23670 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building project Identification PERMIT NO.
Building Address/ phdr z 23670
a• aa(�mpel:(q, one:
CA II`JNqbMI I IAL VA 11,
lei 6 CITY OF CUPERTTN0.6UILDING DIVISION -�
c° °� N'^e0 I/ sac. °� APPLICATION /PERMIT
' V BNLDINC-ELECTRICAL-PLUMBING-MECHANICAL CATEGORY CONTROL M
ArchlM a,Engineer. Lk.No:
QrY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:hereby
PERMTISSUANCR ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION wherebyim,7Dffirm thmlam.I.m3 d under ftheBuprovisionsm Cssi=s ode and APPIdANCESRESIDENfUL JOB DESCRIPTION
Ingwlth5ecilon 7000)of Dlvfect. ofthebuelnmandProleeslondCode,and my
Iimnse le In(u ( effect rr^ PANELS �" —" t O'T' // /• �'//�L/
Limn h 4 J Lite. 7 ' tt G V J 111///VVV
Date Contractor
ARCHITECTS DECLARATION 7014000 AMPS
D O I understand my phms.Fact be used as public exceeds. OVER IOOO AMPS SQ.FT.FLOOR AREA $/SQ.FT.
ly� LI...d Ptotmiorul SIGNS ELECTRICAL.
OWNER-BUILDER DECLARATION $PF-CULCR(CUIT/MISC
1herebyafOrm that l am exempt from the Contractor's License Law forth, ..
pp following reason.(Section 7031.5,Business and profession,Code:Any city or
O y"' TEMP.METER ORPOLE!NST.
PM cmntywanystmhmpflolto lt. raeaLso rvuirestheaprovgdemouch,erreito
any stmcture statement
that
he gaisensed pursuant
to the
providers
of t e POWER DEVICES
O Bleu actors statement that he is ril(codencing to the proWlons of the
Contractors License law(Chapter9(commencing with Section 7000)of Divl-
E sion3ofthe Buslnmand ProfesslonaCod0orlhat belsexempttherefromand SWIMMING POOL ELECTRIC VALUATION
Gthe lash for the alleged exemption. Any violation of Section 70315 by any OUTLETSSWITCHFSFI%'IURES
appllmnt for a permit subjects the applicant to a civil penalty of net comethan
p� live 1,as
nerofthepro NEW RESIDENTIAL ELECTR SQ,FI', STORIES TYPE CONSTRUCTION
Cd dollars($500).
❑I,a.owner of the property,°r my employees Is with wages r their dole
c 1.(Sec.7042 Businetier will do thewoek,andlhe attude:TheC .tended or.".L offered w
O or
dile(Sec.apply to Business and f property
rops ty Code:The C improves License Law
$ doesoes set such torn owner offprough hisonemporlmprwmthercoryand OCC.GROUP RES.UMTS
.hedoes work himself edoor reugh hleowne.If,hoea,pr theb that such or
Improvementsarenotintended earofc forealn If,however deer ilI have TOTAL:
Improvement iseold withinoneycarofcomplelion,the owner-bullderwlllftave
tll0kurdenof proving that he did not build or improve for purpose ofsele.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
U L as owner of the property,am exclusively contracting with licensed PERMIT 158UANCE ,1
contractors to construct the project(Sec.7044,Business and Professions Code: r
The Contractor's License jaw does nm apply to an or of property who ALTER-DRAIN&VENT•WATER(BA)
build@ or impmvn thereon,and who contracts for such p(upcts with a
cqulfactor(s)Licensed pursuant to the Contactor'•License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec B h P C for this eeasem
vrrq
DRAINS-FLOOR,ROOF,AREA,COND. SANITARY Y N-
• Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION m FIXTURES PER TRAP S(7100L TAX Y N
crcby,(firthat I have a certlBmte o!consent m•el(-insure,or RFCEB'T M
malflmteof Workere Compensalimins mncemacenlf4 mpythemf(Sec. GAS EA.SYSTEM@INCA OUTLETS PARK FEE Y N
3800 lab C.)
pwtl RECEIPTp
Cra
GAS EA.SYSTEM-OVER 4(FA)������mPPPPPPanv_ I BUILDING DIVISION FRES
Certified copy is fieri with the
cR. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy Is filed with the qty Inspection division:
CERTIFICATE OF EXEMPTION FROM WORKERS' GRE'A'SE TRAP PAID
COMPENSATION INSURANCE
(This section need CnotO be completed If the SURA isTorous hundred dollars SEWERSANITARYSTORM EA 700FT Date Recei t#
0103)orlm0 WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I certify that in the performance of the work for which this permit is isseed,
1 shall not employ any person In any manner so as to become subject to the WATER SYSIFM/TREATING
Workers'Compensation laws of California.Date PAID
ZZ Applicant NEWRESIDENTIALPLMB. SQ,FT. Date Recei t#
Q NOTICE TO APPLICANT.If,after making t his Certificate of Exemption,you
Pshould become subject to the Workers Compensation provisions ofthe Labor TOTAL-
CC
W Code,you=at forthwith comply with such provisions or this permit hall be
LU > decreed revoked. -BUILDING
dCONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that thereis a mmtructlon isnding agency for the perform- ELECTRIC FEE
M Z ance of the workfor which that perMt le Issued(See 3097,Civ.C.) TOTAL:
V O lander.Name 299 PLUMBING FE
LL I— Landers Address QTYJ MECHANICAL PERMIT FEE MECHANICAL FEE
OW Imrtifythatl have read thisappllcnion and statethatthe above information
1 Incorrect.Iagree tocomplywith all city and county ordinances and state law, PERMITISSUANCE FEES PAID:
>. relating tobullding conshuctlon,and hereby authorlee expeeaentatNes of this
1— Z - city to enter upon the abovemotioned property for Inspection purposes. ALTER OR ADD TO MOCK
V Z (WI)agreelosave,indemNfyand keepharMessthe Cltyot Cupertino Date Receipt#
against he i<t ,judgments,costsand expenses which may In any ya AIR HANDLING UNIT(PO I0,000CFM) SUBTOTAL:
again aid c ue
eqnm ( e I ?this pennil/J
AIR HANDLING UNIT(OVER IO,000CFM) CONSTRUCTION TAX
S mo Applicant o Ira oe Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
RDO SMATERIALS DIS CLOSURE
Will the appllm or(ulure hullding ottvpant store or handle huardoue HEATING UMT(TO 100,000 BTU) Date RBCei t#
material ad defined by the Cupertino Municipal Code,Chapter 9.17,and the
I l,.It Yzansd Safety CodcSSeic
ilon 75537(1)1 HEATING UNIT(OVER 100,000 BTN TOTAL:
W[lithe applicant or❑❑future bulldlegoccupant use equipment ordevices VFNIIIATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit haxadous air contaMrem...dr6red by the Bay Area Air ^ B
. ality Management D❑istrict? BOTLER-COMP OHPOR 100,000 RTU) A
Y:a M No
TMfcmad Health
L out malee,Se tions2menisunder Chapter.1 of BOILER-COMP(OVFR 100,000 BTU)
the Callfomlallef thebudfengdoes Sect currently
have
a tenant,
SEP - 4 1992
resp.rdeonsibility
that notify the occupant notm requiyments tenantthat it be
sut NEW RESIDENTIAL MECFL SQ.IT
rmponslblllty to notify the occupant of the requirements which most be mel
prior to Issuance of a Certificate of Occupancy.
CITY Uh wrtn3 luu
Owner or authorised agent Data -TOTAL: I ISSUEDBY:_
OFFICE COPY