N_
❑I hereby aflinn that I have a certificate of consent to self-Inare,ora RECEIPT#
certl0nte 0lWorkera COmperwtiOn Wurance oracertified ropy thereo((Sec. GAS EA.SYSTEM-11NG6 OUTLETS PARK FEE Y N
3800,Lab C.) —
Policy B'
RECEr M
Company
tl GAEA.SYSTEM-OVER d(EA) BUILDING DIVISION FEES
S ified copy is hereby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy I9 filed with the city Iraptlon division.
CERTIFICATE OF E%EMPEION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.2WFr. Date RCCCI (#
(This section need not be completed if the permit bfw ane hundred dollars
%Iffl)or less.) WATER ETEA]FR W/VENT/Fr Ff.I.R ENERGY FEE Y_ N_
I certify that In the performance of the work forwhlch this pemnit is issued,
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Workers Compensation Laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQFr. Date Recei t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Compeceat)on provisions of the Labor TOTAL:
N Code,you at forthwith complywith such provlsimumrihis permit shall be BUILDING FEE
deemed revoked.
W CONSTRUCTION LENDING AGENCY SEISMIC PEE C
CLI hcrebyaffirmthat there b a corutnctton Nndingagenry for the perform-
F3 TOT L ELECTRIC FEE
M Z ance oftheworkforwhichthispermit bbsued(Sec.3097,Civ.C.) ��
02 Lenders Name TY. MECHANICAL PERMIT FEE PLUMBING FEE
LL I- Lenders Address Q MECHANICAL FEE
OW Imrtilythatl hovereacithisappncationand state that the above Information �.
C correct.I agreetocomplywlth alletyand muntyordinancosand Gate laws PERMIT IS5UANCE FEES PAID:
>- relating to building construction,and herebyamhorlaerepresentativesofthts
I.- N city to enter upon the above�mentioned property for wp tion purposes. ALTER OR ADD TO MECH.
? (We)agree to save,indemnify an d keep harmle s the City of Cupertino Date Receipt#
V against lWbilltle,,rydgments,coatsand expect inanywayacene AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
a Witold t con ecce ofthe a of 'con".
g' yrs a°4," g a AIRHANDLING UhTr(OVER 10,000CFM) CONSTRUCTION TAX
C �-�/R' L
Signature of Applicant/CoNracmr Date EXHAUS"r HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant store or handle havaniom HEATING UNIT(TO 100,000 BTU) DateRCCCI t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the - -t—
Healthand Safety Code Stion2S532(a)7 HEATING UNIT(OVER 100,000 BT1A IOTA b
n Yes �No ,ate
Will the applicant orfutum building occupant use equlpmvnt or devices VENTILATION FAN(SINGLE R 0) �— IsSPNDATE
which emit harardoua air contaminants as defined by the Bay Area Air
')lity Management District? BOILER-COMP OHP OR 100,IX00 BTU)
Yea FEB 18 1992
havread the hazaY Na nat0riala requiremenb under Chapter 6.95 of IIOILGR-COMP(OVQt 1(A,000 BTU)
the Califeomla Health&Safety Code,Sections 25505,25.533 and 25536.I /
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. sQFr Y —
raponsibihty to notify theopant of the requirements which must be martCITY Ur vllf�nj 'Y1 '� �
prior to issuance of a Certificate ofOmupanry. ��/_'y/rn�
Owner or authorlaed agent Data
TOT155UIiD 137V.0
L: t
OFFICE COPY