23417 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
- Building project Identification PERMIT NO.
°"d'ngA 23417
Marc:
CITYOF CUPER'IINO-BUILDING DIVISION
cern ante• / Lic.No: APPLICATION ( PERMIT
BULDING-ELECTRICAUPLUMBING-MECHANICAL CATEGORY CONTROL N
himet/Engineer. Lit.No:
QTY ELECTRICTERMIT FEE BUILDING PERMIT INFO
Addresm - PSEMI TISSUANCE ❑ ❑ El
CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions o(Chapter9(comment, APPLIANCPSRESIDENTIAL JOB DFSCRIILON
ingwlth SecBon7000)ofDivlYon3 ofthe Businessand ProfesslonsCode,and my
license ie in full ffpp and affect. PANELS !l..,,..
License am f,� �Ln.N � 7 1 �
Dat Contractor
ARCHITECTS DECLARATION 201-11X10 AMPS
pQ!DOC I ndentand my plans shall be used as public records, OVERIODOAMPS SQ.FT.FLOOR AREA $/SQ.Fr.
E (/ Licensed Professional SIGNSELECTRICAL rL
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MLSC
z m l hereby affirthatIam exempt fromthe Contractor's License Law fee the
oo_Q following reason.(Section 7031.5,Business and Professions Code:Any city or
ER
FZ^7� countywhkh requlresaperMttocowtruct,ilter,Impmve,demoWh,orrepalr TEMP'METORPOLE INST.
anystm=mpdortolb Wuance,alsarequlreatheappllantforeuchpermltto
yd file a signed statement that he Is licensed pursuant to the provisions of the POWER DEVICES
3 w Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi. SWIMMING POOL ELECTRIC
slot 3 oftne Business and Professions Code)orthat he is exempt therefrom and VALUATION
the basis for the alleged exemption. Any violation of Section 70115 by any OUTLE.ISSNI.ICHESP.D(.LURES
applicant fora permit subjects the applicant to a civil penalty W not more than
five hundred dolbn($500). - NEW RESIDENTIAL ELECTRFT.
❑I,as owner of the property,or my employees with wages as then sok �' STORIES TYPE CONSTRUCTION
compensation,willdothe work,and thestme um is not Intended or offered for
O sale fSec.7044,Butloess and Profeelaw Cede:The Carman?.License Law
r3$ does not apply to an owner of property who builds orlmprovestheMon,and OCGGROUP RES.UMTS
EEEEE whodoasuchworkhimelforthroughhisownemplayeeaprovldMthatmch
Improvements arena Intended oroffered forsale.If,however thebullding or T
Improvement issold wlthinoneyearofcompletlon,theowner-buBderwill have
tt(,,�urden of proving that he dWnot build or Improve for purpose ofsala.). QTy, " PLUIVIBINCPER�MIT FEE • FLOOD/ANE APN
u 1,as owner of the property,am exclusively contracting with limmed PERMITISSUANCE
contractors to constmec
ct the project(S .7014,Business and Professbro Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improve.thereon, and who contracts for such ptoject.with a -
eqnti-acter(s)lianand pursuant to the Contractor'.License Law. BACK FLAW PROTECT.DEVICE FEE SUMMARY
LI I am exempt under Sea B &P C_for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_OUTSI DE FEES
Owner Date
WORKMAN COMPENSATION RECEIPT N
DECLARATION
[]I hereby affirm that 1 have a certlfieste mffcomenconxnt to self-inure,or a FIXTURES.PER TRAP SCHOOL TAX Y_ N_RECEIPT N
certificate of Worken'Cmmpensation lru rano ora ren Ind cop thereof(Scat GAS EA.SYSTEM4 INCA OUTLETS PARK FEE Y N
3$00,Lb C) / /
Polley M �! I ( O RECEIVE N
Com an GAS P.A.SYSTEM-OVER 4IRA)
MY BUILDING DIVISION FEES
Cchifie p ere rthe cit. CREASE/INDUSML WASTE INTERCEPTOR PLANCHHCK FEE
❑Certifiedropy billed hthecity inspection division. asaaa
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID I
COMPENSATION INSURANCE SEWER-SANITARY-STORM PA.200PT. Date Rece) t#
(rnlssectlon need not 4 eomplMed If the perrtJt 4 for one hundred dollars
($1 W)or less.) WATER HEATER W/VENT/F].FATR ENERGYFEE Y N
I certl(ythat in the performance of thework forwhlch this permit le Issued, —
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TRTATING
! Workeri CompensaOon L.w.o(Callfomla.Data PAID
O�� Applicant NEW RESIDENTIAL PLMB._SQFr. Date Recei t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become eubjeet to thn Worken'CompensaOon PmwIaons of the Labor TOTAL:
WF V) Code,you must forthwith comply with such proialore,or this permit shall be BUIL INC; E
;;0 drained revoked.
d CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby.Mrm that there is a construction lending agency forthe perform ELECTRIC FEE
Z ane,of the work for which this permit Is ixacd(Sec.3097,Civ.CO TOTAL:
(,) O Lender's Name - PLUMBING FEE
IL F Lender'.Addree - QTY. MECHANICAL PERMIT FEEMECHANICAL FEE -
O W Iced lfy that l have read t hlsappllcation and Yate that theaboea Information
iscomed.I agnate,complywith all cityand county ordinances and Yate laws PERMITLSSUANCE FEES PAID:
r IL relating to building commactlon,and herebyauthorleemp eartativesofthis
Zcity to enter upon the above-mentioned property for impoctlon purposes. ALTER OR ADD TO MECH.
— (We)agree to save,indemnity an d keep harmless the City of Cupertino Date Receipt#
against liabilities,judgments,rosteand expenses which may In anywayamue AIR HANDLING UNIT(TO t0,030 CFM) SUBTOTAL:
against said City In consequence of the granting of this permit.
AIRHANDWNC UNIT(OVER 10,000 CIM) CONSTRUCTION TAX
Signature of Applicant/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applies rat or Man,building occupant store or hand le hazardous HFA TING UNIT(TO IMODD BTU) 01 iii q
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date Recel
Health and Safety Cade Ion 25532(a)2 HEATING UNIT(OVER 10,000 BTU) TO A
❑Yea Lid No r(p J�s�(�g
Will the applicant a future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) �$$DAV(j5DATE
which emit Ueardousalr contamleanbas defined by the Bay Arca Air Fi-1 U
� �iality Management%1 7 BOILER-COMP DHP OR 10,000 BTU)
4 Yca No MAR 1 (�e
havcreadthchaza mous maledala requlrernenh under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) 1s7s�as,
the California I Iealth&Safety Code,Sections 25505,25533 and 25534. I 9s,9•s,2
understand that if the building does not currently have a tenant that It is my NEW RESID]=AL MECH. SQ.FT.
reeponsibil nota heoccvpantofth qulrementewhichmu Hemet CITYiuhcu tnunU
prior to an of rtlfiate of
Owns ailh zed agent Data ISSUED BY:
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OFFICE COPY
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— + — t-B GIGUERE CT. • SAN JOSE, CA 95133 • TEL (408) 259-8300- 4
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A"joAi;iaR 17 1992
DESIGN / RfIL DESIGN€R ply ' Of
BLDG. INSPECTION OF CU RTINO hi��iT
_ ( DATE ='Y 2 - n SALESMAN DATE CITY Of CUPERTIt10
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