24400 APRLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Foaled Identification PERMIT N 4 T V o
.1jidIlding Address:
�t l�LtO -� CVeiA G ek (3l�sd . Gu 9U,1%Kd C� q �P
caner mc:
IfA LK TY OF CUPERTINO-BUILDING DIVISION
Contract 'sN Lie.No: APPLICATION / PERMIT L ^t
�' *f'A •§�stw� BUILDING-ME TWCAL-PLt1MRING MECHANICAL CATEGORY CONTROL N
�Archited/• gineer.
BUILDING PERM_ IT INFO
�. •,,,' QTY ,,1 j.ELL EGTR[C PERMIT ,' A,,FE6.q )
Address:
PERMIT ISSUANCE ❑ e�j ❑
LICENSED CONTRACTOR'S DECLARATION LJS
I hereectlonr70 t0)of Iv Bcenseduderprosanci roesdonsr9(rommma AP[7.IANCESRFSIDCNTAL JOB DESCRIPTION
ingwe .Infull farm
effect.
30fthe Busineasand Pro(esslonsCode,and my
licensLicense
b i"full force and CA PANELS
License Class
Date Contomb - - r—V.l_a •��f / �!
' rsctorUP TO 2DO ANIPS
ARCHITECTS DECLARATION 201.1000A.MPS
Op❑. I understand my plans shall be used as public records. OVERIMOAMI5 SQ.{T.FLOOR ARG §/SQ.Ff.
�U Licensed ProfesslOnel SIGNS ELECTRICAL .
�< OWNER-BUILDER DECLARATION SPPGALC?RCUIT/MLSC
7L, I hereby affirm that l am exempt fromthe Contractor's License Law for the
op folk wing reason.(Section 7015,Business and Professions Code:An d or
OZI"'q❑q�y c°un whichre 1 Permit to construct,alter,lm Y Pa TEM P.METpt ORI'OLEINST. -
F� 3 t quresa pe promotfreOBSM1,Orre Ir
1 3 le awcture statempdortoent
its that
hec licxmsalso pursuantires to
forsuch s of t e
C floe a algned statement that he b licensed pursuant it the provisions of the POWER DEVICES
3wp Contracmrb 1.stressicense aw(lofeadr9(mmmencingwlthSection xampthcmfof Divi-
cd SWIMMING POOL ELECTRIC r
alebasisie BuslnelegodProfessions Any
rthA lation laexem tberetromany VALUATION
IM1e bash(or the alleged exempilon. Any violation o!Sedbn 703L5 by any
locant for permit sub' stheapplicant to a civil nall of not morethan OIITLETSSWITCFIESHXIURES
'WPP P Mctpenalty
flu net Owner znhe W). I NEW RESIDENTIAL ELECTR
7< ,as owner of the property,or my employees with wages [herr sole �'rT' SCOWGS TYPECONSTRUCTION
neat0K Buldothe work and the sCodure V not Intended or coffered for
a�❑ (Sec 76x6,Business and Professiow Code:The COninctors License law ,
Q S does not apply loan owner of property who build@ or Improves thereon,and
whodoeasuahwork himself orthrwgh hisown employees;providedthat such OCC.GROUP RIS.UNITS
Improverrcnts are not intended oroffered formic.If,however,the building or 'TOTAL:
improvement issold within one year°!completion,the owner-builder will have _
the Orion afproving that he did net build or improve for purpoaeo(eakJ. QTY. PLUMBING PERMITFEEFhOOD ZDNE APN
TeTip ac owner of the property,am exclusively contracting with licensed
cont doss to comtrod the proper(Sec.70K Business and Professimu Code: PERMIT ISSUANCE �
The COntrsctor'e License Law does net apply to an owner of properly who - ALTER-DRAIN&VENT-WATER(G)
hudds or improves thercron,and who mntncts for such ptojecia with a
cq➢t(actor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE . t' ,FEE SUMMARY
Lf I am exempt under Sec. R k P C for this reason
QUIN 1121'L111
Owner -Date - DRAINS FLOOR ROOF,AREA,COND. SANRARY Y_ N
WORKMAN COMPENSATION DECLARATION - RFLRIM'X
1� QI hereby affirm that 1 have a certificate of consent to self-Insure,or a F0('IURES.PER TRAP SCHOOL TA)( Y_ N
certificate of Worken'Comperadion Insurance ora comfred ropythercof(Sec. RECEExT N
MOO,Iabc.) GAS EA.SYSTEM-1 INC<OUTLETS PARKFEE Y_ N
Poli
Camryan GAS EA.SYSTI]N-OVER 4(EA) DING DI N
Y BUILDING DIVISION FEES
MCertifld copy is fiereby-dwtumecity GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
�CcrtNetl copy Ls(Iled with the city inspection division.
CERTIFICATE OF FXFMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE -Sp ARY-STORMEA 200FT t - �'• Date Recef [#
Rhos sedloo need not be completed lithe permit is!°tune hundrod dollars
($100)orl tha WATER HEATER W/VENT/F1 TR ENERGY FEE Y _ N
I certify thato the persounceofthework wastobmforwhich this pemdt is rimed,
1 Whale not employ any Laws In any manner a0 as to become subject to the WATER SYSTEM/TREATING
WOrken'COmpensatlon laws of California, Date PAID '
O Z Applicant Date Recei t#
Z O NOTICETO APPLICANT:If,after making this Cedificaleof. ExemptionNEW,You NRESIDENTIAL PLMB; SQ.Fr,
should become subject to the Workeri COmpewtion powis me,of the Labor TOTAL:
= U) Code,you=at fort Ovid,comply with such provisions or this permit shall be BUILDING j deemed revoked.
a'G CONSTRUCTION LENDING AGENCY SEISMIC PEE
I hereby affirm that there is a construction lending agency for the perform- ELECTRIC IT.E
Z
an.of the work for which this permit is edged(Sec.3119'/,Civ.C.) ' TOT
00 Landers Name , - � PLUMBING FEE
LL F Lenders Address - QT'Y. ','MECHANICAL�PERMIT 'FEE'. MC•CHANICAL FEE
O W Icertifythatl have read thlaapplicetlon and state that theaboveloformation
Ismrred.Iagreetocomplywlthell cltyand muntymdlnancesand state laws PERMIT ISSUANCE FEES PAID:
} C relating to building construction,and herebyaulhrepresentativesiz,representatives ofthis
Z cRytoenterupon the above-mentlooed property for inspection purposes. ALT[RORADDTOMECH, Date RCCCI
_ (We)agree to save,Indemnify an d keep harmless the City of Cupertino Pt#
t.gainst liabilities,judgments,mks and expemeswhlch mayln anywayaccrue AIR HANDLING UNIT CFO 10,00B CFM) SUBTOTAL:
galnsfsald City In c° squenmofthugranting thiapemit.1j��. AIRHANDWNG UNIT(OVER IO,OWCFM) CONSTRUCTION TAX
I tureof AppIJ at/Contradfle EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Illtheapplicant or furore building Occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)
mDate RCCCI t#
merlal as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Eicalth and Safely Cde Sedlon 25532(@)? HEATING UNIT(OVER 100,000 BTU) .TOTAL.
MWillbthe applicant orNO building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hanrdous air contaminants as deflned by the Bay Area Air -
QualityManagementDistrict? BOILER-COMP OIR'OR 100,000 BTU)
4Yes g�I No
havercadtheha ousmaterialsrequlmr nbunderChapter6.95of BOILER COMP(OVERID,000BTU) PAID
the Calofornla Health k Safety Code,Sections 2M5,25533 and 25534. I
\, understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT OCT 27 1992
rmpoodbility,to notify the occupant of the requirements which must be met _
Prior to issuance of a Certificate of Occupancy. ,
CITY
Purser or authorized agent Date -
TOTAL: ISSUED BY:
OFFICE COPY