23103 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification + • PERMIT NO.
BeRdl01�3$ 6 sV:%Ee.. ter', �-r, `� 23103
w sam`e: ` on : - p
L� �+ 2S�-'Z CITYOFCUPERTINOBUILDINGDIVISION
8.=. C.mmilnr°Nares° Lic.Noo, APPLICATION 1 PERMIT
3 BURDINGELECTRICALPLUMBING-MFJCHANICAL CATEGORY CO
Archltect/Engineer. Lic.Na:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION 1'(C
I hereby aHlrrn that l am licensed under provisions of Cha Ater 9(cornmene, APPLIANCES-RESIDENTIAL - TOB DESCRIPTION
Ingwith Section 7000)of Divlsloo3ofthe Businessand Prufeuioes Code,and my
license le in full force and effect. PANELS
License Class Cort
Lic.#
Date or UP TO 200 AhUt./
ARCHITECPS DECLARATION M140DOAMPS
^0 I understand my plans shall be used u public records OVER 1000 AMPB �.FC.FLOOR R
I&il Licensed Profeadanal SIGNS ELECTRICAL 'r]J_Z 1 23
qOWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSC
Z,Fo' Iherebya(Rmn that am exempt from the Contractor's License Law for the sem'[
O following reason.(Section 70315,Business and Profession.Code:Any city or
FZI"'u9 countywhich requlresa permlttoomatruct,alter,Improve,demolbh,orrepalr TEMP.METER ORIOLE INST.
a anystruclum prior M its balance,also requires the applicant for such permit to
�w U Ole a signed statement that he b licensed pursuant to the provinces of the POWER DEVICES
saw
Ow Contractor'.License Law(Chapler 9(commencing withSection7000)ofDivl-
h30G' slon3otthe Busineesand ProfessoraCode)orthat hebexempttherefromand SWBdhIlNGPOOLELECTRIC VALUATION^
the blob for the alleged jecmects the-P Any violation of Section 7031.5 re any a �� V
< a he Ochi for apermited exemption.
Anyvioation ofpenalty of not morethan OUTLETSSWITCHESH
five hundred dollars he pr. NEW RESIDENTIAL ELECTR FI.
�n 10
❑I,as owner of the property,or my employees with wages r!herr sole TYPE CONS UCTION
compenntlon,wRldothe work and lhestructurebnot Intended or offered for 2
O sale lnec. pply manowand Professions Code:The or improves
law b-ACes s
3 does notapplytoanownerofpropertywhobuildsorces,prvithereon,and
whoevessets am khlmsededorough fferedowale.ILyeee,er,theedildleg r ', r �•
improvement usold intendneyear fcomprnln,the oweveg deer ill have 'p p 1 .i
improvement proving
tht he did et build
rove fu purpose
urpose of sale.).��tHI£�.�(1denofpmvingthat he did not bulldor Improve for purposeoOaleJ. QTy, PLUMBING PERMIT FEE pgoO^
c4h as owner of the property, Se ev044,[vxlyBuss contracting with Incensed PFRMITISSUANCE TE
tntlerseoconcurcttheproject(Sec.appy Business nand of
Code: i'
Contractor's License Law does not apply to an owner of property who
Wild. I
ALTER-DRAIN&VENT-WATER(EA)
ser Improves thereon,and who mnVor. for such Pon"with a
off
ort)homsed exempt
Sm to the Contractor'sLicense 1&PLaw. BACK FLOW PROTECT.DEVICE FEESU114MARY
LJ 1 am exempt under Sec B&P C for this reason
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y— N—
Owner Date RECE1171
WORKMAN COMPENSATION DECLARATION )]%TURES PER TRAP SCI100L TA% Y N
Of hereby affirm that 1 have a certificate of consent to self-Insure,ora RECEIPT_ NN
certificate of Workers'Compersallon Laurance or a certified copy thereof(Sec.
/ 380D,Lab C.) GAS.EA.SYSTEM-1 INCA OUTLETS PARKFEE Y_ N
Policy 0 REC ITT 0
GAS EA.SYSTEM-OVER 4(EAJ
{ Cam •nY � BUILDING DIVISION Fr.ES
[Certified copy b herebyfurnished.the city GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEB l 1�3
Certified copy b(lied with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
on COMPENSATION INSURANCE
SEWER-SANITARY-STORM EA.
TThlssenion need not be completed If the permit b forom hundred dollars Date Remi I
(5100)rtifyt.) WATERHEATERW/VENT/ELECTR ENERGYFEE Y. N
I rent employ
an person
an the manner so as to b cornhis permit b Issued, —
I shall not employ any person In any manner n as to become subject to the WATER SYS /TREATING
Worken'Compcnsation laws of Glitomla.Date PAID
O Z Applicant makingDale Remi t>f
Z 0 NOTICE TO APPLICANT:If,after this Certificate of Exemption,you NEW RESIDENTIAL PLMI,_SQ,F[.
should becomesubFct to the WollaWcompenwtlon provisions ofthe Labor TO' L:
N Code,you=at forthwith comply with such provisions orthb permit shall be
deemed revoked. D
Lu
O CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyatfirmthat there b a construction lending agency for the perform- T ELECTRIC FEE
Z ante of the workfor which this permit le Issued C5en3097,Civ.C.)
OO tender'.Name PLUMBING FEE L— I
LL Lendcra Addmw QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W IcenlfythatlhavemadthNapplintionandrtatethattheabovelnfomutlo^ I
bcorred.I agree to comply with all city and county ordinances and slate laws PERMITISSUANCE FEES PAID:
} 1 relating to building cormtruction,and herebyauthomeemprelentativesofthis
Zcity to enter upon the above-mentioned property for impection purposed. ALTER OR ADD TO MUCH.
— (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receiptk
against liab titles,judgmenb,cosh end expenses which may In anywayacnue AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL
•
agaiwty iyconsegoence ft granting ofthis permit. - —
3 AIR HANDLING UNIT(OVER I0,000CrM) CONSTRUCTION TAX ,
Igmtom of Applicant/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZAFOCUS MATERI DISCLOSURE
Will the applicant or future building occopant store or ha rad le ha2ardoe. HEATING UNIT(TO 100,000 BTU) Date BOCCI Hit
as def]ned by the Cupertino Municipal Code,Chapter 9.12,and the _
F3ealth and Safety Cede Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) 1
r7Ycs No
Will the applicant or vmm building occupant use equipment or devices VFNII LATION FAN(SINGLE RESID) ISSUANCE DATE
which cent havardous air contaminants as defined by the Bay Area Air
Quality Management Dbtrict7 BOILER-COMP OH POR 100,000 BTU)
Yes No IsT A B PS
ve read the hazar N materials requirements under Cha Ater 6.95 of BOILER-COMP(OVER 100,DDO BTO) RY
the California Health&SafetyCode,Seniors 25505,25533 and 25534.I
understand that if the building does not mreently have a tenant,that it is my NEW RESIDENTIAL MEIN. SQ.FT. JAN
n[d ,5
responsibility to notify the occv pa rat of the requirements which must be met JAN 26 1993
T
prior Io hem.e c of a Certificate of Occupancy.
CITY uiw�a�l,al, p)
Owner or authorlecd agent Date - — ISSUED BY: V
T 1 —
OFFICE COPY