23117 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Bui in Address:3 sh44q034 Gr 23117
d d re.
one: A A
(� j CITY OF CUPERTINO-BUILDING DIVISION l o�
c facto' Na ��ucea..�No: APPLICATION / PERMIT
^1512 BUILDING-ELECTRICAL-PLUMBING-MECHAMCAL CATEGORY CONTROL N
Architect/Englreee I Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:
PERMIT ISSUANCE ID ❑ [:]LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that am Beensnd under provisions of Chapter 9(commenc APPLIANCFSRESIDENTIAL IOM DFS BR LION
ing with Section 7000)ofDivlslan 3 ofthe Business. d Professions Code,and my
Bourse Is In II lorce an erred. �}�� PANELS
LlmnseC6�y-.%y� .ic.N_r�/'J Or-9�S � , OUF W, 4,
Date Contractor UP TO 200 AMPS
ARCHITECTS DECLARATION 201-IODOAMPS
9Z I understand my plans shall be used as public records. OVER IOOO AMPS SQ.Fr.FLOOR AREA S/SQ.FT.
G LED IN
Licensed Pmfo.ibvl SIGNSELDCTRICAL
t; FA OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MLSC 21,WZ01
7sO, � I herebyafOrmthat lam exempt fromthe Contrador's License Law for the
O 2 t- following reason.(Section 7MLS,Business and Professions,Code:Any city or TEMP.METER ORPOLE INST.
F''Say.0 cmntywhichmquresapermittomwtmd,altenimpro ,demolbh,orrepair ^^
.+ anystructure prlorto Its isvunce,also requlreathe applicant fee such permit to POWER DEVICES �II'1TE , /g 5 file a signed statement that he is licensed pursuant to the provisions of the DA Ir
Ow Contadorb License Law(Chapter 9(commencing with Section 7000)ofDivi-pV4 sion3ofthe BuNnessand PmfemiomCode)orthatheisemmpttherefmmand SWIMMING POOL ELECTRIC VALUAU
$^ the basis for the alleged exemption. Any violation of Section 70)1.5 by any
LTi< or. OUTLETSSWITCHFSFTXTURFS
�j five
applicant dollars
the appilcantmadvil peraltyof not morethan ` O
o. flue hundred1,as dollars he pr). NEW RESIDENTIAL ELECTR SQ.FT, STORIES --TYPE CCONS'IRIX:TION
p 7 I,as owner of the property,or my employees with wages as tMlr sole
compensation,willdo the work,and thestructure is not intended or offered for
O sale(Se.704y B..We s and Professions Code:The Contractors Lice.Law
d$S doesnotapplyto an owner of property who builds or improves thereon.and OCC.GROUT' RIS.UNITS
who doensuch work himself orthrough bnownemployees,provldedthat such
improvements are not intended oroffered formic.If,however,thebullding or TOTAL:
Improvement iasold withinoneyearofcompletbrythe owner-huilderwill have
Ih rden of proving that he did not bund or improve for purpose ofule.). QTy, PLUMBINGPERMIT FEE FTAODyANE APN
Lj I,as owner of the property,am exclusively mntrading with licensed pFRMII155UANCE
contractors to construct the project(Sec.7044,Business and Professions Code: l /
The Cantrador'a Limtue Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER
builds or Improves thereon, and who contracts for such p(ojects with a
factors)ecensed pursuant to the Contractors License FEE SUMMARY
Law. BACK FLOW PROTECT.DEVICE
I am exempt under Sec B&P C for thin reason
Owner DRAINS FLOOR RODE.AREA,GOND. SANITARY Y N=
Date RECEB'T N
WORKMAN COMPENSATION DECLARATION
1 hemby affirm that I have a cettl0ate of consent to set(-Insure,ore SES PER TRAP SCHOOL TAX Y N
mdifiuteof Workers`''ComperuationlmuranmmaaalfWcupythereof LSec. RECEIPT N
3800.Lab C.N'1G,s�7002di'�� GAS EA.SYSTEM-I INCAOUTLETs PARK FEE Y_ N_
liryp W GAB-EA.SYSTEM-OVER4(EA) RFGEB'TN
CoCm any BUILDING DIVISION FEES
[�Ce d mpyb hereby tarnished.
rtCREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Ued copy V rued with the cry inspection division.
CERTIFICATE OF EXEM PTION FROM WOR KERS' GREA'SETRAP PAID
COMPENSATION INSURANCE
(TBlssection need not becompleted iftheperMt isforom hundred dollars SEWER-SANTTARY-STORM EA."Fr. Date Remi Ot#
i ($10D)or less.) WATER HPATEi W/VENT/ELECTR ENERGYFEE Y N
I certify that In the performance of the work for which this permit is Issued, a —
I shall not employ any person In any manner so as to become subject to the WATER SYSI.M/TRFATINIG
Workem'Compensation Laws of Callfomu.Date PAI D
O Z Applicant i
Z O NOTICE TO APPLICANT.If,after making this Certificate or Exemption,you NEW RESIDENTIAL PLMfl.__SQ.ET. Date Recei t#
should become sebjad to the Workers'Compessation provision of the Labor~ TOTAL:W Code,you most comply with such provision or this permit shall be
W > deemed revoked. BUIL NG E
d O CONSTRUCTION LENDING AGENCY SEISMIC FEE
I.itheufflrmthat there bamvtmction lending agency for the perform �Jr ELECTRIC FEE
7Z Lorde,.Nme forwhich this permit i9 Issued(Sec.3097,Civ.C.) TOTAL: VTJ
V O Lender.Name PLUMBING FEE
LL f Lena Agythatl QTY. MECHANICAL PERMIT FEE
O W latch.I agrees comply
with aliayandc linty ordinances
and
MECHANICAL FEE
S Is correct lagrre to comply withallcityand county ordinances and state laws PERMIT FES P ID:
r U) relating to building mmtructlon,a red hereby authorize representatives of this .a
F Z city to enter upon the above-mentioned property for Inspection pu rposes. ALTFRORADDTOMECH. !�
— (We)agree to save,IndemNry an d keep harmless the City of Cupertino Date Receipt#
a gaivtlWlyytin,�jAudgmenh,conaando nsee which Tay In any wayacorue AIR HANDLING UNIT(TO 10,00OCFM)
ag'hest It 'q /' r cquen th r(u or tri.permit SUBTOTAL:
�d� AIRHANDWNGUN7T(OVERtg000Cr B CONSTRUCTION TAX
Sature of Apperan Contractor --mm IXEIAUSTHOOD(W/DUCT) CONSTRUCTION TAX—PAID.
HAIIARDOUS MATERIALS DISCLOSURE
Will theappliunt orfuturc building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)
materblas defined by the Cupertino Municipal Code,Chapter 9.I2,and the _ Date RCCei t#
Ikalth and SafetyCode Section 75532(a)? HEATING UNIT(OVER 100,000 BTU)
Fj Yes (_]No TOTAL:
Willthe nppiluntm(utumbuilding occupant use equipment or devices VEMTLATION FAN(SINGLE RESID) ISSUANCE DATE
which emhazardous
it v
air com.minb as defined by the Bay Area Air
Quality Management District? MOILER-COM P(3HP OR 100,000 BTU) n A ' D
s
YeNo Y
have readthe hoz Q-1 materla6 reqs iremems under Cha pier 6.95 of BOILFR-COMP(OVER 100,000 BTU)
the Ca[it.].Health&Safey Code,Sed ions 25505,25533 and 25534.1 JAN 10 1992
understand that lithe building don not eirrently have a tenant,that it lemy NEWRESIDENTIALMECH.
responsibility porulbility to notify the occupant of the requireenwhich must be Trot SQ}T,
prior to issuance of a Certificate of occupancy.
1 car 'Urthj'II)IU
Owrcror authoriudagxm Date TISSUED ENV t
OTAL:
OFFICE COPY