23109 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
-Building Preen identification PFRWTNO.
Building Add PoPG e zone s0 23109
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CITY OF CUPERTINO-BUILDING DIVISION Z �GO
'c °' Na N ' APPLICATION / PERMITBUILDING-ELECnUCAL-PLUMBINGMECMNICAL CATEGORYL Y
Arch11M/Eng(nser. Lir.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ 1:1E]LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that lam lkmsed under prcwbloneo(Chapter9(mmmrn
APPLIANCES-RESIDENTIAL -OBDESCIN
ing Mth Se on7000)of DiWsien3of(he Susinessand Pmfn onsCode,andmy
limens is in ha foto:and elfM. _` PANELS N s OUT' s
Limn97dv�
Date -' Contractor
ARCHITECTSDECLARATION 00AMI'S
0 CO I understand my phns ehaH be used u public records OVEROVER 1000 AMPS SQ.Ff.FLOOR AREA 5/SQ.FT.
E o(� Licensed Professional SIGNS ELECTRICAL
G� OWNER-BUILDER DECLARATION SI'ECIALCBCCUIT/M1SC
Zp, a Ihereby affirm that l am exempt from the Contractor's Lim..Lw for the
pppp following reason.(Section 70115,Business and Professions Code:My city or
cmntywhichrequlrcsapermitiocmwtructaiter,impmvgdemoiLsh,ormpalr T�I''MECER OR 1101,11 INST.
'y anystmdurt pdort°Its Womm,aleorequlmathe applicant fmsuch permitto �+' Y a
file a signed exte.ment that he Is Emoted pursuant to the provisions of the ]OWER DEVICES C
3mContractor's Llems.Law(Chapter 9Lcommencingwith Section7000)ofDivl- BWIMMINGPOOLELECTRIC DA - Z-'
EOS alod3 of the Bueinesamd Preefeaslmu Code)orthm he is exempt therc(romand VALU TION
the basis for the alleged exemption. Any violation of Section 70)15 by my
OQ appllcantfora permit subjects the applicant to a civil penalty elect morethan OU7i'E'fS'"WI'ICFIGSII%TURGS
Ove hundredsowner
the pro NEW RESIDENTIAL ELE-CTR_SQ.Fr. SOMES� TYPE CONSTRUCTION
�n ❑I,ea ow.r of/M property,or my employees with wages as their sole
compensation,will do the work and the st.ctu re is not Intended or offered for
O sele(See.7044,Business and Professlo.Code:The Contractors License Law
S$ docs not apply to an owner of property who build,or dmproas thereon,and
H who donsuch work himself orthrough hisown employees,provided that such OCC.GROUP RFS UNITS
Improvements am not Intended or offered for sale.If,however,the building or TOTAL;
improvement lasold within oeyearof compietlon,the owner-builderwill have
tl'g,�urdm ofpmving that he did not build or Improve for purpose ofeale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
U L as owner of the property,am exclusively contracting with Iimnsed PERMITISSUANCE
contact..to mnstmn the project(Sec,70K Business and Perceived..Co : Uy
The Contractor.Limas Lew don eat apply to an..or of property who ALTER-DRAIN&VENT WATER(EA)
Wilds or Improves thereon,and who contracts for such pCajecb -with a FEE SUMMARY
off,
Hermad pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
I_I I am exempt under Sec. g &P C for this reawn
Fee.
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEIPTs .111.WORKMAN COMPENSATION DECLARATION RE&PER TRAP ECIi00LTAX Y N
rb-by a((Ithat 1 have a ceflmconsentrtlte o!consent to self-insure,,ora RECEIPT I
certificate of Workers'Compensation leau nem or a mrtlfled mpy thereof(Sec. CAS F.A.SYSTEM-1 INC.40UTLErS PARK FEE Y N
3300[ab RECEIPT#
Ce Y_ y�n��.— I GAS EA.SYSTW-OVER 4 CEA)
Com arae rl BUILDING OI VISION FEES
�CertlBed copy b herebyfurnished.the city CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
�jJrrred mpy V(lied with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-SMRM EA.200FI'. Date Recei t#
(rhlsmnion need not be completed If the permit is forms hundred dollars
(Y100)mless.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I certify that In the performance of thework forwhleh this permit b issued, r —
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
z Z Applicant NEW RESIDENTIAL PLMB, SQPr. Date ReceI till
Z (7 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
Hshould become subjen to the Workers Compensation provide. fthe Labor TOTAL:
cN Code,you must forthwith comply witheuch provlslons or this permit shall be
j deemed revoked. BUILDING
CCONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby a(lirm that there is a construction lendingagency for the perform ELECTRIC FEE
Z mceottheworkfor which this permit is lasued(See.3097,Civ.C.) TOTAL:
00 Tenders Name PLUMBING FEE
LLL) )<n Adam. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W ImAlcertlfythatlhavercad thlsepplimtlonend a atethattheabove Information
1 Is correct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} relatingtobullding construction,and hereby authodze representative,ofthis -
1— U) city to enter upon the above-eventbnad property for inspection purposes. ALTER OR ADD TO MECH.
Me)as.m save,Indemnify as d keep harmless the City of Cupetlno Date Receipt#
t, against Blies,judgments coksa x aseewhlcilmaylnany yacaue AIRHANDIJNCUNrr(TOL0,000CFM) SUBTOTAL:
Xi thio pemyt
// AIRHANDLINGUNrr(OVERIa 0OCFM) CONSTRUCTION TAX
�Jgfiaterreof Appll of r ate EJOIAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
ZZARDOUS MATERIALS DISCLOSURE '
Will the applicant orfuture building occupant store or handle hazardous HEATINGUMT(TOI00,0)0BTIA Date Recel t#
material as defined by the Cupertino Municipal Code,Chapter 9JZ and the
IIe❑alt Yaannd Safety Coe. de Section 25532(x)? HEATING UNIT(OVER]00,000 BTU) TOTAL:
Will the applicant NWe,building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUpt,IVRATE
which emit haardous air contaminants.,defined by the Bay Area Air I7!'' 66YY
y ality Management District? BOILER.COMP GIIP OR 100,(00 BTU)
Ye, ❑Ne DEC 1 s 1991
ave read the fiazazdous material+retrylmmcnls under Chapter 6.95 of BOILER-IbMP(OVER 100,000BN)
the Celifernla I lealth&Safety Code,Sections 2550.5,25533 and 25534.I
understand that It the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECIi. SQ.IT
responsibility to notify the occupant of the requirements which must be met t. CIJI'tHl
'- prior to Issuance of a Certificateo(Occupanry. ^IIY V
Owner or authorized agent Date - TO'rA L: ISSUED BY\1 !i^�
' ,�L!!w�
OFFICE COPY