24122 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Ruildin Project Identification PERMIT NQ, 412 2
Butldin6 Address
ra : _ Z
Jon 125 sa�
�! \ one: APPLICA IIUN bUbM11 I A.UA
5Es G� L
122--2— CITY OF CUPERTINO-BUILDING DIVISION
cn r rAName: LIe.Nn: APPLICATION / PERMIT 9a P9Z
BUILDINGELECTRICALPLUNIBINGMECHANICAL CATEGORY CONTROL`
1 Architect/Engineer. Lic.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE T
LICENSED CONTRACTOR'S DECLARATION _oa E
I hereby affirm thatlam licensed under provlalona of Chapter9(rommenc- APPLIANCESRESIDENTIAL JOB DESCRIPTION
Ingwith Seelon 7000)of Division 3 ofthe Bus nese and Professions Code,and my
license is In force and d(M. L1 PANELS
Llrnnsec s LIC` 1
Date Contactor pt-1000 AMPS �G l •~s_
ARCHITECT 5 LARA ION
7 I understand my plans shall be used as public records. OVER IOW AMPS SQ.FT.FLOOR AREA 5/SQ.FI.
O
Limnsed Profesaksal SIGNS ELECTRICAL
6 OWNEReBUILDER DECLARATION T I ALED '
1n a Fn SPECIAL CIRCNT/M1SC G
P�o j Ihercby.(firm thatlam exemptfromthe Contractor's LknwUwforthe
O Z H following reason.(Bectlon 70315,Businex and Profealons Code:Any city or
TEMP•METER OR POLE INST.
requires requla permlttoroatruct,alter,Improve,demolish,orrepair �fn��1//nJ1 yI V�
c�1 anystm=mpdortoibR ance,al requimtheappBrantforwchpemdtto POWER DEVICES U V Y
C file a signed statement that he is Beensed m
pursuant to the pvolons of the Y
3 u Contractor.License law(Chapter 9(commencing with Section 7000)of Diel- SWIMMING POOL ELECTRIC
,.�0e slon3ofthe Businessand PreffemlonsCode)orthat hebexemptthere(romand Es
n&F?, 59.r]• the basis for the alleged exemption. Any violation of Section 7MI.5 by anyOUIT.ETSSWITCHFSFIXT URES .7,
pa applicant for a permit subjects the applicant to a civil penalty a not more than
five bund red dollars(5500). NEW RESIDENTIAL ELI:CTR
6 ❑1,as owner of the property,or my employees with wages as their sole SOFT' STORIES TYPE CONSTRUCTION
compensation,will dothe work,and thestruaR ure not Intended or offered for
asale&c.7C4 BusNex and Professions Code:The Cormacto's Llcenx law
�$ docs not apply to an owner of property who Wilds or improves thereon,and OCC.CROIJI' RES.UNITS
who does such work himself or through his own employees,provided that such
improvements are not Intended oroffered forsale.If,however,thebuliding or TOTAL:
Improvement bsold within one yearofcompletion,the owner-bullderwlll have
tFL�urden of proving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FIAODTONE APN
LJ 4 as owner of the property,am exclusively=trading with licensed PpRMITISSUANCE
rentoolors to emu met the project(Sec.7006,Business and Pro(easloa Code:
The Contractor's License law does not apply to an owner of property who
Wilda or Improves thereon,and who contracts for such ploje in with aALTER-DRAIN&VENT-WATER(EM
ri5actor(.)Bane t po.nam to the Contractor'.License Law. FEE SUMMARY
LJ BACK FLOW PROTECT.DEVICE
I am exempt under Sec B &P C for this reason
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N_
Owner Date JtpCEp•(p
WORKMAN COh1PENSATION DECLARATION FIXTURES MR TRAP SCHOOL TAX Y_ N_
I hereby affirm that I have a art rarm of consent to opytnmre,ora RECEIPT p
certiflateof Workers'Compevatlonlauranceaacertlfkd copy thereof(Sm. GAS FA.SYSTEM-1 WCA OUTLETS PARK FEE Y N
P.Rey 0b C.I ' 1S2.y O` �� RECEEPT#
I ffC 1 J .-H1 GAS FA.SYS EMA OVER4(EA)
Com anv +Vn BUILDINGDIVISION FEES
�Cedtf p here Pu . ed. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified mpy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE SEWFR-SANITARY-STORM FA.200FI. Date ReceI tIt
(This section..it out be completed Ribs,permit bfor one hundred dollars
(SIDE)or less.) {PATER HEATER W/VENT/EI.ECTR ENERGY FEE Y_ N_
1 codify that N the performance of thework forwhlch this permit is issued,
1 shall not employ any person in any manner ro as to become subject to the WATER SYSTEM/TREATIN'G
Workers Compensation laws of CaWamia.Date PAID
O Z Applicant NEW
PRESIDENTIAL PLMB. SQF7. Dat#
te Recel
Z O NOTICE TO APPLICANT.If,after making t his Certificate of Exemption,you
should become,subject to the Workers'Compensation provisfoa of the Labor TOTAL:
CC N Code,you must forthwith comply with such provisions orthis permit shall be BUILDING '•E
j deemed revoked.
CL — CONSTRUCTION LENDING AGe`CY SEISMIC FEE
CL I hereby affirm that there R a construction tending agency for the perform ELECTRIC FEE y2,�
7 Z ance ofthe work for which this permit V Word(Sec.3097,Civ.C.) TOTAL: /
U O lender's Name PLUMBING FEE
LL E= 1<nder.Addre.. QTY. MECHANICAL PERMIT FEE MECHANICALFEE
1 certifythat l lave mad this application and statethatthe above information
O W
4 bcomecc l agree to comply with all city and county ordinances and state laws PERMITISSUANCE FEES PAID:
relating to building construction,and hemby authorlu representatives of this
I— W city to enter upon the above-mentioned property for inspection Purposes. ALTERORADDTOMECH.
Z (We)agree to save,indemnify an d keep harmless the City of Cupertino Date ReeeiptN
V
against Babillties,judgment.,roars and expenses which may in any way accrue AIR HA NDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agai t 11,sal City in conae uena of the gnndng of thi. r it.
, � RL AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Sig.aVirdTdApplieant/Canraemr Efate EHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haeardoua HEATING UNIT(TO 100,000 BN) Date Recei tN
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the -
I Ivallh and Safety CoQ�S=dies 25532(1)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes tf[I No
Willthe applicant rebuilding occupant use the Bay Area Ai vices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emithaementsair
rid? antaasdefined by the Bay Arca Air
Quality Maagem.nt Qlsidct7 BOILER-COMP PHP OR 100,0110 BTU) q (i
4Yn 1�1 No C LW
have read the baz r us materials rcquircments under Chapter 6.95 of BOILER-COMP(OVER100,000 BTL)
the California Health&Safety Code,Secure;25505,25533 and 25534.1
understand that if the building does not currently have a tenant,that it is my NEW RISIDENTTAL MECH. SQ.FT AUG� 1 g '1992
respons' dity to notify the occupant of the requirements which most be met % 1
priRrto Banco of to of 0<eu a �%a CITY (����
{I),` 6 I 1r��`1 `u-mirCfl'1.11YU
Oy/re'r or authod agent Date ISSUEDBY:��4NK> `V 1' w
TOTAL:
OFFICE COPY