24119 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PFRMiT NO.
BaOding Addenix - . 24119
s o
2ers e- e / one: ,
L CITY OF CUPERTTN66UILDING DIVISION Z
ConhactorsName: LIc.N. APPLICATION / PERMIT
2• BUfLDING-ELECTRICALPL I BINGMECHANICAL CATEGORY CONTROL 0
reh ten/ ghaer. Lie.No:
.,QTY ELECTRIC PERMIT., 'FEL BUILDING PERMIT INFO
Addreesi PERMITISSUANCE 11 ❑ 1:1LICENSED CONTRACTOR'S DECLARATION
Iherebyaffirm that l am Bcmaed under provisions of Chaptcr9(comment, APPLIANCFSRESIDEM7AL ` B DPSCRIPTI
Ingwith Section 7000)ofDiWalon3oftha Businessand ProfessloneCode,and m JO
JOE rs L.N
license le in full foj�and often. PANELS
License CWm_[y_Lic.»
Date /)-f`7 Contractor 62;1.1 /tyro' UP TO 200 ANTS /��'4 ,S/fW� L•�
ARCHITECTS DECLARATION 7014000AMPS
Ootl' (understand myplarashalibro
eused aspublicrerda OVERIODOAMPS SQ.Fr.FLOOR AREA $/SQ.Fr.
E IN
L� Licensed Professional SIGNS ELECTRICAL.
<< OWNER•BUILDER DECLARATION
In SPECIAL CIRCUIT/M1SC
Lp, Ihc. rasorm Sectioat I 731.5,B fmmlhe Contractor's License AnyLaw cit or
ZO?
following ntyreh TDgULenimn7 ttO Business and Pimp lonsemie hnympair TAMC METERORPOLEINST.
P f' c ystm hlmpr orltol pe nee alwrequi thea prom memos ch,orre tto
�a`� anystmcture prlortolts lsmcance,elw requlrntheappBcant forsech permitm ]OWER DEVICES D TE
(g file a signed statement that M is licensed pursuant to the provisions of the — TA
3wG Contractor.License Law(Chapter9(commsnnngwith Senlon MM)or Dlvl-
SWIMMING IDOL ELECTRIC
COS slon3ofthe Buslnesiand Pio(embraCade)mthat helee,,empttherefromand VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESFIXTURES
65 applicant fora permit subjects the applicant to a civil penalty ofnot more than
five hundred dollar(5500). NEW RESIDENTIAL ELECTR SQ.[rf. .'TORIES TYPE CONSTRUCTION
�n em
❑I,as owner of the property,or my employees with wages as their sole
compensation,will do the work and the structure Is not Intended or offered for
O .1.(Sec 7044,flusbeas and Prefealons Code:The Contractors License law
$ does not apply to an owner of property who builds or Improves thereon,and OCC.GROUP RES.UNITS
EE whodoes such work himself or through his own employees,provided that such
Improvements are not intended oroffered forsale.If,however,thebullding or TOTAL:
Improvement issold withinoneyearofcompl&ioMtheowner-builderwill have
t rden of proving that he did not Wild or Improve for purpose ofsale3. QTY; PLUMBING PERMIT-' FEE
� buFLOOD yDNE A]'NI,as Owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
..MOO.to construct the project(Sec.7064 Business and lim essums Code:
The Contractor's License Law does not apply b an owner of property who ALTER-DRAIN&VENT-WATER ffN
Wilda or Improves thereon,and who contracts for such p(Oprmi with a
,➢.t ctorW llcenmd pursuant to the Contnnor'a License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LI[am exempt under Sec. B &P C for this reason
OwnerDRAINS.FLOOR ROOF,ARRA,COND. SANITARY Y N
Data RECEIPT p
E31 here WORKMAN COMPENSATION DECLARATION FD(TURpS,PER TRAP SCHOOL TAX Y N
by af(Irm that I have a certlBote of consent to self-Insure,ora RECEExT M
certificate O(Worken'CompensatlOnlnsurance ora rertl(Kd copy thereo((Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y N
3800,Lab CJ
Cam nv a ' PT N
GAS FA.SYSTEM-OVER4(EA) DING DIV
b. BUILDING DIVISION FC CS co Is heed with the city CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECICFEE
Certified copy V filed with the Illy Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE
(Thissectionneednot becompined lithe permit lsforonehundred dollars SEWER-SANITARY-.[ORM EA."Fr. Date Remip[#
($100)or loss.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I certify that In the performance of the work for which this permit Is Issued,
I shall not employ any pension In any manner an,six to Demme subject to the WATER SYSTEM/TREATING
Workers!Compensation Laws of California.Date PAID
0 Z NOTICApplicaE
If,after making NEW RESIDENTIAL PLMB. SQFr. Date Recei t#
Z O NOTTCETOAPPLiect of the
oteofons oft eLyou
shwld became subFct to the Work<n'Cgmpensatlon provisions ofthe Labor TOTAL:
41 Code,you must forthwlth comply with such provisions or this permit shall be
doomed revoked. BUILDING W F3 CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Ihereby affirm that there is a construction lending agency for the perform
TOTAL: ELECTRIC FEE
7 Z Le der Name (OrwNch this permit btssued(Sec.3097,CIv.CJ
U O I<nder'sName PLUMBING FEE
LL 1— Lenders Add. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I mrtlfythat l have Mcithb ab
application and thattheovelnfomatlon
a Ismrrect.I agree to comply with all city and county ordinances and elate laws PERMIT ISSUANCE FEES PAID:
relating to building construction,and hereby authorizc representatives ofthls
U) city to enter upon the above-mentioned property for inspection purposes. ALT[RORADDTOMECH.
(We)e c to save,Indemnify an d keep harmless the City of Cu pert Inca Date Receipt#
V against Itlee,/a rte,mYa and expenses which may In any way accrue AIR HANDLING UNIT IOp00 CFM) SUBTOTAL:
agar tlCit sequence of the granting of this permit
8'Y7" 9 AIR HANDLING UNIT'(OVER lq"CFM) CONSTRUCTION TAX S' imeo Applor Date IXEIAIJS'f HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA7A
HA7ARDOUSDOUS MATERIALS DISCLOSURE '
Will the applicant or future building occupant atom or handle hazardous HEATING UNIT(TO 100,OD0 BTU) Date RCcei I#
material as defined by the Cupertino Munldpal Code,Chapter 9.17,and the
Healthand Safety Cod Section 2S537(a)7 HEATING UMT(OVER 100,001i TOTAL:
❑Yea No
Will the applicant rfuturc building oavpant use equipment ordevkes VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which rout hazardous air contaminants as defined by the Bay Area Air
.� Quality Management District? BORER-COMP DHP OR 100,00)BTU) P A''
Yee IlNo
have read the h ue materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the GlBomis Health&Safety Code,Sections 25505,25533 and 25534. I AUG 1 1992
understand that irthe building docs not currently have a tenant,that It In my NEWRFSIDENTTALMECH. SQ.FT
responsiblli onotify the occupant of the requirements which must be met
prior to coo Certifkate of Occupancy. OF vVr-CNIII.0
?-9
Pio Date _ ISSUED BY:cg
TOTAL:
OFFICE COPY