24428 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project mamm«elan r1:wwTNg, 4 4 28
ewlamg Aeare..:
�2w/ SAtJ 14 OA) �D
n mne sine: /� one: A
K ANW 6.9.1 A) z'5?-y9'q9 CITY OF CUPERTINO6BUILDING DIVISION 17
Coat / Lie.No: APPLICATION / PERMIT — Z� C _
rs °raNan.:
�O� 1/�a ry b d4CATEGORY CONTROL#
BUILDING-l7.ECTRICAL-PLUMBINGMECI IAMCAL
Architct/Engineer: Lk.N.
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMIT ISSUANCE �{'J9 �/I ❑ ❑
LICENSED CONTRACTOR'S DECLARATION (�
. ]hereby affirm that I amDivision
o(the Business
and Pro Chapter 9(commnc APPLIANCES-RESIDENTIALing JOB DESCRIPTION
homenh ].fail 7000)forwarDlvWon3 ofthe Bunnemand Professions Code,and my
Lim ac bin lull forward dfect. - PANELS
Data Clem Lcor
Date Contractor l/ -
ARCHITECPSDECLARATION 701-1000 AMPS
a{yn Zp I understand my plars.hall be used as public mo rda OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
lee U Licensed Professional SIGNSELECTRICAL
cid
OWNER-BUILDER NLDER DECLARATIONthat n n
In SPECIAL CIRCUIT/MISC
yl-'vl, owing yafRr (Seal ore 31.5,Rxempt fmms.the dPrafContranorb Cgin:icense Lawforthe
pppp
following per031.5,Ruetruc and Professions Code:Anycityor
K�h'� coantywhlch requlrcea permi[tomrowct,alter,improve,demolbh,arrcpair TGh]P.METFR ORIOLE 14r.
q� anyrtramon prior to Its Issuance,also requleastheappllmnt forsuch permit to pOWFA DENIES 1 - A b-
E��6 file a signed statement that he Is licensed pursuant to the provislon of the 1�
OK Contractor's License Law(Chapter 9(commencing with Section 7000)ofDivi.
�OS slon3 oftheBusinessand ProfessimesCade)orthat he is exempt lherefromend SWAIMINC]Y)OL ELE C — _ VAC ATION
6 X the basis for the alleged exemption. Any violation of Section 7MI.5 by any OUILETSSWITCHESFI 6'�---
applicant for a permit subjectatheappllcart to a civil penalty of not more than
Qvee undreddollars%Spp. NEWRESIDENTIALELECIR
�n �[{J,as owner or the property,or my employees with wages as their sole e"Q.FT'4FEE
TORIES TYPE CONSTRUCTION
t6mmpemation,willdothe work andthe stmdum ts not Intended or offered for
Osale(Sec.7044 Business and I'rafessloru Code:The Contractors Llceme Law
does not apply to an owner of property who builds or improves thereon,and
C• who doessuch work himself or through hisown employees,provided that such CC.GROUP RES IINHS
improvements are not Intended moffered forsake.If,however,(hebuilding or TOTAL:
i provenrntlssddwithlnoneyearofcompldiogtheowner-builderwBHave
", !den of proving that he did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT AOD ZDNE APN
LJ I,as owner of the property,am exclusively contracting with Boomed PERMIT ISSUANCE
mounciors to mrisned the project(Sec.7044 Business and Professions Code:
no Contractors Llmne Law don nor apply to an owner of property who AL1ER-DRAIN&VENT-WATER(EA)
builds or Imes provthereon, and who contracts such p(oject. with a
cgtlt�actm(s)Beemad pursuant to the Contractor's License Law. BAIX FLOW PROTECT.DEVICE FEE SUMMARY
I_J I am exempt under Sec. B&P C for hismuses LLES
Owner. DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y N�
• Date RECEIPT p
WORIO•tAN COMPENSATION DECLARA 1 F]%il1RES PER TRAP SCHOOL TAX Y N
01 hereby alftrm that I have a mrtifiate of can.I to self-Ineum,ar a RECEIPT#
certl(IrateofWmkeriCompenatlan lmuraneeara«rilfled mpythemof(Sec. GAS EA.SYSTEM-1 INCAOUTLETS
3800,Lab PARK FEF. Y N
Policy# RECEIPT a
• Co. an CAS EA.SYSTEM-OVER4(EA)
` Y BUILDING DIVISION FEES
Certified copy bembycity
furnished. CREASE/WDUSFRL WASTE INTERCEPTOR PLANCHECKFEE
❑Ccrtl(led a copy V filed withhthethe city Wpe Sion division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SAMTARY-STORM EA XpF1, DRi
(This mdlan need cad bcomplded lithe permit b(orone hundred dollars ate em
PIM
a1 OOJOf1y
IceNifythat lethe performance arthe work for whichaWATER HEA�W/VENT/E.ECIR ENERCYFEE Ythls permit leb
ed, N_
I shall not employ any Parson In any manner so as to became subject to the WATER SYSTEM/TREATING
Workcri Compensation Lawsof California.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Remi tM
Z Z NOTICE TO APPLICANT.If,after king this Certificete of Exemption,you
should become subject to the Workers'Compenation proal Ian of the Labor TOTAL:
N Cade,you swat forthwith comply with such provisions or this permit hall be
j deemed revoked. BUILDING FE
ILC CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL 1hereby afilm that them isamntructionland Ing agency for the perform, ELECTRIC FEE .p
Z ance of the work for which this permit b issued(Sec.W97,CIv.C.) TOTAL:
U O Lendar.Name PLUMBING FEE
LL I— Leader.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icomirythatl have readthls application and katethatthe above lnformallon
C 6mrrect.I agree to comply with all city and county ordinances and nate lawn PERMIT ISSUANCE FEES PAID:
>. N relating to building mmtm&ion,and hereby authorien apresentativesofthis
F Z cityto enlerupon the above-mentioned property for Inspection purposes. ALTER OR ADDIO MEGA Date Recei iN
C) — (We)agree to save,Indemnify an d keep haredem the City of Cupertino P
against llabilltlen,Judgments,mks and expenses which may lnanywayacaue AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL: 1 8
againbald in mn.aci eamofthe granting ofthl.permit.
//�/�,� AIRHANDLING UNIT(OVER 10p00CFM) CONSTRUCTION TAX
Sigwturc of Appllmnt ontractar Z Out. EXHAUST HOOD(W/DUCT? CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building ocavpant store or handle haaardoua HEATING UNIT CM 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.IZ and the Date Receipt#
Flealth and Safety Code Setion 75537(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes r]No
Will the epplinnl orfarm,building ocmpatt use equipment ce devices VENTILATION PAN I5MCLE RESID) ISSUANCE DATE
which emit hazardous air motaMmnb as dented by the Bay Area Air n
lity Management District? BOILER-COMP QHPOR 100,00U BTU) P9
Yes d No
have read the Nazar ..,?.No
materials requlrcments underChapar 6.95 of BOrLER-COMP(OVDI 100,000 BTU)
the California Health&Safety Code,Sect lora 25505,25533 and 25534. 1 NOV 2 1992
understand that if the building does not mrramly have a Intact that It E my NEW RESIDENTIAL MECH. SQ.FF
responsibility to notify the compact of the requirements which must W rrct
prior to issuance d a CcAiflnte of O=pancy.
;11'r OF UFcnulvv
Owner or authorlmd agent - Data . ISSUED BY:
TOTAL
OFFICE COPY