23026 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY .
Building Pra ea Identification PERMITNO.
Building Address; /� F n 3 O 2 6
rases a
APPLICATION / PERMIT
L / BUILDING-MECTRICAL.PLUMBING.MECHAMCAL CATEGORY CONTROL X
Architect/Engineer. Lt.NO:
QrY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address
PQ{MITISSUANCE I1 ❑ ❑ ❑
Lmthat ED CONTRA n R'S DE RATION �J
!hereby affirm thatlam licensed and p ons 0
(Chapter9(mmmenc- APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Incense I.In
7000)of DlViect. lthc sand eWons Code,and my Sao Q
license Is In full force and effect. PANELS
ials Claes Conte
Date Contractor UP TO 2DOAM5
ARCHITECTS DECLARATION 201-1000AMPS -
p�p�uu
9
0 O I understand my plane shall he used as public records OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
fa �j Licensed Professional - SIGNS ELECTRICAL
<6 OWNER-BUILDER DECLARATION
fn] SPECIAL CIRCNT/MLSC
7F"vl I hereby afOrmthat I am exempt from/he Contractors License Law for the
following reason.(Section 70715,Bueland Profmio..Code:Any city or Q9
O r~� TEMP.MLTOR/aOLEINST.
K p my stmenlch requlma petMtbmnsrequ Ing
fees such permit
to
g
any.signed
prior to tataments hat he I.also license mesas tack to the pro miens of It a POWER DEVICES
L5 O file a signed ehlement that he Is licensed pursuant to the proNelons of the
3w Contractor's(~n License Low(Chapter mmrrtutdogwithSection700BofDivl-9( SWIMMING POOL ELECTRIC
the basis for the alleged exemption. Any Violation of Section 7031sion3ofthe Buslnemand Professloro Code)arthat he Isexemptthem(romand I � VALUATION
5 by any
applicant for a permit subjects the a ppllcant to a civil pe
naltyofnot morethin UILETSSWITOHESFIX'IURFS O —_
$ five hundred dollars(}S00). -
L as owner of the Property, NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPECONSIRUC ION
7< p perry,ormy emture Es
snwithended Or
s theledole
compensation,70K Business work andthestructurehe C Intended orofferedfor
D rale(Sec.apply
Boniness andProfessions
property Code:The builds orimpmans ors Llanselaw
S$ deet notapplytoan imaerofthroug ywhonempoyers,povided thereon,and OCC.GROUP RES UMTS
who doersuchwork 1 int eB ed orough hisowne.If,ho ell,provided that such
improvementsarenotintended e...fremplatile.If,however,thebulldingve OT
improvement Iswld withlnomyeara(complelbn,theowner-buBderwlil have
tlpe*rden of proving that he did not build or Improve for purpose niggle.). QTy. PLUMBING PERMIT FEE FLOODZONE APP!
LJ L all owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7094,Busimm and Professions Code:
The Contractor's License law does not apply to an owner of property who ALTER-DRAIN&VEM-WATER
W Ilde or Improves thereon, and wha contracts for such piojena with a
(EA6 t17
TTI
I1aneN pursuant to the Cminctars License
Law. FEE SUMMARY
am exempt under Sec. B&P C for this reason BACK FLOW PROTECT DEVICETE
Owner - DRAINS FLOOR ROOF,AREA,COND. S ARY Y N
Date RFOEBef X
WORKMAN COMPENSATION DECLARATION FIXT11RE5-PER TRAP SQ{ODL TAX Y N
[-]I hereby M.that I have o Insurance
a c of consnt to"If-hustre,Ora RECEIPT X
mrtiEabte ofWarken'COmpensatloninsunnm ora certified copythereo((Sec. GAS.F.A.SYSTEM-I INCA OUTLETS PARKFF.E Y N_
3EOQ 4b Cd
Cc an GAS FA.SYSTEM-OVER4 LEA) BUILDING RECEIPT
FE ES
Y
[Certified copy is herebydwithfamished.tcity GREASE/INDUS IU,WASTE INTERCEPTOR PLANCHECK FEE
❑
Certified copy Is Bled with the city Inspection dlvLlon.
CERTIFICATE Of E79EMPFION FROM WORKERS' CREASETRAP PAID
COMPENSATION INSURANCE SEWEWSANTGRY-STORM EA.200171. Date Remi)tis
(This settlers need net be complcted Bthe permit Is fm one
hundred dollen
(f100)orl`seJ WATER HEATER W/VENT/ELEGTR ENERGY FEE Y N
I cartlfy that In the per(ormanceof the work forwhlch this permit Is Issued,
1 shall not employ any person N any manner so as to become subject to the WATER SYSTEM/TREATING
workan'Compeneationlawsof GlBornla. Date PAID
0 Z Appliant
_Z NOTICE.tdbacOAPFLICAM:H, mLers'kinglhis reatio provicate (Exemption,you
fter NEW RESIDENUAL PLMB. SQ.FT. Date Recei tic
shmidbecome forth 1O the ply wit ComperovisimproWsis p of the Labor TOTAL:
~ N_ dermadoumloat ad.forthwith comply with each provlslans or this permit shall be BUILDING ie
� y deemed revoked. '
d G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby af0rmthat there Isa construction lending agency for the perforrte
Z ance of the work for which this=t Is heated(Sec.3097,Civ C.) TOTAL: ELECTRIC FEE
L) O Lender'.Name - PLUMBING FEE
LL t= Lander.Addnrea QTY. MECHANICAL PERMIT FEE MECHANICAL PLUMBING
FE FEE
OW Imrtifythatl have read this applialionand statethat theabove information
6 bmrrect.Iagree tocomply with all city and munlyordlnancesand gate lam PERMLTISSUANCE FEES PAID:
N relating to building construction,and hereby authorize representatives ofthis
Z city to enter upon the above-mentioned property for Inspection purposes, ALTER OR ADD TO MECH. Date RecCi til
— (We)agree to save,indemnify and keep harmless the City of Cupertino
against liabNties,Judgments,cosisand expenses which nay In anywayacerue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL'
ag.Imtsaid Cly nmns a theipanting of this permit
_ 2 ! 9 AIR HANDLING NIT(OVER 10,"CFM) CONSTRUCTION TAX
Slgnatureof Appiant/Contractor Date / EXHAUST HOOD(W/DU'C'D CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a ppBant or(utum building occupant store or hand ie hazardous HEATING UNIT(TO 100,000 BTU) Date Receiptmaterial as defined by the Cupertino Municipal Code,Chapter 9.IZ and the _
Health and Safety CodeY. ` o
Section 25532(a)2 HEATING UNIT(OVER 100,000 BTU) TOTA .
Will the applicant or future building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit ham rdous air coram minsnts as defined by the Bay Area Air� P A Q/
Quality Management Mind? BOTLER-COMP Old'OR 100,000 BTU)
1
Y. �No
have read the hav ow materials requlremenbunder Chapter 6.95 of BOILER-COMP(OVER10(1,0(108111)
the Gllfernla Health&Safety Code,Sections 25505,75533 and 25534.I NOV 25 1991
understand that if the building does not currently have a tenant,that it Is my NEW RESIDENTIAL MECH. SQ.FT.
rnpoesibility to notify the occupant of the requirements which must be mM
prior to Issuance ofaCxttiOate of Occupancy. 011y Ur Calll'1tY1 IHUN,.
dagent
Owner or authorizeData
TOTAL: ISSUED BY; V
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OFFICE COPY