22236 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALLPOINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: /�^^ f�
0 Lki �nJ - Vs G G G 3 l6
neane. A
r. CITY OF CUPERTINQBUILDING DIVISION /�
c.no-act.ra Name: - sae.No: APPLICATION /PERMIT 6 __ 1
V BUILDING-ELFCTRICALPLUMBINC-MMHANICAL CATEGORY COI�$RO9[T
Architect/Engineer. He.Na L�aFj X77 �7
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: ' , PERMEEISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby afflrmthas l am Beensed under provisions tttiof Chapter9(cammcnAPPLIANCESRESIDENTIAL �
IngwhhSon 70W)of Dlon3oftheguelnenand Professlone Codc,and my �
license is In full farce and effect. PANELS
License Clan LI[.X
Date C.rmcmr UP TO 2DOAMPS
ARCHITECTS DECLARATION 201-IODO AMPS
pQ±Q GO (understand myphmshallbe used as publlcremrds. OVERIODOAMPS SQ.FT.FLOOR AREA ( QFr
E z E Licensed Professional SIGNS ELECTRICAL - 7 I ' (`VMa
F hereby
Ot Ism exempt DER
DECLARATION SPECIAL CB{CNT/M15C �� I �
Iheceb (Rrmlhatlam exam (romthe Contractor's Llanselaw for the ` L
o
following
reason.(Section 7031.5,Business and Professions Code:Any city or f.�
z0 B TIME.METER OR POLE(NST.
F c.27? cwntycture requUesaperMttommwcLes the
applicant
permit
�,
q ir
any structure statemeprior to nt
that
he is also sed pursuant t the poo inions of t e POWER DEVICES {[ —�
6 0 ASM
file a signed statement ( hs b licensed pursuant to the provisions of the
Contactors License Law ha erg mmencin with Section 7000).(Divl-
3u0' Ce R SWBAMINC POOL ELECTRIC
.lon3 of the Busmen sad ProfenionsC.de).rtM1at M1ebexemptthere(romand TION
{! the basis forthe alleged exemption. Any vlolatlon of Section 7031.5 by any OUTLETSSWITCF{FSF[%TI1RE5
applicant fora pemdtsubjeastheappllcanttoa civil pwulty ofnat renretlun
live undred dollars( An. i
QQ owner aflM roe N7iW RE4DENTfAL ELFLTR SQ,IrI'. STORIES TYPECONSIRUCTION
7�n e p p rty,or my employees with wage as their sole
pensatlon,wlll clothe work and thestsuchure V not Intended or offered for
=.a7044,Buslnns and Profession.Code:The Contractors Woman law
�$ pply to an owner of property who builds or improve thereon,an OCC.GROUP RES.UNITS
who doeasuchworkhimaelforthrough hisown employees,provided that such I I a
Improvements arc not Intended oroftered fornk.If,however,thebuilding or T
improvement issold within one ycarofcompiction,the owner-bullderwlil have ALE D
t)r-*vden of proving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE
Lf 4 as owner of the properly,em exclusively attracting with Ilmnxd PERMIT ISSUANCE
cantactors to omedruct the pmj d(Sec.7010,Busmen and Professions Code:
The Coats o License the Lw doe.. apply el an owner of property who CK FLOW
P A VENT-WATER
tF
bu Ods or Improves thereon,and who mntnce,for such p(ojecta with
Off,
licensed pursuant to the Contractor.License Law. ATE F
L , am exempt under Sec' 0 k P C for this meare IXFLOW PROTECT.
Owner DRAINS.FLOOR ROOF,AREA COND. SANITARY Y N—
Date RECEIPT N
WORKMAN COMPENSATION DECLARATION
E31 /� SCI{OOLTAX Y N
1 hereby a(llrm that I have a certificate FE(TURF_S.
ate of consent to self-In
,or• PFRTRAP RECEIPT X
3800,Lab
CJ aof Warken'Compecoatlon lcuunnreoracertlfkd ropythereof l5ec. CAS EA 9YSTEM1 WC/OUTLETS PARK FEE Y N
3800,T
policy M GAS EA.SYSTEM-OVER 7(EAI RECEIPT N
Com eny BUILIJINC DI VISIONFF.ES
�CertiOed copy is herebyfurnished.the cid. GREASE/NDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
- ❑Certified mpyLfiled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE
(Thlssecuorreed not bec.mpletad lfthe permit leforme hundred dollar SEWEWSANITARY-S3DRM EA.200RT. Date Remi t#
(5100).1..) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I celtifythat in the performance of the work for which this penult is issued,
I shall not employ any person In any manner so as to became subject to the WATER SYSfChf/TREATING
Workerc'Compensationlaws of California.Date PAID
O Z Applicant Date Remi t#
O
Z NOTICETO APPLICANT:If,after ma king this Certlfiate.f Exemptkm'y.0 NEW RFSIDEM7AL PLMB. SQTT.
Hshould become subject to the W.rkers'Comecurtmn pprovisite ofthe Lebor TO
fA Code,you must forthwith comply with such provisions orlhis permit shall be I
j deemed revoked. BUIL12ING FEE
(L C CONSTRUCTION LENDING AGENCY SEISMIC PEE �.� _
I hercbyaffirm that there b a construction lending agency for the perform- asELECTRIC FEE L
Z ance.flhe work for which this permit is lseued(See.3097,Civ.C.) T
V O Lender'.Name IPLUMBING FEE
LL F Lcndee.Addren QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Imrtllythatlhavercadthi.appllati...MYatethattheahoveiefommtlon —�,
M bmrmct.lagreetocomplywlthalldyaMrountyordinanmsendstatelawe PERMIT ISSUANCE / FEES PAID:
} relating tomildingmmmuction,and harebyauthorlaarepmacrativesolthb
F.. Z city to enter upon the abovementloned property for impectlon perposee. LTERORADDTOMECH.
_ (We)agree to save,Indemmiy an d keep harmless the City of Cupertino - Date Reccipl#
a galrutllabilltle, dgment;msts.ndeapame,which may many wirypecma AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against ni sating of this pemNL AIR HANDLING UNIT(OVER 10,000 CIM) CONSTRUCTION TAX
/
S o ppgmnt/Contractor t EXHAU9'THOOD(W/DICT) CONSTRUCTION TAX PAID:
I;=11OUSMATERIAL. SCLOSURE
Willtheapplia at or future building occupant store or handle haeardous HEATINCUMT(TO100,0DOBTU) Date Reeci t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
Health sad Safety Code Section 25532(a)7 HEATING UNIT(OVER I00,00D BTU) TOTA
❑Yes No
Willthexppllantor W b,.Ildingoaupantuxequipmentordevicc. VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which omit harardma air c.ntamlwnts as defined by the Bay Area Air
Quality Management Dbtrict7 BOILER-(AMP OHP OR Im,DM BTU)
Ycs . oNo
I A
have read the hu.rnatedals requirements Chapter6.95 of BOILER-COMP 100,000 BTU) (!�
the California health A Safety Code,Sectlon.25505,25533 and 25537.I n
understand that if the building does cwt currently have a tenant,that It E my NEW RESIDENTIAL MECH. SQdTT APR responsibility to notify the occupant of the re
requirements which=at be met K ss 1994?prior to Issuance of a Certltiate of Occupancy. ���
Owner or authorized agent Data T ISSUEDD W. I
Ts
OFFICE-COPY