23888 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Pre'ect Idenaficatlun - - PERMIT NO,
Building Addmaa:
23888
�j
G0// %/ eto.a CITY OF CUPERTINO-BUILDING DIVISION
°ntrattnr.NaT APPLICATION /,PERMITAmok
�•" s� N3 •� r 7 L'- BUILDINGF],ECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROLM
Archi / glneer. Lle:No:
"Q'n ,�! ELECTRICPERMIT ,It FEE .I '.� !I" PLUMB
Address: .-. l PERMIT ISSUANCE ❑ C—/I '❑ . ❑
LICENSED CONTRACTOR'S DECLARATION - l_YJ
I hercM1y affirmthatlam licenced under provieimna o(Chapterm
9(comnnc- APPLIANCES-RESIDENTIAL JOB DESCRIPTION '
lnlicense
1.ectbnf eenefDieffect oftheBuslneesand Pro(essloneCode,and PANELS
to Li.a.Clae(yull y- kMR � 'OL ��
Date C/2 Y� Contraar �IA?4'
ARCHITECTS C RA 1 N 201-10DOAMPS
07p ]understand my phv elull be used apubllc records. DYER 1000 AMPS e; IID RARFA S/SQ.FT.
Licensed Professlovl - SIGNS ELECTRICAL �=' -.: �...,
L�
6 OWNER-BUILDER DECLARATION
(here affirtnthatiam ea m fromthc Contnttore Lirenm law for the SPECIAL CIRCUIT/MISC
Z9 p'
followingreason.(Section 7811.5,Business and Professions Code:An cit r -�
FLT.It❑❑+�I o p° TEMP.METERORPOLEINST.
county cture requBna issuan ealsor un,alt e.thea provers fors chpr mit tr
g
anystructure Friesen its Issuance,alcensed pursuant
to the
of permit POWER DEVICESCmi1IL
W63f9 rNG file a signed statement that he b licensed pursuant it tSe pro7000) of the _
O al.o 3f the Llcevenaw(Clupler9Commencingwith xenlon7000)a Divi- SWIMMING POOL ELECTRIC O
the bass for theev and Profptions An violationhat of Szem therefrom and VALUATION
the basis for the alleged exemption. Any violation of nalt ane)1.5 by any OUTLIT SSWITCHFSFIXrURES -
`ra'�" p aPPllranttora permit aubjeda the applicant too civil penalty of not more than
$� five hundred dollars(S500). NEWRESIDENTIALELECTR SOFT. SI'OIEIS TYPE CONSTRUCTION
�n ❑I,as owner of the property,or my employees with wages as their In
compensation,will do the work and the structure is not intended or offered for
HO salt,(Sec.70K Business and Pvfessiom,Code:The Contradore License Law
�$ does not apply to an owner of property who builds or Improves t hereon,and
^ who does such work himself or through his own employees,provided that such OCC.GROUP RFS.UNITS
Improvements are not Intended oroffcredforsale.If,however,thebuilding or T
Improvement 6aold wltMnoneyearofcomplellon,the owner-builderwlll have
tjtTilyden of proving that he did not build or Improve for purpose of sale.). 'QTY,' PLUMBING PERMIT FEE y FLOOD ZONE APN
u I,ore owner of the property,am exclusively contracting with licensed I'FRh11.1.ISSUANCE
to outrun the project(Sec.7044,Business and Professions Code:
The Contractor.License Law does net apply to an owner of property who ALTER-DRAIN&VENT-WATER(PA)
Wor Improves.heron, and who contram for such p(ojem with a 'FEE.SUMMARY
cgp(raetor(s)licensed pursuant to the Contractors License Law. ,( r �
LII am exempt under Sec B&P C for this reason BACKFLOW PROTECT.DEVICE01 1TQ 11117�IzE
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Data RECEIPT R
WORICMAN COMPENSATION DECLARATION FIX'NRES PER TRAP SCHOOLTAX Y N
❑I hereby iffirmWorkers'
thaCo I have o cenlBrem of consent to op thereof
(S a
�--
3800,Lte ofad,
Workers Compevatlonlvunnre ore certified copy thereof(So. GAS EA.SYSTIM-1 INCA OUTLETS PARK FEE RECEIPT
�./. Palle N CJ _
I'°Ilry p GAS FA.SYSTW-OVER 4(FA) RECEIPT'x
Cc any - BUILUINC DIVISIONITf:S
[fCenlRed copy is hereby furnished. CREASE/INDUSML WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy I.filed with the city Inspection division.
CERTIFICATE OFF EM PTION FROM WORKERS' GREASE TRAP '1 PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM PA.WOFT. Date ReC i tri
(This section need net be completed if the permit hiferone hundred dollars P
(9100)orless) WATER HEATER W/VENT/ELE-CTR - ENERGY FEE Y N
Icerunrtify emplhat oy
anhe pert°rmanc any of nohe woek va as to be. subniect to the I shall not employ any person In any manner n v to become subject!o the WATER SYSTEM/TREATING.
Workeri Compevatlon Laws°fGII(omia.Date 'PAID
Z
NOTIC
Z -
z NOlicaE
Applicant
APPLICANT:If,after making thO Ceniflnle of Exemption,you NEWRG4DENT1ALPI.M11. SQ.FT. Date Recei til
should become subject to the Workers'Compensation provisions of the Labor TOTAL:.
w
Code,you=at forthwith omplywlthsuch prehdons orthh permit shallbeCC BUILDING
CCC decried revoked.
d FEE
CONSTRUCTION LENDING AGENCY _ SEISMIC FEE.
I herebyaftirmthatthere is a construction lendingagency forthe perform ELECTRIC FEE ^�
Z anceofthe.,itferwhichthis permit is iswed(9ec.3097,Ch,.C.). TOTAL:
O O Lender's Name - PLUMBING FEE
F Lenders Address QTY.1' MECHANICAL PERMIT '' FEE
Ow Icenuythaslhavereacithb applicatlonand statematme above information - MECHANICALFEE
CL Incorrect.l agree to comply with all chyand county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. relating to building construction,and hereby authoris mpreeemaevn of this - -
I� Z cityto enteruponthe abovtmentlimrd property for Inspection purposes. ALTERORADDTOMECH. Date' Recel to
_ Mr)agree to save,Indemnify an d keep harMess the City of Cupertino -
agaWtliabilities,judgments,costs a ratexpenses which may in any way accrue AIR HANDLING UMTrr010,000 CFM) SUBTOTAL:
against said City in consequence of the gra nUng of this permit. -
AIR HANDLINGUNIT(OVER IO,000cru CONSTRUCTION TAX
Sigwtum.(Applicant/Contractor - Date ExHA➢sr HOOD(W/DUCD CONSTRUCTION TAX PAID:,
HAZARDOUS MATERIALS DISCLOSURE
Will theapplleantorfuture building occapantamreorhendle hazardous HEATINGUNITOO100,00011TU) _ Date RCCCIpIN
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
I ealth and Safety Code Section 75537(11)7 HEATING UNIT(OVER 100,000 BTU) TOTA �
❑ Yes rj No
Will the applicant orfuturc building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) p� ISSUANCE DATE
which emit hazardous alrcontaminsntsas defined bythe Bay Arca Air - r A I �J'
Quality Management DlsMtt7 BOILER-COMP OFR'OR 100,000 BTU)
I Yea No
haveread theh.&r fmy Codd ls Sections
2555,2553 and 25534.
of BOILER-COMP(DVFR 100,000 ETU) JUN 24, 1992
the California health&Safety Code,Sections ntly h,75 a t and 75534. I
understandyt not
wilding don of t erequire entsw which
that It met NEW RESIDENTIAL MECH. SQ.FT.
responsibility is naify the avpant of the requirements which moat be met CII'i lJf (vllt'CIIIIIVV
prior to Issuance of a! tcateof pa ory.
Owner or author d agerif Date 155UEDBY:�ise�il
TOTAL:
OFFICE COPY