23409 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro ect Identification PERM)TNO.
Building Address: 23409
Mro ams: one: p
h V^\--\1 v—e_ (a).—a00 CITY OF CUPERTINO-BUILDING DIVISION
Catlora Name: Lie.No: APPLICATION /PERMIT
1 I w� (I o, • "omit, b BUILDING-ELECnUCALPLUMBING-MECHANICAL CATFLORY CONTROL#
Architect/Engineer. Lie,No:
-1 ,1 G QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
1/
Addrear 6aile s ektz- ci. Sa Zm? ITV 1, PERh4TISSUANCEjHL El ❑ ❑
LICENSED CONTRACTOR'S DECLARATION I
I hereby affirm that am licensed under provisions of Chapter9(comment- APPLIANCES-RESIDENTIAL JOB DFSCFJvnON
ingwlth Section70M)of Divl,lon3ofthe Businnsond Profen .noCode,and my
Ilmnse le In fail(o and off et Cj l b PANELS
Llrenee C=m= Lk.Y t �0��.
Dale Contntlor `
ARCHITECFSD CLARATION 201-1000 AMI5
pZ IuMentandmypiznssh UB us mpubllcrecorde. OVERIOOOAMPS SQ. .FLOOR AREA $/SQ.Fr.
E-)
Licensed Professional SIGNSELECTRICAL I
OWNER-BUILDER DECLARATION PALED
Z.a G Y SI'FGIAL CIRCUIT/MISC
'U IM1ereb affirm thallem.seem (romlhe Contractors Llrenx law(or the
following reason.(Section 70115,Business and Prefessiona Code:Any city or T
0 � mpair TEMP.METER OR POLE INST. a
�� c.usmuctuh reiorwia permitto constroct,eathe.pmvert forsbh,ormitto
< ER
any atmetare tatemeitehat he
orequlrersuant to the
of to POWER DEVICES
V
Me a elgned statement that he L.r 9(cam pursuant to the provisions of the
3u' Con 3 ofthe License Law Prafe ion,Comm enthathecing exempnherefom and
� ti�Os slon3.(Rise Business and Pro(e®Ions Code)orthat hebexempt therefrom and SWPIMINC POOL ELECCRICDA
psE57yy��6 5 the basis for the alleged exemption. Any violation of Section 70315 by any OUTLETSSWITCI-IFSFIXTURES ^/ /, O s
Mp
applicant lots permitaubjects the applicant to a civil penalty of not room than ! V
a flue hundred dollars(SSW). NEW RESIDENTIAL ELECTRSQ.Ff. STORIESTYPECONSTRUCI'ION
7
F-1 1,as owner of the property,.r my employees with wage,as their sole
compensation,wllldothe work andthe structure b not intended or offered for
Osale(Sec.70K Business and Professime,Code:The Contractors License Law
F�'$ don not apply to an owner of property who Wilda or improvn theme,and OCC.GROUP RES UNITS
who doeasuch work himseelforthrough hisown employees,provided that such
improvements are not Intended oroffered ferule.If,however,lhebullding or TOTAL:
Improvement b sold within omyearefcomplelldry the mvner-builder will have
ttLurden of p.t.,that he did not build or improve for purpose a(sa1eJ. QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
U L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
mnrractoat to rorulrue,the project(Sec.7014,Business and Professions Code:
The Contractor's License law does not apply to an owner of property who PETER-DRAIN 4 VENT-WATER(EA)
builds or Improves thereon,and who mrmus. for such pkojecus with a
c L� FEE SUMMARY
��BjfTto
acr(.)licensed pursuant to the Comcast.,'.License Law,I am exempt under See BAIX FLOW PROTECT.DEVICE B k P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Data RECEBT
WORKMAN COMPENSATION DECLARATION FDRURFS PER TRpI. SCHOOL TAX Y N
❑f hereby affirorke that I have o Insurance
.f consent to elf-Insumcopy thereof
ora RECEIPT#
3800,certifILab of Worken'Compensation lnsurenre ora rertl(led mpytM1ercof(Sec. GAS FA.SYSTEM-1 INCA OUTLETS PARKFEE Y N
3800,lab C.)
Policy# — RECEIPT p
CAS EA.SYSTEM-OVER 4(FA)
Com any _ BUILDING DIVISION FEES
OCertlfied copy is hereby te
❑CertJied copy b(fled withh the city
Inspection divides. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
ty
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORMEA 200FT Date ReceI t#
(fhlssectlon need not be completed](the permit L+(orone hundred dollars P
($10(fiorless.) WATER HEATER W/VENT/ELLCTR ENERGYFEE Y N
I certify that In the Fetterman.of the work for which this permit is ed, —
I shall not employ any person In any manner so as to bemt>) aubject o 1hn
WATER SYSTCM/TREATING
Workers'Com pp ❑.nV a LCallfor a. { . PAID
�T`"� �f � Date Recei t#
Z Applicant NE'WRFSIDENTIALPLMB. SQ.FT.
Z O NOTLCET abject to
ager making Ihb Ccrtillcale o(Ezemptiory you
aM1ould
subject to the Workers'Compensation provisions ofthe Labor TOTAL:
ai Cade,you et fort hwith mm ply with such provisions or this permit shall be BUILDING
W ) deemedre ked.
a c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there Is a construction lending agency for the perform, ELECTRIC FEE
Z once ofthe work(.,which this permit is Issued(Sec.3097,Civ.C.) TOTAL:.
OO Landae.Name PLUMBING FEE
IL — Lenders Addre.e QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Irertfythatl have read thbappBcathm.rd etatethattheabove Information
IL is comet.I agree to comply with all city and county ordinances and state laws PEKMITISSUANCE FEES PAID:
>. W relating to building construction,and hereby authorize representatives of this
H Z city to enter upon the above-mentioned property for inspection pu rposes. ALTER OR ADDTO MECH. Date Retei t#
(We)agree to save,Indemnify an d keep harmless the City of Cu pertma P
V against liabilities,Judgments,costs and expenses which may in anyway ammo AIR HANDLING UNIT(170 I0,W0 CFM) SUBTOTAL:
again teald Clty In roneryuenre o(tM .caring of this pertnll. AIR DANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
est 3-i3-5,L
n sere of Applicant/Contractor Date EXHAUS'THOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
BIIthe applicant or futum bulidingoccupam.tore or handle harardow HEATING UNIT 100,000 BTU) Date RCCei t#
tectal as dented by the Cupertino Municipal Code,Chapter 9.1 2,and the -
IlhandSafetyCodeSection 25531(a)I HEATING UNIT(OVER 100,"BTU) - TOTAL:
❑ Yea rz��J No
Will the applicant or fumrebuildingompant me equipment.rdevlces VENTILATIONr•AN(gINGLE REBID) ISSUANCE DATE
which emit hazardous air cents minants as defined by the Bay Area Air
Qu a Iity Management District? BOILER-COMP Otm OR 100,000 BTU) D
Yes ❑❑No
Thaveread the ha ardousmaterials requirements under Chapter 6.95of BOILER-COMP(OVER I00,OODBTU)
the California Health k Safety Code,Sections 25505,25533 and 25531.I
understand that lithe buildingdoes not currently have a tenant,that It b my NEW RESIDENTIAL MEC}i. SQ.Fr MAR 13 1992
responsibility to notify the occupant of the requirements which must be mel
prior to issuance of a Certificate of Occupancy.
CllrL C.f3111YV
Owner or authorized agent Date ISSUED BY:� d V
TOTAL:
OFFICE COPY