24049 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulldin Pro a Identification �xA 4s..o O
Bulldin Address: Ce4 4' l.- • 7 PERMIT N0
ne. 24049
Grr5/�/d 2$Dy
s ams: one: APPLICAIHJNbUbMII1ALUA1h
CITY OF CUPERTINO-BUILDING DIVISION —�
contrado ,Name: Tic.No: APPLICATION I PERMIT L
BU[LDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL 11
Aahltect/Engineer. Llc.No:
PERMIT "'''FEE ' +'.=BUILDING"PERMIT INFO
Address:/(,/ 7(p S C fYJ I G 11W. / PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION //'',0 �JQ
FEE
I hereby affirm that l am licensed under provisions of Chapterll(commun¢ APPLIANCESREMDENITAL JOB DESCRIPTION
Ingwith Sedkm7000)Of Divislon3 ofthe Buslnessand ProfessionsCode,and my -
Llmr Is I.hi full(ores and effect. PANELS - /�
License Class ontr N
Date Contractor La!To 200 AMES
ARChall be used
DECLARATION 201-IOVER00 AMPS
pq±�O Zp ]understand my plansahaLLbe used upubllcreroMs OVERt000 AMPS 9Q.Fr.FL AREA $/SQ.Ff.
Tod Licensed Professional SIGNSELECTRICAL
G OWNER-BUILDER DECLARATION
O
I herebya(firmthat I am exempt(mm the Contractor's License Law for the SPECIAL CIRCUIT/M15C
following moson.(Seetion 70313,Business and Professions Code:Any city or TEMP.METER ORPOLEINST.'
C4 =ntywhlchrequlresapert ttocostrut;alter,Impmve,de=lBh,orrepalr
g anystructure ptlorto ltatssuance,alsorequiresthe appllcantfor such permit to POWER DEVICES
f5 file a signed statement that hs Is licensed pursuant to the provisions of the '
Contractor's License Law(Chapter 9(emnencing with Section 7000)of Divi- SWIMJMINGPOOLELECTRIC
O:} sion3 ofthe Business and ProfessionsCode)orthat he is exempttherefromand VALUATION
a.•,�77 the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHE4FIXTURES
applicant for a permit subjeetsthe applicant to a civil penalty of net more than
five hundred dollars($500). NEW RESIDENTIAL ELECIR -'SQ.Fr. STORIES TYPE CONSTRUCTION
�n ❑1,as owner of the property,or my employees with wages as their sole
compensation,wlli dothe work andtfie stmmm la not intended or offered for
Osole(Sec.7064,Buslnessand Professions Cade:The Contradofa Llrense law
' $ does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RFS.UNITS
who deeasuch work hlmselforthmugh his own employees,provided that such
Improvements are not intended oroffered for sale.If,however,thebuilding or TOTAL:
improvement issoldwithln oneyearofcomplelioRtheowner-builderwill have .
t)USjmMen of proving that he did not baud or Improve for purpose of sats.). QTY, .+"'.:PLUMBING PERMIT , FEE' FLOODZONE APN
owner of the property,am exclusively m......ing with IlreneM PERMIT ISSUANCE
rontrad—to mnstrud the project(Sec.7044,Business and Professions Code:
The Contractor's License Law doe,not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improve,thereon,and who contracts for such pkojects with a �FEE'S,UMMARY
Cq0[ador(a)Bernard punuantto the Contractor',Llmnse Law. BACK FLOW PROTECT.DEVICE
I,J I am exempt under&c. B&P C for this reason
DRAINS-FLOOR ROOF,AREA,CONED. SANITARY Y N
,s o Owner. Date 9 RECEIPT N
c WORKMAN COMPENSATIONDECLARAT FIXTURES PER TRAP n
QI hereby affirm that I have a certificate of consent to self-insure,ora ^,r 1 r I� !I X RLCEII'1'N
certlfiateofWork m'CompensatlonlmumnmorarertRledmpythereof(Seb' GAS EA.SYSTEM-I IN 4OUTLETS I- �P/lRK R6� Y N
3800,Lab C.) )
Policy 9 RECEIPT p
GAS EA.SYSTEM-OVE 4(EA)
Cam any � � tlU1LLDING DIVISION FEES
�Cedified copy is hereby furnished. GREASE/INDUSLWASIEVI 'rERCFPTOR 'CKFEE
Certified copy b filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID
'y
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Recei IH
(Chia lesion need not W completed lithe permit b(Drone hundred dollars
($100)orlessd WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
[certify that o tany Personhe
in any moanerhe so as to b tomhis permit is bo theed, —
I shall not employ any person In any manner so as to become subject to the D
Workers Compensation Laws of California. ATER SYSTEM/TREATING y. Date PAID
'
'O Z Applicant NEWRESIDENTIALPLMB, Sq.Fr. Date Recei t#
Z O N0710E TO APPLICANT.If,after making this Certificaleof Exemption,you
should become aubjed to the Wmlo n'Compensation provisions of the Labor TOTAL:
CO Code,you mu at forthwith comply with such provedons or this permit shall be BUILD[
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
NG FEE
Q. I herebyaffirmthat therefs a mnstrudion lending agency for the perform- ELECTRIC FEE
D Z arm of the workfor which this permit is Issued(Sec.3097,Civ.C.) TOTAL
(,) O landera No PLUMBING FEE .Va
LL ~ Lenders Addrea, QTY.: MECHANIGA4'$ERINIT •" 'FEE'.• MECHANICAL FEE
OW Ierrtitythatlhave read thisapplicattoond etatsthatthe abovemformation
11 bcomed.I agreeto complywith all city and counlymethances and state laws PERMITISSUANCE FEES PAID:
N relating to 6ulidtng mretructlon,and hereby authorize representatives of this
(— Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH. Date Recei [#
— (We)agree to save,indemnify an d keep harmless the City of Cupertino P
against BabLLlties,judgments,mstsand expenses which may in anywayamme AIR HANDLING UNIT CEO 10,000 CFM) SUBTOTAL:
against said City in consequence of the granting of this permit.
3 J9 rAIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
rylgna�n eof Applicant/Contrader Lj Mir IXHAIIS'r HOOD(W/DUCT) CONSTRUCTION TAX PA ID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future,building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Ilealthand SafetyCode Sedlon2S532(a)1 HEATING UNIT(OVER 100,000 BTU) TOTAL: qQy
n Ye, ri NO
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCEATE
which emit hazardous air contaminants as defined by the Bay Area Air pp
ality Managen�entDistridpPy�7 - BOILER-COMP OHPOR 100,0(0 BTU) PAI
Yes n No
havereadthelt .arOusmaterialsmquimmenNunderChapter6.95o( BOILER-COMP(OV77t100,000BTU) AUG = 3 1992
the California Health&Safety Code,Sections 25505,25533 and 25534.I
understand that if the building does not mrrcntly have a tenant,that It is my NEW RESIDENTIAL MECH. Sq.Fr -
responsibility to notify the occupant of the requirement which must be met '
prior to issuance ofa Certificate of Occvpanry. - - CI[Y Or 4NAIN'CIlt!1190
Owneror authorized agent Date - ISSUED BY. V Q Ik
TOTAL:
OFFICE COPY .