23602 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Address: C / D v 23602
`� 63 . S cog.
nera ante, one: p
S'/it1ilC, Cl2Y•C/[.nFr-KJr PSwhs✓ CITY OF CUPERTINO-BUILDING DIVISION
. Cnn ador'sName: Lc.No: APPLICATION /PERMIT �lL
UI
BLDINGELECTRICAI.PLUMBINGMECHAMCAL CATEGORY O
AshitM/En ate k.No:
C
erC
- .. QTY . ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addresa'yt8G3 T S L_✓_ 3 PERMITISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commene APPLIANCES.RESIDENEHAL BDFSCRIPI ION
ingweh In full
7000)oforce and
effeon3oflhe8uanenand Prolecelona Code,and my � a o V A'L ^ D 1
license le Section
form and visi PA C
License Class It.g . • Li s
Date Contractor is
ARCHITECT'S DECLARATION 211-11wV
ne Z I understand my plana shall be used as public records. OVER SQ.Fr.FLOOR AREA 6-�
'Roo I
W�� LittrvsM Professional SIGNS EL l/9
Q OWNER-BntUILDER DECLARATION-
{n]
7 s"F. Any GI 1 hercbyalllrtn that]em exempt from the Coraaorb License Law for the SPECIALCIRCUIT/MLSC
following reason.(Section 7(131.5,Business and Professions Code:Acity or
O TEMP.METER OR POLE[NST.
ceystm= pr orrcs,isma locoomquinstruct, athempli=tfwsuch,orrepair
tto
ggg any structure psormlta that
he is abo sed pursuant
the forwlons of It a POWER DEVICES
P� floe a actors statement that he(Chapter 9(codening it the tion 70om of the
w Contractor's LkenseLaw and Proession (commenting with SMlon7000)of Diel-sloVAL TION
the b sis for
Butnne e d exemption. Any violation
n of exempt therefrom and SWIMMINGPOOLELECTRIC R � ��O
thebashfor thealleged exemption. Anyyt tola civil
of Section 7031.5 bymore
any OUTLETSSWITCHFSH%IIIRES '(�a�j
applicant(ora permit subjects the applicant to a civil pemlty int more Ilun
five hundred asrewner of thepr. NEW RESIDENTIAL EL
E] STORIES ' 7YfaE CONSTRUCTION'
❑I,as owner of the progeny,or my employees with wages as their sole
�X, compensation,wllldolhe work andlheslmdure Isom lnlended or of(emdfor
0 sale(Sec.7044,Business and Podeniom Code:The Cantratols License law
Q doe.not apply to an owner of property who builds or Improves I hereon,and OCC GROUIa RFS.UNITS
who does such work himself or through hos own employees,provided that such
improvements not t reledoroffered forsale.ILhmveveglhebuildingor TOTAL: "—
improve sold withinone yearofcompition,Iheowner-builderwill have
le n of Evening that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT' FEE ' -F=D ZONE APN
L as .at of the property,am exclusively contracting with licensed
contractors to construct the project(Sec.7614,Business and Professions Code: PERMIT ISSUANCE
The Contractors License Law don not apply to an owner t property who ALTER-DRAIN k VENT-WATER(EA)
builds or Improves thereon, and who contracts for such ptojets with e
��Tador(s)licensed pursuant to the Conlratola License law. BACK FLOW PROTECT.DEVICE ' FEE SUMMARY
LJI am exempt under Sec. B k P C for this reason
•
Owner are S
DRAINFLOOR,ROOF,AREA,COND. SANITARY Y N -
rc RECEIPT#
WORKMAN COMPENSATION DECLARATION FIXTURES-PER TRAP SCHOOLTAX Y N
❑i hereby affirm that I have a l r rare of cenxnt to apythe or RECEIPT a
3801(icaleofWorken'Compensatlonlmuranceon certified copythemo((Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARR FER Y N
Polis 380Elab CJ
I'ollry p RECEIPT M
GAS G.SYSTEM-OVER 4(EA)
Com any BUILDING DIVISION FF.IiS
❑p Certified copy is hereby filed
thecity
furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCFIECKFEE
Certified copy Is(ikd with the ttylnspedlon division. Ty ats8
GREASE TRAP _l• Y
CERTIFICATE
COMPENSATION
NS FROM WORKERS' PA _
COMPENSATION INSURANCE
(This section need not be complied if the permit V(oronc hundred dollars SEWER-SANITARY-STORM G.200FT. �fN
eCCI�(7100)orless.) E • GY FEE i19
Icertify that In the perfomunce of the work for which this permit is Issued, WATER HEATER W/VENT/ELECTRI shall not employ any person In any manner an as to b' to the H,A.��,SfFA1/.<REA.nNC
Worken'Cpn�Rens tion{ .if C. f i Date '�+ '�t PAID
O ApEllant./t�n/CiY.o.c..-x ' �"" > - (4,
Z Q NOTICE TO APPLICANT.If,after making this Cenlfkateof Exemption,you NEW RESIDENTIAL PLMB. SQJiT. De1C e 1
should become subject to the Workers'Compensation provisions of the Labor - OTA
N Code,you most forthwith comply with such provisions orthis permit shall be ING '- t
9 deemed revakrd.
IL CONSTRUCTION LENDING ACM7 SEISMIC FEE
Z thereby a!(Irmthat there lsacomwdlon lending age ,forthe perform- TOTAL: ELECTRIC FEE Z a3
ance of the workfor which this permit e,bell (Se 097,CIv.C.)
V O L.endere Name / PLUMBING FEE
L4, F LendersAldmie -- QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W- lechifylhatl have read thisa cationand statethattheaboveinformation
IL
isconrd.Iagreetoc I�ith all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} N relating to bulldin mtmtlon,end hereby authorize representatives of this
F Z city to enter nthe above-mentioned property,for inspection purposes. ALTER ORADDTOMECH,
Date Reeef t#
— (W c to save,Indemnify an d keep harmlen the City of Cu pertlno P
.&mt lWbWlies,jud
g
nments,ro and expenses whkh may lnanyw 4,a a AIR HANDLING UNIT 17010,000 CFM) SUBTOTAL:
Id city Inc sof thr$rantthla permit.
AIR HANDLING 111VIT(OVER 10,IX70CFM) CONSTRUCTION TAX
g atu o AppBp odtra r D e EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
AA RDOUS MA ERIALS DISCLOSURE
Will the applicant orfutum building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)
oulerizl as defined by lM Cupertino Municipal Code,Chapter 9.17,and the Date ReceI t#
Health and Safety Code�a-S�ed�i�on 7S532(a)7 HEATING UNIT(OVER 100,00)IEW TOTAL:
❑Yat . ff�- -
WE)the applicant orfuture building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants a.defined by the Bay Area Air
Quality Management DisWd7 BOILER-COMP OHPOR 100,000 BTN P A f D
o
California
the hoz oet Code,Sections
25505, under 5533 aChapter.1 of BOILER COMP(OVER 100,00D BTU)
thecerstannta Heathe lth building does
m755have toad,that
MAY 4 1992
understand that iltify the ing occupant net arottlyequire meat which
that It met NEW RESIDENTIAL METH. SQ.FT.
responsibility to notify the occupant of the requirements which must be mel .
P uan�,g?
of ane}'.
_ . o f'-e- CI Y'U _UrtnluvU
ate iniDate ISSUED BY-.TPA
' TOTAL:
OFFICE COPY