23306 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
HuildIng Project Identification - PEJOIUT NO.
Building Adders.:.
_ ' ?.ESULzs w� ,�,��� y 23306
wners me. . _ hone:
K t_=Fk3 U'itE l( CITY OF CUPERTINO-BUILDING DIVISION
co�n-tTrart�Inr1a�Nam��-a:1s,� a{ Lie,No: APPLICATION / PERMIT --
1 IT�eC3�krT 17040Ll T BUILDINr-aECTMCALPLUMBINC-MECHANICAL CAT RY CONTROL It
Archhcct/Engineer. Lk.Na;
` 3 '�` - - +' •' - - 'rBUILDINGPERMITINFO
- .QTY • ELECTRIC PERMIT , FLS','.' .t --
Addms: PFRMITISSUANCE _ �+
LICENSED CONTR CTO under rDECLA RATION
I hereby lrmthatlamlicm3ofthe erpravbeonsblesdonsCode,ammc A1'I'I.IANCESRESIDENIIAL JOB DESCRIPTION
Inense1 in
forceofDlW-%IF,14i;BuslneaandProtealovCode,and my
license Is in full force anQ p(fee1 s,V�i PANEL4
Date Cha C�V,IQti4 nu
Date ?•11-91 CHITEor DECLARATION
RMA Z`.•te p1-1BW AMPS
LIP IQ 2DQAMPS
ARCHITECTS euSD rubbcm ON SQ,Fr.FLOOR AREA— $/, .FT:
a0 O - I underaland my plan sluff be ueM a pubec rccards OVER 1000 AMPS SQ
(Cj Licenced Professional SIGNS ELECTRICAL '
6 OWNER-g U1LDER DECLARATION SPLCIAL CIRCUIT/MISC
7 (hereby affirm that l am exempt fromthe Contract oe.Li...lawforthe
pO following matter.(Section 7031.5,Business and Protections Code:Any city or
O Z i. TEMP.METER OR POLE INST.county .
anystm hichrequlmaapermitmancoa construct, lbh,orrctto
$mm any awtlure staortoltement
that
hecgaco sed pursuant t the foranlora of it a POWER DEVICES
S o'a file a signed rtce ns eLa that he b licensed uncing with
the provisions of the
FQj3O Contractor§Licencelaw(Chapter9(mmmencingwith� Seniorsof Divi- gWpdhgNrG POOL ELECTRIC�} �g sion3oltheBusincaandProfealovCode)orthathebexemptthemherefromand VALUATION
the hisb far the alleged exemption. Any Aolalion of Section 70HS by any OUTLETSSWITCHFSFIMRES
applicant for a permit subjects the applicant to a civil penalty of not neirethan
E pjo
five hundred delta.(S500), NEW RESIDENTIAL GLECIR IT.
QQ
E]1,as owner of the property,or my employees with wages as their sole SQ. STORIES TYPE CONEURUCUON
tcompensation,will d o the work,and the structure is net intended or offered for
5,J O sale(Sec.7044,B.sirma and Proleaiav Code:The Contractors License Law
!,3 does not apply to an owner of property who builds or improves thereon,and ,OCC.GROUT' RFS.UNITS
who docasuchwork him+elforthrough hisownemployees,provided thatstch
improvements arc not intended oro(lered for sale.If,however,the building or TOTAL:
impmvementissold withinoneyearofcompketlon,the owoerbuilderwill have .. ,
m�*rden of proving that he did not build or improve for purpose ofule.). QTY, 'PLUMBINGPERMITS' -'
L f L as owner of the property,am exclusively contracting with licensed FLOOD ZDNE APN
contractors to comtmct the project(Sec.7044,Business and I'mfc lons Code: PERMIT ISSUANCE
The Contractor's License Law does not apply to an owner of property who
buPETER-DRAIN&VENT-WATER(Elx)
ilds or Improves thereon, and who contracts such piajects with a jFEE SUMMARY
ce!actor(s)licensed pursuant to the Contractor's License Law.,, BACK FLOW PROTECT.DEVICE
LI am exempt under Sec. B k P C for this mason
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
• RECEIPT - .
WORKMANCOMPENSATION DECLARATION pLXTQgEg,PER mAls SCHOOL TAX, Y N
❑1 hereby affirm that I have a certificate of consent to copy
Chemo,or RECEIPT N"
3800,certifiLab o(Workeai Comperwuon]nsuranm ora certified copy themof(Sec. GAS FA.SYSTEM-1 INCAOUILEIS PARK FEE Y_ N_
3800,lab CJ
Policy p RECEIPT N
CAS EA,SYSTEM-OVER 4(IA)
Com any - .BUILDING DIVISION FEES
�C Ified wpy b hemby fumished, - GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
rtified copy b(fled with the aty Inspection division. -
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORMPA.200FT. .Date RCCCI t#
IThb section need not be completed tithe permit Is for one hundred dollars(3100)orless.I WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I mnify that N the perfomance of the work forwhich this permit is loured,
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workera'Compenation lawn of Glltornla.Date ' ' PAID -
O Z Applicant NEW RESIDENTIAL PLMB. SQ.FI'. Date Recei f#
Z NOTICE TO MPLICAM:If,aBer making this Cenlllote of Exemption,you
shwld become subject tothe Workere'Compenaallon provisions ofthe Labor - TOTAL:
M I) Code,you=at forthwith comply with such provisions orthis permit shall be _ UI G
ILIa. > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
• M z'Z Ihereby affirmthat there ts a construction lending agency for the perform- TOTAL: ELECTRIC FEE
.nor ofthe work for which this permit bbsued(Sm.3097,Civ.C.)
O O Lender.NaPLUMBING FEE _
1L F Leeaee.Aaaress 4TY. MECHANICALPERMIT FGE MECHANICAL FEE
OW l oudlythat l have read this applicatlonand statethatthe above information
1 bcormet.Iagrmtocompkywith all aty.ed countyordinancc•land state laws PFR_MITLSSUANCE _ PEE$PAID:
no
to building constructioniand herebyauthortae Z repreaentativesotthb ..city to enter upon the above-mentioned property forivpecrionpurpows. + ALTER OR ADD TO MECH. DOfc RCCef f#
V ,(We)agree to save,end reunify an d keep harmless the City of Cupertino p
against liabillti.,judgments,costs and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) „r SUBTOTAL:
Id Cit consequence ofthe granting ofthis permit. AIR HANDLING UNIT(OVER 10,000CFM CONSTRUCTION TAX
��- a'I I CONSTRUCTION TAX PAID:
SlgrsmreofAppltanl/
ntractor Date EXHAUST HOOD(W/DIK:T)
HAZARDOUS MATERIALS DISCLOSURE '
Will the applicant or turn.building occupant store or hand to harardma HEATING UNIT(TO 100,000 BTU) Date RCC f#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the - -
71alth and Safety Cod,9edion 25532(.)7 HEATING UNIT(OVER 100,000 BTUs T
F-1 Yca r]No,
Will the applicant or future building occupant use equipment or devices VELATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haurdou.zit cummidnanta as defined by the Bay Area Air .
Quality Management Dlstrict2 _ BOILER.COMP(3HPOR 100,000 BTU) � ' D
q Y',, `-
s Na
have read the hazarous materiila mqulrements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California health k Safety Code,Sections 25505,25533 and 25534.1
understand that tithe building does not cdrrenibiiBy have a tenant;that it is my NEWRESIDENTIALMECFI, SQ.FC FEB �� 'I 199
L
rexporuity to notify the occupant of the requirements which must be cont _
prior touance of a Certificate ofoccuparcy.
CiIk,: ,; , 1�
Owner or authorized agent - Date N l n� ISSUED BY. .1_ �11, IL
` OFFICE COPY S�\�