22752 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Build Ing Add me.: 22752Z0840
�sfEJBNS G{zEg}� $�tiD G�p�z�,Na
mereName: one: - A,
ey- :K CITY OF CUPERTINO-BUILDING DIVISION
ContraetoraName: Lm.No. APPLICATION / PERMIT e'(L3NJ�!"AZLTGT/OsJ C.CJ. Z'ry2(cJQ_ BUILDING-ELEOTRICAUPLUMBINGMEOHAMCAL CATEGORY CO O
Architact/Engineer. Lie.No:
QTY ELECTRICPERMFT PEE BUILDING PERMIT INFO '
Addreaa: - PERMITISSUANCE ❑ ED ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions o(Chapter 9(consmme APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwlth Svction 7000)of DWislon 3 of the Businses and ProfesslonsCode,and my
licence is In full force and effect. PANELS `
Llcenm Chas LION ' ` �'
Date Contractor UP TO 200 AhU
ARCHITECTS DECLARATION 201-1000 AMPS
MZ I understand my plans shall be used as public records. OVER1000AMPS - SQ.Fr.FIGO AREA S/SQ.FT.
pq O
k Z Licensed Professional SIGNS ELECTRICAL fE I
G OWNER-BUILDER DECLARATION L n} SPECIALCIRCUIT/MISC _ _ I�
7t' Ihereby affirm that l am exempt from the Contractor's Lim se Law for the 0A P U T E
o following orems.(Section 70315,Business and Professions Code:Any city or
Fcounty which requires a permit to construct,alter,improve,demolish,or repair 'IEMP.MEft>2Oft POLE INST.
any structure prior to its Issuance,also requires the applicant for.uch permit to POWER DEVICES
c. file a signed statement that he h licensed pursuant to the provisions of the TE
3 t: Contractor's License Law(Chapter9(mmnandngwith Section 7000)of Divi- SWIMMING POOL ELECTRIC
t E50S elan 3otthe Busloessand Professions Code)orthat he b exempt theretromand VALUATION
r <� the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLE'ISSWITCHESHXTURFS O D
applicant fora permit subjects the applicant to a dull penalty of rat rtnm than
( o five hundred dollars(¢500).
Sn ❑I,as owner of the property,or employee,with wa es as their sole NEW RFS[DEbMAL ELECTR SQ.FC STORIES TYPF-CONSTRUCTION
P ]arty, mye
fln rompensation,will CSe,.7KBe.[ hework,and
eun.todurehnot
ontractor or Licensed for
vie snot 7044,Business and Professions Code:The Contractors License Law
$ does not apply loan owner of properthrong hiswho
nempor impeovist yees,povide tar,and
tsuch OCC.GROUP RES,UNI'rS
who does
mantswork himvEorthwghed ors employees,er,the uIld Ing or
Improvementsared intended
earofredforale.theo er. Hder ilI have TOTAL:
improvement bsold withlnoneyearo(compldlomtheowner-W Bderwlll have
inrden of proving that he did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
( 6L as no,of the property,am exclusively contracting with llmnsed PERMITISSUANCE
..trade.m construct the project(Seo 7044,Business and Professions Code:
The Contractor's Licence Lw does not apply to an owner of property who ALTER-DRAIN kVENT-WATER(G)
Wilde or Improves thereon, and who contracts for such project.with a
cop1rador(s)licensed Pursuant to the Contractor.Lt..Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B k P C for this reason
DRAINS-NFLOOR A,ROOF,ARECOND. SANITARY ' Y N
Owner Date RECEIPT N
WORK MAN COMPENSATION DECLARATION FIXTUREPER TRAP SCHOOLTAX Y N_
L311 hereby affirm that I have•certificate a(consent to eel(-InmrcS,or RDCRPT N
3800'tbC.) rkers'Compewtlonlnsurance mracertified copythemo((Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
Polis lab CJ
Policy p GAS EA.SYSTEM-OVER 4(EA) RECEIPT
Cam BUILDING DIVISIONFEES
Ified copy is herebyfurnished.the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified mpyb(fled with the city inspection division. U
CERTIFICATE OF UEMPTION FROM WORKERS' GREASE TRAP PAID7nt9!2I e `D� (�
COMPENSATION ION INSURANCE SEWER-SANITARY-STORM STORM EA.200Fr. Date G•1 Rccei t#
Rhbsedbn need nm M completed tithe Permit h(Drone hundred dollars
($1 l0ftifess') WATERHGTERW/VFNT/ELLCTR ENERGYFEE Y N
I artilythato the personiaofthework so as tobthio pertains lamed,
I shall not employ any person In any manner so v to become subject to the WATER SYSILM/TREATING
Workers!Compensation Laws of California. Oats PAID
ZZ Applicant NEW RESIDENTIAL PI.MB. SQ.Ff. Date RCCe1 t#
O NOTICE TO APPLICANT:E,after making this Certlfiateof Exempllon,you
(- should become subject to the Workers Compnuatlon provbioru ofthe Labor TOTAL:
N Code,you moat forthwith comply with such provisions orthbpermit shall be r BIN 00
W j deemed revoked. '
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE B
-17
I herebyafBrmthat there is a construction lending agency for the perform - ELECTRIC FEE
D Z arm of the workfar which thle permit blssuM(Sec.3097,Civ.C.I TOTAL:
O O fender'.Name PLUMBING FEE
LL ~ Lender's Addreaa QTY. _MECHANICAL PERMIT FEE MECHANICAL FEE
O W
UI certilythat l have read thisappllationand statethatthe above Information
fl ismired.Iagmetocomplywithall dtyandcounty ordinances and state laws PERMIT ISSUANCE
} N
testing tobulldiagcomhuction,and hereby authotl repmeara Nes.fthb -
H Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH. - Date Refei 1#
V — (We)agree to ave,Indemnify an d keep harmless the City of Cupertino
against liabilities,judgments,costsand expenses which may In anywayamme AIR HANDLING UNIT(TO I0,0I0CFM) SUBTOTAL:
against id Clt Ina of the granting of thisit
Ttm AIR HANDLING UNIT(OVER 10,MoCrM) CONSTRUCTION TAX
Slg.wm.f Applicant/Contactor Data FXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or(uture building occupant store or handle hazardous HEATING UMT(TOI00,000 BTU) Date RCCCI t#'
materhl as defined by the Cupertino Municipal Cod,Chapter 932,and the
Health and Safety Cade Section 25S32(a)7 HEATING UNIT(OVER 100,000 81" TOTAL;
❑ Yea No
Will the applicant opium building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BORER-CAMP QHPOR 100,000 BTU) P A 1 D
4 Yee he q No
haveread Health
&r fel Code,materialsSections;
e tioWremenb5533 aChapter. 1 of BOILER-COMP(OVER 100000 BTU)
the Gltand tHeftthQ Safety Code,Sectloru25505,Y533and,that it
OCT 2'3 1991
understand that if notihe fy
the ing occupant earrantly requir have amere tenant,thatb met NEW RESIDENTIAL MECFi. SQFT.
responsibility to notify the occupant of the rcqulremenlawhicM1 moat be net
prior to issuance of a Certificate of Occvpanry.
CITY OF CUPEHTINU kO
Owner or authorized agent Date TOTAL: ISSUED BYQ.R
OFFICE COPY