23374 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Address:
Building Addves: 23374
cPZ2� -56Av'I C �1� D�
ra _ one:
�eV'lg � 14 CITY OF CUPERTINO-BUILDING DIVISION T�yn
Contractors Name: LIc.No: APPLICATION MITL
Aprch BULDINGELECTRICALI'L NG-MECHANICAL CATEGORY CONTROL N/ 8 /
1^�G Rinn�
Lie.No: b ah
I'� '' II ��, -- G -'' QTY ELECTRI P MIT FEE BUILDING PERMIT INFO
Add ID W t4A' fq, S, , PERMTISSUAN
LICENSED CONTRACTOR'S DECLARATION I�Ya LQ"
I hereby affim,that l am licensed under provisions of Chapter 9(mmmenc APPLIANC NTIAL Fi,Lp
ingwlth5ection 7000)of DiW.ion3ofthe Buainessand ProfessionsCode,and my
lI vnse is In full( e and died. PANELS ^O
_Llmnse I.
Lie.N (V tel,
Data Contactor . qj=s'
ARCHITECT'S DECLARATION I AMPS
olCz Iundemtandmyphnssl Ubeuxdupublicrerords. I000 AMPS SQ.Fr.FLOOR AREA $/SQ.FT.
dU Limnssd Professional IGNSE O "�•
�<rf. OWNER-BOLDER DECLARATION
7i., Ihdrebyaffinnthatlamexemptfromthe Contractors License Lawforthe
O.. following reason.(Section 70115,liminess and Professions Code:An d or
Z I–u9 Y city P. OR LE]Iv ST. �a
5 county which mquimsa peroutoconstruct,alter,Improve,demolish,orrepalr
anyrtsignure prior taten am Issuance,alsoreqhemmed pursuant to the rovislhpermitto
he p0 DEV
file a added statement that he(Chapter 9(commencing
co d pursuant it the tor,7lora of the
slon3ofthe Bes usiness anticense Law Prfeions Codne1 orthat heIs exempt therefmm�nd ROOLE.ECTRIC _ VALUATION
O 5 the basis(or the alleged exemption. Any violation of Section 7mt5 by any ^ �.N w �`
appBmnt Ima permit subjets the applicant to a civil penalty f not more than31)
TSSWITCHFSHXIIJRF5 ` NVQ V`
five hundred dollars($500).g WRESIDENTIALELECTR SQ.FI. STORIES TYPE COh'STkICT10N, ❑L as owner of the property,or my employees with wages as their sole
G < compensation,will do the work.and the structure is not intended or offered for
5 O sale(Sec.701¢,Business and Profeselores Code:The Contractors Lt..Law
dads not apply to so owner of property who Wilds or improve thereon,and • OCC.CROUP RFS.I1NTfS
CC.• whodoes such workhterseforthrough hisown employees,provided thatsuch
SIDE
Improvements are not Intended or offered for sale.If,however,the build ing or T
improvcnx:nt usold wlthinoneyearofcompletion,the o-wner-budderwillbave
t ben of proving that he did not bund or Improve for purpose ofsals.). QTY, PLUMBINGPERMIT FEE pLUpp ypNrp APN
L as owner of the property,am exclusively contracting with Ilmnaed PERMIT ISSUANCE
contractors to construct the Project(Sec.7044,Wainessand Professions Code:
The Commences License Law doe not apply to an owner f property who
Wilda or improve thereon, and who comrade for such plojects with a ALTER-DRAIN&VENT-WATER(EA) �+
m,,RId([[ador(a)hmnwdpunuanttothe Cmn admeLimnw Law. BACK PLOW PROTECT.DEV ICE �� FEE SUMMARY
Lj I am exempt under Sec. B&P C for this reason
Owner DRAINS FlAOR ROOF.AREA.GOND. SANITARY Y N—
Date RECEIPT
M
WORKMAN COMPpgSATION DECLARATION plKgllREq l'ER TRAIa �� SCHOOL TAX Y N
❑I hereby affirm that I have a certificate of consent to self-insure,ora
mAEC®xC Y
rtifirne of ropythereof(Sm. GAS EA SYSTEMIINC40[lTLETS
3800,Lab C.) PARK FEE Y N
I'ollry N RECEIxf N
II >> C,o_m,Pany GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION LSCS
1, �Certined copy isherebywith
hme city GREASE/IN WASTEINTERCEPTOR PLANCHECK FEE ^ /� �s, r)�
❑CcrtBledcopy b,find withtW city Inspection division. !sI tr'i Vis `OJ,
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE 1
COMPENSATION INSURANCE
(This section need not Wcomplatcd if the permit le forone hundred dollars SEINER- Y(S"C" Date R
(fl W)orlWATER HEATER W/VFNT EL NERGYFEE Y N �a
XU
I cattily
that ceat In the pedm ormanof the work for which this penult Is hed,
I shall notemploy any pe n in ny manner m u to me jrat to the WATA�SYS n
Worken'Com /nJg6s�n9T)�N1i�( nU.LLteat L_ �i PAI
O Z NOTIApplies. �j/rm �/ NEW RESIDENTIAL PLMB. FT. Date p
Z O NOTICE TO I A ,a}�er ng this Ccrtnicateof Exemption,you —SQ
F _ should become subject to the Workers'Compensation provision ofthe Labor OTAL:
WN Code,you must forthwith comply with such proviatons or this permit shall be
> deemed revoked. BUIL NG -E _
d p CONSTRUCTION LENDING AGENCY SEISMIC FEE _
I hereby affirm that there Is a construction lending agency for the perform
M Zanm ofthe work for which this permit is Issued(See.3097,Civ.C.) TO �. ELECTRIC 6
O g Lender'sNam PLUMBING E
LL ~ LendereAddress QTY. MECHANICAL PERMIT FEE MECHANI LFEE
O W I certifythatf have readthb appncationand aatethat the-be veinformation �'
IL Is cormrt.I agree to comply with a0 city and munty ordinances and gate laws PERMIT ISSUANCE FEES PAID.
} W relating to Wilding nom uctfnt,and hereby authomm representatives of this
F Z city to enter u Pon the aWve.mentioned property for Inspection purposes. ALTER ORADDTO MECH.
_ (We)agmc to save,indemnify an d keep harmless the City of Cupertino Receiptil
against liabilities,judgments,cogs and expenses which may In any way acerae MR HANDLING UNIT(To 10,000 CFM) UBTOTAL'
against said City in cur siumom of the gram ing of thta permit.
AIR HANDLING UYTf(OVER 10,000 CEM) NSTRUCTI TAX
Signature of Applicant/Cmuractor Date IXFIAUS'T HOOD(W/DUCT) CONSTRUCTIO TAX PA D:
HAZARDOUS MATERIALS DISCLOSURE
Willtheapplimm orfuture Wilding occupant store or handle havardous HEATING UNIT(TO I Do,"BTU) /� Date
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the CCCI
1lealth and SafetyCede Section 25532(a)7 FMATING UNIT(OVER 100,000 BTU!)
1T�''��Yea �No
TA'llHheapplimm oM N.building occupant use equipmen[ordevims VEVfILATION PAN(SINGLE RESID) 0 ISSUANCE DATE
which emit hasardous air contaminants as eldlned by the Bay Area Air _
40Quality Management District? BORER-COMP('Lip 100,000 BTU P
4Ya I�1 No T
h avercadthehazarllo mueriaiarequirementsunderChapter6.95of BOILER-COMP(OVE2100,000BM
IHealth&Safety Code,Sections 25505,25533 and 25534.1
t lfthe building does not currently have atenanLthat it is my NEW RESIDENTIAL MECH. SQ.Ff. PR •17 .1992o notify the occupant of the requirements which must be met �jd. 1x7Lsa1Lce of a Certificate o(0.pa ocy.
oriud agent pate ISSUED BY. (�� � \•—/
10 1"Zo
OFFICE COPY