22959 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES = USE BALL POINT PEN ONLYB. '
" 0 IIulldingAddress;ildln ��tlaentlfioJlan O � PERMIT NO. •
lV11 . 22959
ersPh.re7 IL
CITY OF CUPERTINO-BUILDING DIVISION ' -
t°^tr•n°:•N•n : Lic.No: APPLICATION I PERMIT
- - BUILDING-Q,ECTRICAL-PLUMBING-MECla LAICAL CATEGORY CONTROL It
Architect/Lnglneer. Lic.No:.
+QTYCTRICPERMITpF
BUILDING PERMIT INFO PI _ +
- '. y ELE '_' ,.� EE''
Addieda: - .`' - PFRMITISSUANCE .rIw ,
rul
LICENSED CONTRACTOR'S DECLARATION 0 . .'
Thereby affirenthat l areheresed under provialonsof Chapter9(comment, APPLIANCES-RESIDENTIAL -JOB DISCRUHON
limteeIs ca(un�-ref. °(tine Bualnneand Prp(esaipnsCode,and my PANFIS
License ClTss Lic.p I�VTO_'JG \'J ,"C
Date' 1 ContractorOAHM*
ARCHITECTS DECLARATION X11-1000 AMf5 -
q�q�uuaOZp [understand myplansshallbeusbdaspublicrerordsOVER1000AMPS SQ.Ff.FLOOR AREA $/SQ.FT.
6d Licensed Profess3cnsl SIGNSELECTRICAL
6 OWNER-BUILDER DECLARATION E-f^p '
es I N
tees,] SI'ECIALCfRCUIT/MISC
FQul I hereby affirm that I am exempt learn the Contractar'e License Law for the '
0 2 q following reason.(Section 7031.5,Business and Professions Code:An d or
F 1'q county which requires a permit to retained,alter,Improve,demolish,Any
7L•MP.ME77R OR TOLE[NST."
1 a❑❑a file
prlorto its issuance,aborequlrea the applicant forduch permit to POWER DEVICES
(--
c4 U', file a signed statement that he b licensed pursuant to the provisions of the
3w� Contractor.License Law(Chapter9(cmenexecing with Section 7000)of DWI- SWPiMING POOL D.EGTRIG E ATE
-
�0� sloe 3 ofthe Been.and Professions Code)or that he is exempt therefromand
the bast•for the alleged exemption. Any violation of Section 7031.5 by any O Were
applieant lots permetsubjecutheapplicanttoadvll penalty ere morethan
live hundred dollars he Pro NEW RESIDENTIAL ELECTR SC O TYPECONSTRUCTION
I,sa owner will
the property,or my employees with wages r thele dole SQ.Fr.
compensation,wBldathe work and the Cmcture to not intended or°!(seed for
$ q sale(Sec.7076,Business and Professions Code:The Contractors License law r ,
does notapply to an owner°(property who Wilds or improves thereon,and OCC.GROIID RIS.UNITS
as who doesauch work ht.1f ethrwgh Motown employee•,provided that such - r
Improvements art not Intended proffered forsale.If,however,the building or TOTAL: ' a2.�
Improvement Ideoldwlthlnoneyearofcompleti°n,the owner-buliderwill have
tj� ardlen of proving that he did not build or Improve for purpose ofsak.). QTY, •t.'.�'�PLUM$ING+PERMIT •" 1 " ' FEES" ELODD"LANE APR ' "
LI L as owner of the property,am exclusively contracting with licensed
comrstunstocorwrodthe project($ec.7076,Buslnemand ProfessionsCode: PERMIT ISSUANCE
The Contractor's License Law does net apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) '
Wilds or improves;thereon, and who contracts for such ptpeco with a
m,,(1IU([[ad. . kenaed pursuant to the Contractor.License Law.. V' i lt"FEE,SUMMARY,
IJ I am exempt under Sec B&P C for this revue BACK FLOW PROTECT.DEVICE OUTSIDE 1:1 FS
' DRAINSFLOOR ROOT,AREA,CONI). SANITARY Y N
Owner Date a RECETT
WORKMAN COMPENSATION DECLARATION FD(7TTRE5.PER TRAP SCHOOL TA% Y_ N
-•� ❑I hereby affirm that I have a rnrti0cate of consent to self-Insure,ora
ceAECEIIrT M
rtificate of W.,ken'Compereation Insurance or a certified copy thereof(Sec.
3800,Lab C.) CAS FA.SYS[iM-1 INC.4OUTLETS PARK FEE Y N
,.
Policy B - RECEIPT a
Com an GAS EA.SYSTEM-OVER4 UTA)
EY tlU1LDINC DIV]SION FEES
Certified copy Is hereby herniated. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy h filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' . GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA XpFT Date RCceI I#
(This sedlon need cad bem
copleted if tM mi
pert b forces hundred dollars
($100)or less.a WATER BEATER W/VEM/ELECTR ENERGY FEE Y N
I certify that In the performance of the work for which this permit is Issued, -
I shall not em toy an men �manner•o a to bject to the WATER SYSPENI/TRG.RNC .
Workera'Cn ..at law 'CatJarnia, Dare -L— PAID
ZZ Applicant s .�is A n1_ - NEWRFSIDFNTIALPLMB. SQ.pf. Date 'e RL'C01 t#
O NOTICETO LIC(to the
allerma ngthis
scalonloteol Exemption,you
should odeyo mus subteen°the Workers Comp rovislmorthloruoftheall or
be TOTAL:
W~ N Codedrevoeforthwith comply withauchprovislota orthbperMtshalibe _ IL NG • v
> deemed revoked. -
CL O CONSTRUCTION LENDING AGENCY SEISMIC FEE eSD
I hereby affirm that there Its construction hridlegagency for the perlorm�
7 Z nce ofthe work for whim this permit is bsued(Sec.3097,Cl,C.) TOTAL: ELECTRIC FEE 1
U O ie.Ace.NamePLUMBING FEB
LL F Lendsr'a nddreae QT'Y: MECF[ANICAL.PERMI,T FEE.!' MECHANICAL FEE
OW hmI cerdlythatl have read thisappllotion and Cate that theabove Information
C geci.Iagersto comply with all city and county ordinances and Cate laws PERMIT ISSUANCE FEES PAID: -
>_ relating to building construction,and werbyauthorize representatives ofthls ,
I.- Z' city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH: , Date RECeI t#
_ (We)agree to save,Ind emnlly a d keep harmless the City of C.NA Ino p -
aga Wt liablllties,judgments,costs and expenses which may In any way acome AI R HANDLING UNIT(TO l 0,0D0 CFM) SUBTOTAL:
against said City In consequenm of the grant Ing of this permit
.- AIR HANDLING UNIT(OVER 10,(U0 CFM) CONSTRUCTION TAX '
Slgnstureef Applicant/Contractor Date ExnAus r I iom(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or futum building ccdipaot store or handle hazardous HFATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the Date. Rccc!P#
I(scan Yced Safety Cods,Sectioon75" ap - BEATING UNIT(OVER 100,000 RT(A TOTAL, S
Will the applicant or❑future building occupant use equipment or devicea VFNITLATION FAN(SINGLE RFSID) ISSUANCldATE
which emit hazardous air contaminants as defined by the Bay Area Air �Y+ 61 111
Quality Management Duvict7 BOILER-COMP OHP OR 100,0M BTU)
4 Yes No ry7 q 1
have read the hazaroN materials requirements underChapter 6.95°! BOILER-COMP(OVFR 100,000 BTO) NOV -'/" 1991
the Calllomix Health&Safety Code,Sed ions 75505,25533 and 75534.I
understand that 3f the Wilding does not currently have a tenant,that It b,my NEWRESIDENTIALMECH. ' - SQ.FT ,
responsibility to notify the occupant of the requirements which must be met 1.�IV11
prior to imuanre of a Certificate of Om CITY Llf laVktY1
pa ncy.. - , .I " V
Owner or authorized agent' Date
.F TOTAL: ISSUED BY:11
OFFICE COPY