22907 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulldin Project Identillratlon P10RBTNO.
Building Add...:
231(,-0di,,- ESP�Enrne - f� 22907
rs . alis: "� / one:
/I,/,eB Hes f,6//I�s6,, CITY OF CUPERTINO-BUILDING DIVISION
.� Coolnd°r'sName: Lie,No: APPLICATION I PERMIT f
7�oU LT-!2/Gtr`' B BUILDING-ELECTMCALPLUMBING-MFCHAMCAL CATEGORY CONTROL#
Architect/Fagineer, Lic.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add": PERMITISSUANCEEl ElLICENSED CONTRACTOR'S DECLARATIONrsifl
]hereby affirm that l am Licensed under provisions of Chapter9(rommenn APPLIANCESRESIDENTIAL JOB DESCRII'1'ION
ii nsal infuil7oppeardeffeon3o(the Buelnessand ProfssslonsCode,and my ��
ingwit binrum to anddied. PANELS
Ll.e..Class_ Lacy
Date /�—YS^4-�Contntlor
ARCHITECI'SDEC RATIO XB"1000 AMPS
090 Zp I understand my plane shall be used as public relit s. OVER1000AMPS 1Y�'H{F�Bl� )A $/SQ.IT.
6s� Licensed PmressWtul SIGNS ELECTRICAL 1 s L E V
<6 OWNER-BUILDER DECLARATION L4/
UT C SPECIALCBiCUIT/MIST GIhercbya(flrmthetlam exempHromthc Contractor'•Llcenm law(or thep� following reason.(Section 7MIS,Business and Professions Code:Any city orOZ TEMP.METER OR POLE INST. Yp muntywhire riov tosapermn e,aBe,re ct,ui esthemplicGdemollah,orrepilrat'y
any structure statement
shat he Is licensed
toiontfwsuch ions of ate POWER DEVICES
file a signed Yatement that he k Ilcenud pursuant to the provisions of the
Contractor's p I'n License l,aw(Chapter 9(commencing with Section 7000)of
SWIMMING POOL ELECTRIC
F. slon3o(the Business and Pro(essiaru Code)°rthat M1ekexampttherc(romand VALUATION
Q the bests for the alleged exemption. Any violation of Section 70115 by any OUTLETSSWITCHES-FIXTURES
appmonl for a permit subjects the applicant to a civil penalty of net nnrc than
five hundred dollars($500), NEW RESIDENTIAL ELECTR SQ.ET.
�n ❑1,as owner of the property,or my employees with wages as their sok STORIES TYPE CONSTRUCTION
compensation,wllldothe work,andthestrudure is riot intended or offered for
Msale(Sec.70K Buelnearand Prefesslom Code:TM Contndoes License Law
s does net apply to an owner of property who builds or improves thereon,and
0,5^ whod°eswchworkhimselforthroughhisownemploye ,prdvidedthatmch OCC.GROUP RS.UNITS
Improvements an red intended oroffeyed for sale.If,hmvever,the building or TOTAL:
Improvement is sold within one yearofcwnpletion,the°caner-bumderwill have
t)IS.Ilurden of pmvmg that he did na build or improve for purpose ofule.). QTY. PLUMBING PERMIT FEE
u FLOOD—ZONE APN
L as owner of the property,am exclusively Business
contractingwithIs Codd PERMIT ISSUANCE
TheAnAC.ors to e.Lic..thew doe notec.Apply
Business and Professions property
Code:
The Coor imp Lk the ., does red apply tc an owner of property who ALTER-DRAIN k VENT-WATER(EA)
Wild.or improve thereon,and who contracts(w ouch pto(eda with a
ctoKUempt licensed
under SntmtheContradofaLlcenaa law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under^xr. B k P C for this mason
Date
DRAINS FLOOR ROOp,AREA,COND. SANITARY Y N Owner - RECEIPTA
WORKMAN COMPENSATION DECLARATION
01 hereby affirm that I have•certificate of consentto sem-metre,or pIX.��S PER TRAP SCHOOL TAX Y_ N a BBC=Y
La
38WUeb C.)ofWorken'C°mperwtl°nlnsunncewacertlfkd mpythemof(Sec. GAS EA.SYSTEM-I NCA OUTLMS PARKFEE Y N
3800,
Policy N GAS EA.SYSTEM-OVER 4(EA) DING rf#
Cowry BUILDING DIVISION FEES
Certified copy is hen,bywith theM1id. CREASE/NDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy is filed with the city Inspection dlvblon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREAS13 RAP PAID
COMPENSATION INSURANCB SEWERSANDARY.5IORM EA 2DOPT Date Read t#
RFlesedion need reddbebe comcomplded lithe permit V!w om hundred dollen
C41°°)nrh'n.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Imrtl(employ
that nAnypethe omuIn An thewwk forwm.hre Aubjctrmit In I.
—
I shall not employ any person In any manner n u to become subject to the WATER SYSTEM/TREATING .
Worlicant mpensatlon law.of GLi(o la.Date in-23.4/ PAID
O Z Applicant
Ll7UGLfLS rAC1An/T NEW RESIDENTIAL PIMB. �}7, Date Remi t#
Z O NODCETO APPLICANT:Ir,after making this CertBinteor Exemption,you
Hshould become subject to the Workers'Compematlon provisions olthe Labor TOTAL:
N Code,younwatforlhwith limply withsach ImvisiosarthB permitahallbe
W 7 deemed revoked. BUILDING FEE
CL C CONSTRUCFION LENDING AGENCY SEISMIC FEE
D Ihereby affirm that then is a conslending agency for the perform- ELECTRIC FEE
Z anco oflhe work(or which this permit is inued(Sec 3097,Civ.C.) TOTAL:
(.) 2 Iander's N. - PLUMBING FEE
IL 1- land.:.Adde, QTY. MECHANICAL PERMIT FEE MECHANICAL FEE07-4
OW Icertlfy that)have read thinappmotlonand statethat lheabovelnformation
1 isoond.l agree to complywith all cityand county ordinances and pate laws PERMRISSUANCE /� FEES PAID ;
} relating tubulldingmrmhudlon,and henbyauthoroemprevntativeeofthk
I" Z city to enterupon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH. '-
(We)agree to save,indemnify an d keep harmless the City of Cupertino - Date Receipt'
against llabWtks,judgments,ooatsandexpan.which nay In any weyamue AIR HANDLING UNIT(T010,000 CFM) SUBTOTAL'
Against said City in consequence of the granting or this permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
gwmreof Applicant/Contractor Date M(HAUS'T HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wllltheapplinnt or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Revel t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the -
Healthand SSfety Code Spelm255320)I HEATING UNIT(OVER 100,000 Bm TOTAL: ^'~
❑ Ycs No
Wlllthezppllont rfuWmbuildingoccupantuuequipmentardevlces VENTILATION PAN(SINGLE FWD) IS� !#Clln-
which.mit hanrdous air cent.minants as de0ned by the Bay Area Air `IE DA
Quality Management Dlstdd7 BOILER-COMP OHPOR 100,000 BTU)
4 YP9 "° OCT 2 5 1991
have read the ous rtuterlab requirements under Chapter 6.95°( BOILER-COMP(OV[R 100,000 BTU)
the Cil]fomla Health A Safety Code,Sections 75505,25533 and 25534.1
undentand that lithe building docs not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.F]'
Ac,Pm,ob1A to Adfythe ocmpa orthe mclulmments which must bem.t � CITY OFCUPERTINU
Prior to nm of Cemficale mvpanry.
O neragen /O Date �1
TOTA; ISSUED BY:
OFFICE COPY