23293 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Buildin Pruett Identification - PERMIT NO.
Bu1Win Address: �}� C,�•. . 2 3 2 9 3
no:
CITYOFCUPERTINO-B LDING DIVISION G� Z
con ora Name: �_N APPLICAT / PERMIT
v`
C
.PSD �a�iNa'Gl. G' BUILDING ELECTlI PLUMBINCMEC NICAL CATEGORY CONTROL a/ �Z
Gatted/Engineer. LIcN.
I 0.. CoolpiII•rBUILDING PERMIT INFO
(D
�'7 QTY EL C RIC PER FEE
Adders. 3 69 PERMIT ANCE A4 _Q
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions ofChapter9(rommen CESRESIDE JOB DESCRIPTION
ingwlth Sedion 70D0)of Divlsion3ofthe Buslnessand PmfesioneCade,and
Lim. -
Is in full fora and dd
ie .
LlcenseC6s LIe4
Date - Contractor
ARCHITECT'S DECLARATION X11-1 PS
0ZO I understand my platy shall be used as public records. OVER SQ.FP.FLOOR AREA
$/SQ.FC.
U0 Llmnsed professional SIGNS EC C �er C,7 S� 4f%rSc'C �_ le
� R OWNER-BUILDER DECLARATION SPECIALCIR T/MLSC
z0~ IherebyatBrm that Iamexempt fromthe Contrador's License Law for the '/3 lYar �o•b6
oo following reason.(Section 7031.5,Business and Professions Code;My city or ,saa//ra Os S r b
p4 county which requires a permit totarulretct,alter,Improve,demolish,or repair iEMp'M - OR POLE[NSI. •(rsi ,_04
IRS`'0 v any.tmcture prior to Ire issuance,also requires the applicant(orsuch permit to $'Q
L5 O S file a signed statement that he Is licensed pursuant to the prov,.,re of the D SS S-9 CIS7iv- 6,GK 14-
Contractors y Contractor's License Law(Chapter 9(mmmenclng with Section 7000)of Divi- XVIMMING POOL ELECTRIC
�O} sion3 ofthe Business and Profesloru Cade)mthat he is exempt therefromand _ - VALUA ON
y�.'•3 the basis for the alleged exemption. Any violation of Section 7031.5 gy anyO d
p0 applicant fora permit subjects the applicant to a civil penalty of not comethan OUTLETSSWITCHESFIXTURES rSTTO�F�lEg
7940five hundred dollars%5W). NEWRFSIDEMI7ALELEC7R I as owner of the roe SQ.FT. TYPECONSTRUCTION
courp, p p rty,or my employees with wages r their sole r9 O.1.&eaHon,B,aireu.mi randthesC de:ThrCommerce orm..L w Ddoes e(Sec. pply tet ansesandf property Code:The Contractors License Lawwhodot apply roan owner ofp rough whonembuilds orlmproovidedves reoMandUP RES.UNITS
who dfessuch workhlmselorthrough hieownemplgeea,provided lhatsuchImprovements are not intended or offered for sale.If,however,the building or TOTAL:improvememttssold withinoneyearofcompledon,lhe maner-bullderwlll have
tl(gjurden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEEONE APN
�f;as owner of the property,am exclusively contracting with licensed a
rontractors to corutmpggMlT ISSUANCE
ct the project(Sec.7044,Business and Professions Cade: ��-00 3���Z 3-I00
The Contractors ot License Law does napply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
build.or Improves,thereon,and who contracts for such p1pocts with a FEE SUMMARY
tr)B(Tador(e)Bansed pursuant to the Contradels License Law. BA T T. EVI
LI I am exempt under Sec. B k P C for this reason
D NS SANITARY OUTSIDE F
Y N
Owner Date RECEIPT p
/ WORKMAN COMPENSATION DECLARATION FIXSCl{OOL TAX Y N_
❑I hereby ef(Irm that I have a certHtrate of consent to self-Insure,ore RECI]I'1'N
certificateofWorkers'Comperoaianlesurance macertifW mpythereof(Sec. PARK FEE Y GAS EA SYSI'FM lIN O . N
3500,Lab C.)
Policy N RECEIPT p' -
Com any CAS BUILDING DIVISION FEES
Certified copy is herebyfurnished.the city GREASE/INDUSTRL WASTE INTERCEPTOR' PLANCHECK FEE
Corn
copy V flied with the city Wpection division. f77�'
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID 2-16-T2-
COMPENSATION
INSURANCE SEWER-SANITARY-STORM EA 200FT Date RCCei t#
(Thi,aectlon need not be completed if the permit V(or one hundred dollars
($10metifyss.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N p`
I certBythat la the perffmanceny n.,r an an to thbpermit is 74Tto the J z_; s'�
I shall not employ any person In any manner at u to to the PAID -L
O Z Workers'Com s f rn ,Dated WATD25YSR'EM/TREATING
AppBont NEW RESIDENTIAL PLMB. SQJ}T. Date Recei t#
6 NOTICEcome ,ICI to the
atermaklnmh le o(Em.fthe Lyou
Code,shouou=atforth ithcoWorken'suchprovisinproWlaruoftheLabhe p �f �/ .; , , TOTAL: (VU s
N TV--
deemed
comply with such provisions orchis permithall be { Y ^ a� ��_ BUILDING deemed revoked.
LUCONSTRUCTION LINDING AGENCY - SEISMIC FEE ,
Iherebyaf(Irmthat there is a construction lendingagenry forthe perform TOTAL: t! .e� ELECTRIC FEE 33a
O7O once ffthe work for which this permit is Issued(Sec.3097,Civ.C.) PLUMBING FEE
Lender's Name
IL F Le.der.Aadre.. QTY, MECHANICAL PERMIT FEE MECHANICAL FEE
U Icertifythat I have read thisapplicatlonand statethattheabove Information
O 1 s iscemd.I agree to complywith all city and countymelinancand slate laws t PERMQISSUANCE _0J FEES PAID:
�. W relating to building mrutrudion,and hereby authorize represntativea a(thls
city to enter upon the Above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH.
Z Date ReCeI t#
z (We)agree to save,hucen,i/y an d keep harmless the City of Cupertino P
against liabilities, t2w
hmayleanywayacaus AIR HANDLING UNIT(TO 10,"CF'M) SUBTOTAL: Q
gal 1.perm .-� AIR 7{ANDLING UNIT(OVER IO,000CFM) CONSTRUCTION TAX
lg ref Applicntractor a e hxTIAL)BT HOOD(W/OUCH - CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date ReCeI
material as defined by the Cupertino Municipal Code,Chapter 9.I$and the
a Health and Safety CWLLdlon 75532(a)7 HEATING UNIT(OVER 108000 BTU) TOT L;
Yea m No
if lllthe applicant oKl m budding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
y)lch emit harardoua air contaminants as defined by the Bay Area Air .
�Quallty Management Ojst11d7 - BOILER-COMP OHP OR 100,000 BTU) p
4 Yes J�t�No ppqq M B Q
have read Health
ar feta Code,
tions 20305,255under 3aChapter.1 of BOILER-COMP(OVOt 100,000 BTU) B'
,6e CaliforniatandtHealth he building
Code,Sections25505,ently ve a tandt,that I
reapontandthat notify the occupant not a mquimmvea tenant,that b is et NEW RESIDFNITAL METH. SQ.FC. WAY
��
prior to Issuaitynce
ce ofaCthe occupantoftherequirements which must be met
prior to issuance o/e Certificate of Occvpanry. x D ?a( 1992
11
Owner or authorized agent Date CITY
TOTAL: ISSUED BY:
0
OFFICE COPY