23749 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Build]. ?•mica Identification PIRMIT NO.
Building Add.; 23749
101"l �+�wca.,F 0-04, _4T sr,,,
Phone A A
are ameL J CITY OF CUPERTINO-BUILDING DIVISION �^ 1-1-Al
. con a or'aNa APPLICATION / PE MIT [�
BUILDING-111ICTRICAL PLUMB ECF4INICAL CATEGORY C
Archit /Engineer. Lk.N
GemP «1st 12TY ELECT IC PfrMIT FEE B ILDING PERMIT INFO
Add. 1,44e� D PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATIO
I hereby af(bm that lam Bcenxd underprovblov o(Chapter9(comment, APPLIANCES L jOill DPSCRII'TION
agwlth Svctlon] )of Divlslon3 ofthelluslnessand ProfesslonsCode,and my sus
license Is In full form and effect. PANELS
LicenseCbn Lill,M 5 EL
Date7—!T-717ill,N r
ARCHITECTS RATION 1 MI5
02 I understand my phns shall beu aspubhc records cacao AMPS IN p ® I f/SQ'Ef'
O �v
Licensed Professional SIGNS EL
oaf OWNER-eNLDER DECLARATION SPECIAL T/M M P U T E
1 herebyafRrmehat lame.impt fromthe Contractor'sLlmnx Law for the
following resse. (Section 7WIS,Business and Professions Code:Any cityor TEMP.M OR LEINST.
F51"' county which rNutrn a permit to construe,alter,bnprove,demoiIsh,or repair TE
a eystructurepricrtofe Issuance,also requiresthe applicant for such peuNtto POWER DEV
�a 5 file a signed statement that he ls licensed pursuant m the provisions of the
Contractor's License law VALUATION
(Cha 9(commend. with Section 7000)of Divi-
OO r^ slon3ofthe Busineesand Profeanlons Code) orthN he is pttherefromar�d GIOOL ELECTRIC •t., semi. .. ..
the blab for the alleged exemption. Any violation of Section 70315 by any ETSES S
SWITCHFIXTURES O(`'K
<$ applicant for a permit subjects the applicant to a civil penalty of not more than / V ��av✓
C. o five hundred doll..(&500). NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
I,as owner of the property,or my employees with wages as their sole
compensation,wBl do the work and the structure Is not intended or offered for
psale(Sec.701 Business and Professions Code:The Contractor's Llcense U
does not apply to an owner of property who builds or improves themm nd OCC.GROUIP RFS UNITS
who doessuch work himself orthrough his own employees,provided that such
improvements arc not intended or offered for sale.If,however,the build Ing or .�
improvement Istria within one yearof completion,the owner-build erwlll have
t rden of proving that he did not Wild or improve for Em Talent of axle.). QTY. PLUMBING PERMIT FEE FLOODZONE APN
LL as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractorn to construct the project(Sec.7044,Business and Professions Code:
The Cont.ctor's License Law dm not apply to an owner of property who ALTER-DRAIN 6 VENT-WATER(EA)
Wilds or Improve thereon,and who central far such ptojeea with a
c .acmr(0licensed puntieec to the Contractor.License Law. BAC(FLOW PROTECT.DEVICE FEE SUMMARY
(j 1 am exempt under SB A P C for this reasonOUTSIDE FLES
DRAINS FLOOR ROOF,AREA,CONTI. SANITARY Y_ N_
• Owner Date RELEB
WORKMAN COMPENSATION DECLARATION FIX'IVRFS PER TRAP f SCHOOLTAX Y_ N N_
❑I hereby afOrm chat I have•certlRote o!conxm to self-insure,ora
RECEIPTN_
certificate of Worku tCompensation Insurance or a certified copy thereof(Sec. GAS EA.SYSTFMdINCd OUTLETS PARK FEE Y N
3800,lab C.)
CPolicy o N GAS EA.SYSTEM-OVER 4(EA) RECEBTM
BUILDING DI VISION FEES
yl(Ied copy Is hedwith the
GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECI
IRed ropy Is filed with the city inspection division. 17
CERTIFICATE OF EXEMPTION FROM WOR KERS' GREASETRAP PAA V
COMPENSATION INSURANCE SEWERSANHARY.STORM EA 200FT ate Recei t#
This section need not W completed If the permit Is for one hundred dollars
($100)or leas.) WATER HEATER W/VENT/FI.ECTR ENERGY FEE Y N_
I comfy that In the performance of thrwork forwhlch this permit is blued,
I shall not employ,any person In any manner ex,as to become subject to the WATER SYSTEM/TREATING
Workers Compensation Compensation Laws of California. Date PAID
OZ Applicant NEW RESIDENTIAL FILMS. SQFT. Date Recel t#
Z O NOTICE TO APPLICANT.If,titer making this Certificate of Exemption,you
should become subject to the Workers'Compereat cat provblrns of the Labor TOTAL:
f' fn Code,you must forthwith exmply with each Eremitic.or this permit 0.11 be BUi IN "LlsIlte.At C-1
XG FEE
IL j deemed revoked. SEISMIC FEE
— CONSTRUCTION LENDING AGENCY
CL IhembyafOrmthat there tsaconstructlon lendingagency forthe perform ELEC ERIC FEE
7 Z once of the wmk far which thin permit 6 Issued(Sec.3097,Civ.C.) PLUMBING
V 2 Lender's Name
LL ~ Lendcre Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
W Irertlfylhatlhavercadthbappliwtlonandstatethattheabovelnformatlon
O
umreect.I agree to comply withal]city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} N relating to building construction,and hereby autharom representatives of this ALTER OR ADDTO MECH.
F Z city to enter upon the above-mentioned property for inspection pu rposes. Dat Receipt
(We)agree to save,IndemNfy an d keep harmless the City of Cupertlw
O against liabilities.jdiments,costeand exponxewhkh mayln anyw.yaccrue act HANDLING UNIT CTO 10,000 CFM) SUBTOTAL:
age Inst sal Cityinconsequenceo egrantin Wthlapernit.
-�_ qf% AIR HANDLING UNIT(OVER IO,"CPM) CONSTRUCTION TAX
Sign u Ap,kant/Contmcm Data EXHAUST HOOD M'/DUCT) CONSTRUCTION TAX PAID:
'HAZAR)OUS MATB ALSDISCLOSURE
ltheappllcantorfuturebuilding pant store celundlehaaledow HEATING UNIT TO IM,0008TU) Date Recei #
r�Nlerl I as defined by the Cupertleo Municipal Crde,Chapter 9.12 and the –
i Ieallh and Safety Code Stolon 25532(a)? HEATING UNIT(OVER 100,000 BTU) TO :
Yes M No
Will the applicant orfuturc building occupant use equipment ordevices VENTILATIONPAN(SINGLERESID) ISSUANCE DATE
which emit haraulous air contaminants as defined by the Bay Area Air
Q.a lity Ma rugement District? BOILER-COMP 0111'OR 100,000 BTU)
Yea ❑No
I have read theh rdous materials requirements under Chapter 6.95 of ROMEII-COMP(0VQt1W,00081U)
the California Health h SfetyCode,Sections 25505,25533 and 25534. I
understand that if the building docs not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FF. Ig) ID
responsibility to notify the occupant of the requirements which must be mat Y
prior to Lssuence cfa CcrtiBate o1 Occupancy.
f'Q Io�fZtl
Owner or authorlmd agent Date ISSUED BY: 11992���`9
�_ . . eYP w) cnluaV
OFFICE COPY.