23827 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY '
Building Project Identification Q IJS/ /�u PERMIT NO.
liuilding Address: 1�^(�N�
z'a2lp e a �' G38G
i-ovn'. one: -
a, s�Jje CITY OF CUPERTINO-BUILDING DIVISION
on iidgame: Lie•No: APPLICATION / PERMIT f
BUILDING-ELECTRICALPLUMBINC-MECHANICAL CATEGORY CONTROL is
' Architect/Engineer. LI o: '
! KJ Y /TT .Qtt(I� "ELECTRIC PERMIT 1 i' •FC•E, ' i., T'BUILDING PERMITINFO '
., .... '
Addmsr 9i/ f�"�� PERMITI55(IANCE e—
�. ._
LICENSED CONTRACTOR'S DECLARATION
Iherebyafftrmthntlemlicensed under providonsofChapter9(mmmenc APPLIANCESRESIDENML !1 JOB DN<RB'TION
Ingwlth Section 7000)0(4 effect.
ofthe Bue nand Pro(eselonsCodc;and my
ingwit b in full tors and effeci. PANELS r /_
Lhxnse Chs(r-/n We.N VV �/ -
D.hp�!/ Contractor /: r L 124 7 /�
9! �O.G/�
-- _�A �cPS EC RATION 201-1010 AMPS
q�q�uu ON pZ tan b1crecreds. OVER I ODD AMPS SQ.FT.ILOOR'AREA S/SQ.FT.
k zLleefiard Professional SIGNS ELECTRICAL
<<< OWNER-BUILDER DECLARATION
rl'i 3 SPECIAL CIRCUIT/MISC
owing r asonnlhat on 7031Z,
B from Business
d ProfctsionsC rase Lw(canoe
following reason.(Section mb,to Business and Professions Code:Any city it
O H� TEMP.MEfER ORIOLE INST.
county which requfreea pemNt to comtmct,alter, demolish,
OVanystrocture prlorto its issuance also requlrcstheapplicant for such pernatto POWERDEVICES'
O c.U fila a signed statement that he b licensed pursuant to the provisioi of the _
Contractor's License Law(Chapter 9(commen o th Section 7000)of Divi-
� B SWIMMING POOL ELECTRIC
slon3ofthe Buelneesand Pro(emioruCade)orthat hers exemptlherefromand VALUATION
< the basis for the alleged exemption. Any violation of Section 7011.5 by any OUTLETSSWITCHESHXTURES s
applicant fora permit subjects the applicant to a civil penalty of nee more than
five hundred dollars($50(B. NEW RESIDENTIAL ELECTR SQ.Fr.
�n ❑I,as owner of the property,or my employees with wages as their sole STORIES TYPECONSTRUCTION
compensation,will do the work and the structure isnot intended or offered for
m O ale(Sec.7094,Business and Professions Code:The Contractors License Law
1,} $ does not apply to an owner of property who Wilds or improves thereon,and OCC.CROUIs RFS UNITS
CC.. who doe.such work himself or through his own employees,provided that such _.
improvements arc not Intended proffered forsale.If,however,thebullding or - - TOTAL:
improver ntissoldwithinoneyearofcomplMiorytheowner-WBderwill have
r t Iden of proving that he did notbu0dorimproveforpurposeofale.). QTY. ��.,'„ 'PLUIVIBINGPERMIT�:1�" sr', .FEE"+ FLOOD WNE APN
j1,as owner of the property,am exclusively contracting with Ilmosed
mntmdm to construct the project(Sec 7064,Business and Professions Code: PERMIT ISSUANCE
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EM'
Wilds or Improves thereon,and who contracts for such upiects W'th a " FEE SUMMARY '
0t(scions)licensed pursuant to the Contractor's License Law. . BACK FLOW PROTECT.DEVICE
Cq
L5 I am exempt under Sec.' B&1P C for this reason
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
• REC N '
\ WORKMAN COMPENSATION DECLARATION pD(TURES PER TRAP SCIi(30L TA% Y_'-N
❑i hereby affirm that 1 have a l d rare sof consent to self-Insure,or RECEIPT If
¢rtifisveofWorken'CompewtlonlnsuranceoracertRlad ropytM1emof(Sec. GAS EA.SYSTEM-1 WC.40UTLETS PARKFEE Y N
3800,Lab C.) RECEIPT N
I o11cyaM GAS IA.SYSTEM-OVER4(EA)
Com nv ) ( flU1LDING DIV]SION PEES
❑pCeniiied copy b herebyth the cid. GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy V filed with the city Inspection division
CERTIFICATI OF EXEMPTION FROM WORKERS'` GREASE TRAP PAID
COMPENSATION INSURANCE SEWER SANRARY -
(rhlstaction need not be completed lithe permit Marcos hundred deltas STORM EA.20OFT. Date Re i t#
($10D)
I - N
mor de.at N the performance of the work(orwNch this permit le atWATER HEATER W/VENT/ELECTR ENERGY FEE Y
sued, —
I sha11 not employ any person In any manner n as to m
becoe subject tp the WAT[IR SYSTEM/TREATING
Worken'Compensatbn Laws o(Cali(omla.Date . . PAID
Z Z Applicant NRWRESIDENTIALPLMB. SQ.T. Date Romi t#
Z p NOTICETO APPLICANT.If,after making this Certificate of Exemption,you
~ .
should become subject to the Workers'Compensation previsions of the Labor TOTAL:
N Code,you must forthwith comply withsuch provisions or that permit shall he
W j deemed revoked. _ - LD
ING FEE
CL c I CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency forthe perform- ELECTRIC FEE
Q anreofthework(o�wtr�p,�h0 Ib issued(Sm.3097,CIv.C.) TOTAL:
V _ Lenders Name p`�+ t, PLUMBING FEE - -
LLF Lender'.Addreas - • - QTY. ;ME_CHANIC•AL-PERMIT" ;, FEE',(* MECHANICAL FEE '
.O W Imrtifythatl have read lhisapplicalionand statethal th¢abovelmormation
IL iscormct.Iagree to comply with all cityand county ordinances and state laws PERMIT ISSUANCE FE SPAID' /
relating to building construction,and hembyaulhorize mpresentativcso(this - —1/l--T/Y-fX
N 2 city to enter upon the above-neatloned property for inspection purposes.' ALTQRORADDMMECid.
(We)agree to ave,indemnify and keep harmless the City of Cupertino Da�. Receipt#
V against liabilities,Pdgments,mks and expenses which may in anywayacerm AIRHAN1)LiNGUNIT(rOIQ000CFM) _ SUBTOTAL:
Cuy kiruc�)%Z of this permit AIR HANDLING UNIT(OVER 10,000 CIM) CONSTRUCTIONTAX
x -
o(AppllcntrDate FXFAUST HOOD(W/OUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS td.m E
Will the i,fireirat the use ruin ngoccu.ICmI,Ch. mr9.hawrdous HEATING UNIT(TO 1(D,(IOOBN) - Date Reeel t#
materials.defned by the Cupertino Municipal Codc,Chapter 9.12,and the
He❑ yea
Safety CodeL�jS�eNoon 25532G)7 HEATING UNIT(OVER 100,11017 BTU) .,"{N�.,ONTAL:
Will the applicant or future building ocmpmrt use equipment or devices VENRLATION FAN(SINGLE RESID) ISSLrAAE1D9TE
which snot hazardous air contaminants as defined by the Bay Area Air
Quality Management ErdA07 BOILFR-COMP OHPOR 100,00)BTU)
yes
radthe ha3ardp�]
No JUN 12 1992
4have ns materials requirements ender Ghapier 6.95 of MER-COMP(OVER700,000 BTU)
the California Health&Safety Code,Sections 25505,25533 and 25534, 1
understand that if the building does nolagriently have a tenant.that It is my NEW RESIDENTIAL MECH. SQ.FT
responsimut to notify the pampa t requimmentawhichmuatbemet C��Ir of L;urrn I IIYt.7
p' rlp an sofa c ancy.
mod. /f G,a /�/1/V1/[/�
au vdmd agent . . / Date ISSUED13 /' -! • .
\J TOTAL:
OFFICE COPY .