23200 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - - PERMIT NO,
Building Address: Q _
sPlaa 23200
nero�f afrs�e:X-� �Lyy U^n one:
CITYOF CUPERTINO-BUILDING DIVISION
con rador.Nanr:• ./n'1 �s APPLICATION / PERMIT I '^ t,'�Z
4,Q�� UG �VIV s'" �l BUILDING-ELEC•TMCAL-MtJMBING-MECFUMCAL CATEGORY rNTCIA to
rc Itect/Engineer, ,Lie.No:
' Ir ` BUILDING PERMIT INFO ' •-'t,-
TY_ C ELECTRIC PERMIT �'4EC '• '•
Address: PERNUTISSUANCE .❑ ❑ ;
LICENSED CONTRACTOR'S DECLARATION
-. Ihereby dioA70that lamBcensd under.BusimssandPmfenton&C(moderate. APPLIANCES-RESIDENTIAL - JOB DESCRIPTION
ingwith force odd died. oflheBusinessdnd ProfemioneCde,and my \�X
iicenm la m full force and drect, PANELS
License Clam LIc.N '
Date Contractor ,
ARCHITECTS DECLARATION 201.1000 AMPS _
q�q�uu NO 7OI understand my plares,hall W used as publle remds. OVER IOW AMPS SQ.Ff.FLOOR AREA f/SQ.Ff. .
FG z ELicedsed Professional SIGNSELECTRICAL
I
<6 w OWNER-BUILDER DECLARATION
n
7� Iherebyafflrmthatlam exempt from the Contractor's License Law forth¢ SPECIALCIRCUIT/MISC
'
pO following moson.(Section70115,Buslnessand Professions Code:Mydtyor
�Zt-u9
county which requlresa permit to construct,alter,Improve,de=lbh,or repair TCMP.MEIV20RI'OLEINsf. -
q� anystm=m priorto Its issuance,also requlresthe applicant for,uch permit to
6 r file a signed statement that he is licensed pursuant to the pmvblons of the POWER DEVICES .,
FE QContractor.License law(Chapter 9(ce.ocing with Seeded 7000).f Divi-
s1on3 of the Busmessand Professlom Code)orthat he is exempt therefromand SWIMMING POOL ELECTRIC " VALUATION
<•-' the basis for the alleged exemption. Any violation of Section 7011.5 by any OUTLRTSSWITCHFSHXTURES
o
appU.tf.rapmil
et.ubie theapplicanitoadvilpemityofnMm mthan s� ✓ `l
pjfive hundred delta. NEWRESIDENTIALELECIR FT.
QQ
01,as owner of the property,or my employees with wages as their sole —SQ.Fr. STORIES TYPE CONSTRUCTION
compenutlon,wB1 dothework andthestmcture isint blend d or offered for
R O sale(Sec,7044 B.,Iness and Profemloru Cade:The Contractors License Law -
$ does not apply to an ownerof property who Wilds orimproves thereon,and
�^ whodomsuchworkhm Horthwghbisownemployees,pmvidedthatsuch �+_' OCC.GROUIs RFS.UNITS
improvements are not Intended ororfered for sale.If,however,lhebuilding or T a i•�
improvement lssold within one yearofcomplMlon,the owner-builder will have
I�a died or proving that he did not build or Improve for purpose of sale.). QTY, " "� PLUMBING PERMIT,: FEE
tFhOOD ZONE APN
J L d a,owner of the property,am exclusively contracting with Ikena1'FRMITISSUANCE
contractors to construct the project(Sec,7044,Business and Professloru Cade:The Contvdorb License Law does not apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA) ,
Wilds or Improves thereon, and who contracts for such opjacts with a FEE SUMMARY
ce dorts)Ilmn. punuanttothe Coat.cm,.Limma Law, BACK FLOW PROTECT.DEVICE
LI I am exempt under Sec B k P C for this rcawn
Owner Date DRAT NS FIAO ROOF ARCA, SA Y Y_ N=
RECFL f N
WORKMAN COMPENSATION DECLARATION pD(TURES OOL AX Y N
01 hereby affirm that I have a mrtlficate of commot to mfr-Inwre,or RECEIPT X
udifluteor Workers•CompensationlmumnmoracedifWmpythereaf(Sec. GAS,EA SY - I C FFE Y_ N_
3X00,fab C.)
Po11ryX GAS EA.SYSTEM-0VER4(FA) RFGCITp
Crab ry BUILDING DIVI ONErrs
LJ Certified copy Is hereby famished. GREASE/INDU ECK FEE r
Certified copy bfiled with the city inspection divielon. `
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA200FT, 'DB[e RCWI lY �—
(this section need not be completed if the permit b(orone .hundred dollars -
(f1W)nrlaasJ• baWATER HEATER W/VENT/ELEC'fR - ENERGY L•E Y N
I certify that In the performance of the work for which this permit Is Wood,
I shall not employ any person In any manner w as to become subject to the WATI7t SY51FM/TREA77NC .
Workers'Compensation L..of California.Data PA
QU—
O Z Applicant NEW RESIDENTIAL PLMB._SQFT. Date RCcei t#
Z O NOTICE TO APPLICANT-.If,after making this Certificate of Exemption,you
F N should become subject to the Workers'Comperuatlon provisions of the Labor
a. Cade,you must forthwith comply with such provisiow or this permit shall be
LUTorsi:j deemed revoked.
LENDING AGENCY SEI
IL I FEE
Ihareby.mrmthatthembamnstrodlonlendingagencyforthepadnm. -ELECTRIC FEE
7 Z ance of the workfor which this permit is Issued(Sec.3097,CIV.G.) -
U O. Iandar.N.ma PLUMBING FEE
LL F Lenders Address QTY. MECHANICAL'PERINIT,` .FEE MECHANICAL •E
OW Imrtifyth.tlh.acreadthis.ppliatio...dnatethattheabovemforrades,
4 bcormd.I agree to comply with all city and county ordinances and state laws PERMTTISSUANCE FEES PAID:
} W relating to building construction,and hereby authorlra representative of this
r city to enter u Pon the abovcmentlond property for inspection putrposes. ALTER OR ADD TO MECH.
Z
Z (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
a Samdh.bIIBlr,jud47 matsand expenses which mayin any wayaccrue AIR HANDLING UNIT(TO 10,000 CFM) S BTOTAL:'
aga uul y i nm of the granting of this permit.
/1� � Z?, z. AIRHANDLING UNUT(OVER I0,000CFM) CONSTRUCTION AX
nSignsture !a p Tc it Cont actor D. ON/ EXHAUST HOOD CONSTRUCTIAX PAID: '
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous 1 fEA77NG UNIT(TO 100,000 BTU) Date R CI [
material a.defied by the Cupertino MurddpaI Code,Chapter 9.17,and the -
tj
Health and Safety CdeSedlo 32(a)7 HEATING UNIT(OVER I01),000 BTU) TOTAL. L
Yes o
Ill the applicant or futum Wilding occupant use equipment or devices VENTILATION PAN(SINGLE RESID) SUANC-E DATE
which emit hamdous air contaminants as defined by the Bay Area Air PAW
lJ
Quality Management District? - BOILER-COMP(31II1OR100,OWBTLB
Ya.
4o
have cess the ats materials requirements under Chapter 6.95 of BOILER-COMP(OVIR 100,000 BTU) .FEB 251992
the California Health k Cod,CSections 25505,25533 and 25534.I
understand that if the building does nut currently have.tenant,that it It my NEW RESIDENTIAL MECI'L SQ.IR. '
responsibility to notify the occupant or the requirements which must be met
Ind or Issua of ific4p of ccupanty. CITY Ur Uur ,Gn I UIV
Owner or aulird agent pall TOTAL: ISSUEL)g
OFFICE COPY