23413 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildingProject Identification - _ PE Ivill NO.
BuEdddrem: - (40 _ S _ 23413
_ wner. ame: one: A A
CITY OF CUPERTINO-BUILDING DIVISION
cqn dor.N me Lk. o: APPLICATION I PERMIT •
.r s BUILDING-ELECTRICAL-PLUMBINGMECHANICAL CATEGORY CONTROL#
A d/Engi ee .Lie o
QTY a 1, 11
ELECTRIC PERM IT FEE "' ";BUfLDINC PERMIT INFO
Address: - PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION iTIO
IMhb iolm+thatlaiv Bcen3ofthe usimvlalonsofenionsCode, mere APPLIANCES-RESIDENTIAL , JOB DPSCRBrITON
Ingwlth 1.Inn7000)o(d efeon3oRhe Buslnessand Pro(esslonsCodn,and my
license is In . cad effect 7j � ''Y PANELS '
License ass. LIc.N CI I .�
DaleContradorUP TO 200 A S
ARCHITEeuSD rublic ON OVER
�pp�uuraz cc Iuntlentand my phm shag be used as public recarda OVER 10(10 AMPS SQ.77.FT.00R AREA S/SQ.Fi.
E� Licensed Prolealanal - SIGNSELEOTRICAL
<Q OWNER-BUILDER DECLARATION
In a
L., asormthI.mmecrpt from doreLicense hw fore he
SPECIALCIRCUIT/MISC
7following reason. 7llI,S,Business and Professions Code:Any city or
-
TEMP.MCTPA OR POLE WST.'
r� county which requlma Issuantomrorequialter,implica tlemol4h,arrepair t
any atndurc priorto statement
Issuance,Wored!pursuant to7cant rowastomoor such fNtto
e POWER DEVICES
file a dgned statement that he V Ilcensed pursuant to the tion7X ns f the
SOSOn Con3ofth eLicense ximessaw(Chapter9(cammendng with SempitherefXB of Dlvl- VALUATION
eicn3otlhe Business and Pro(esslom Code)orthat hehexempitherefromand SWIMMING POOL ELECTRIC � .
6 5 the basis for the alleged exemption. Any violation of Section 7MIS by any OUTLETSSWITCHF- FIXTURES.
applicant fora permit subjeststheapplicant to a dull penalty of nut more than
o live hundred dollars($500). INEW RESIDENTIAL ELECTR SwlF STORIES .TYPE CONSTRUCTION
GQ1 F1 I,as owner of the property,or my employees with wages as their sole
compensation,will do the work,and the structure Is not intended or offered for
OIn(See 70K Business and Professions Code:The Contractor.Lt..Law
3$ does not apply to an owner of property who builds or improves thereon,and OCG CROUP RES.UNITS
does such work himself orthrough his own employees,provided that such
Improvements are not intended motioned for sale.If,however,thebuliding or TOTAL: _
Improvement bsold within oncyearotcomplMbn,theowner-buiderwill have
trye�nrden of proving that he did not build or improve for purpose of sale). QTY. �'.1•• •,PLUMBINCTERMIT, eFEV FLOOD ZONE APN
Ij L as owner of the property,am exclusively contracting with licensed r PERMRISSf1ANCE w�
contractors to construct the project(See.7044,Business and Professions Code; l
The Contractor's License I<w don not apply to an owner of property who ALTER-DRAIN&VENTWATER[P.A) _
Wild. or Improves thereon,and who contracts for such p - -
toje with a )IFEE:SUMMARY,
agp(pdm(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
IJ I am exempt under Sec. B k P C for tuts reason
DRAINS FLOOR,ROOP,AREA,COND. SANITARY Y N
• Owner ECL RECEBrr N.
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP OD SCHOOLTAX Y_ N
'hereby affirm that I have a cartiBnte of consent to self-insure,or RECEIPT N
mRcateofWorken•CompensatlonlnsuranmmaceAlfWmpythemof(Sec.
38 , b e S CAEA.SYd INCA PARK ITE Y N
00La
Policy 0 I a)�,�,�` GAS EA.SYSTEMAVER 4(EA) RFL 11`17 K
Com any /• - BUILDING DIVISION FEES
Cc
ropy b here hthecity
famished. CREASE/INDUSTRL WASTE IMFRCEPTOR PLANCFIECK FEE
�edl(Ied copy Le filed with the dty lrupeRlon division. .
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.2WFT. Date ReceI t#
Cl is section need not be completed It the permit is for one hundred dollar P
($100)orfy that ceor. - ENERGY FEE Y N—
I
an the performance of work for this permit le Lased, WATER HEATER W/VENT/ELEOTR
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATINGWorkers'Compensation Laws of Callfomia.Date PAID '
O Z Applicant - NEW RESIDENTIAL PLMB. SQF(. Date 'RCceI t#
Z O NOTICETO APPLICANT:If,after making this Certificateof Exemption,you
'F should became subject to the Worken''Compnuatioo Prov is .of the Labor TOTAL:
.� N..
Code,you=at fort hwith comply with such provisions or this permit shall be BUILDING .
W j deemed revoked.CONSTRUCTION usa ON LENDING AGENCY SEISMIC FL•G
'dC Therebyaork for
Lacamtis tion lendingIssud(Sec. agency MCIvorthe perform- -
0 Z .nese(the work!or which this permit Lleved(Sec.309],CIv.C.)
TOTAL: _p ELECTRIC IEE
C1 O I<nder'a Name PLUMBING FEE
I— Lendnr.address QiT. 'MECHANICAL PERMIT PEES
'O O Imdlfy thatl have read thisappiteation and statethat theaboveleformation MECHANICAL FEE
111
IL Ismured.I agree to comply with all cityand county ordinances and Yate laws PERMITISSUANCEr FEES PAID:
). N relalingtobullding construction,and herebyauthorize representativesofthis
~ Z city to enter upon the above-m<ntiomd property for inspection purposes. ALTER OR'ADDTOMECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino - Da[C Receipt#
V against liabilities,judgments,costa and expenses which may in any way accrue AIR HA NOLING UNIT(TO 10,000 CFM) SUBTOTAL:
again Id City in aonseque ofthe an gof spermit. ,
AIR HANDLING DNTT rovrx lB,000 cnf) CONSTRUCTION TAX-
. narco AppEcant� Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: . . .
HAZARDOUS ERIALS DISCLOSURE _ +4
Will the applicant or future b. ing occupantstore or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei tit'
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and SafetyCoder.�Sed1on 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
u •
❑ Yes No '
Will theapplicant or future building part use equipmenterdevicn VENDLATION PAN(SINGLE RESID) ISSUANCE DATE
which emit hamedous air contamlrunb as defined by the Bay Area Air"
• Quality Management District? BOILER-COMP OHPOR I00,"BTU)
4 Yes d No
haveread ealtha Let mateddi requirements
ons 2505,25533 aChapter. 1 of BOR.HR-COMP(OVEI(100,000 BTU)' f AID the
erstandt HealthbSafetyCode,Sedlrrentl05,ti a tenantnd,
that I
rcdp standthat Rthe fy the occupant of
of t errentlyhave menta hick that it is my.et NEW RESIDENTIAL MECH. SQ.F7
rnponsibWty to of a Cehn cafe o cat Occupancy,rcqulrements which must be mets
prior to Lauance ola Certllkate of Ocevpanry. 16 t 1992
Owner or authorised agent Date
ISSUIiDA ' y till
TOTAL: 1. fT *
OFFICE COPY