23219 APPLICAN�IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building 1'ro art Identification 4 � PERMIT NO. 3 219
Building Addreu: r�
le-N
cur ane. A
i CITY OF CUPERTINO-BUILDING DIVISION
Contractors Name: Lic.N. APPLICATION / PERMIT
Architect/Engineer. LIc.Na. BUILDING-ELECTRICALPLUMBINGMECIiAMCAL CATEGORY CONTROL
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addreu: PERMITISSUANCE `z q] �I
LICENSED CONTRACder pr DECLARATION o(ChON LSI jL{I
I hthb toRrm )ofat I amsion3 ftheBuirmandsof Cssims ode,and
APPIlANCESRE51DENfIAl JOB DESCRIPTION
Ingwlth5e t1on70W)of Dlvislon3°fthe6uslneuand Pm(osione Code,and my _—^a naa Q
license Is in full fora and effect. PANELS G�R�J/ �'{ai
License Clan LIc.11
Date Contractor UP TO 2DO AMPS
ARCHITECTS DECLARATION 211-1000A.MPS
7. 1 understand my plare shall be used as public recoeds. OVER 1000 AMPS SQ.ET.FLOOR AREA 5/SQ.FT.
ly
OC(/ Licensed Professional SIGNS ELECTRICAL
t ° OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC 1
O�aj There'syaffirmthatlamexemptfmmtheComranorsLlceneeUw(orthe ALE D
Oy� following reason.(Section 7mlS,Buslneuand Pmfeulons Code:My cityor �1p MEIR OR POLE INST.
county which requima permit toconstmm
ct,atter,Improve,demolish,compair f1,1`/f,1
anystm=mpdortoltsUmance,ahomquUstheapplimntforsuNperMtto POWER DEVICES pFJ� P T
w V file a signed statement that he is licensed pursuant to the provisions of the
p�Ow Ccotmetor's Lice.Law(Chapter9(commencing with Section 7000)of DWI- SWIMMING FOOL ELECTRIC
Os sion3ofthe Busineuand PromseloneCede)orthat bels exempt therefromandE
O, the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS-SWITCHES ppll ntfora permitsubjectsthe applicant toa dull pealtyof na morethan
undyed dollars($500). NEW RESIDENTIAL ELECTR SQ.FT. STORIES 'TYPE CONSTRUCTION
vn 1,as owner of the property,or my employees with wages as their note
7a nsatlon.will do the work,and the mmeture h rut intended or offend for
❑ vic(Sec.7Gq Business and Professions Code The Contractors License Law
�$ does not apply to an owner of property who builds or improves therms,and OCC.GROUI' RFS UNITS
c. whodoessuchworkhimselforthrough hisoweemployees,provided that such
Improvements arc not intended oroffered for sale.If,however,the Wilding or TOIs .
Improvement issold withinomyearofcompletb theowner-WIderwill have
t rden of proving that M aid not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LI,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
rentractmst.mnslruct the project(Sec.7044,Business and Profrulons Code: ^
The Contrectar s License Law does not apply to an owner of property who
ALTER-DRAIN&VEM-WATER(G)
Wilda or Improves therson,and who comram for such pRojects with a FEE SUMMARY
�qIl�+et r(s)hmnx punuanttothe Contractor'&Lke Law. BACK FLOW PROTECT.DEVICE
LJ f am exempt under See. B k P C for this mason
DRAINS FI.00K ROOF,AREA, ND. SANITARY Y_ N_
Owner Date 50 RECEITI'N
WORKMAN COMPENSATION DECLARATION FC(.NRFS PER TRAP SCHOOLTAX Y_ N_
1-11 hereby affirm that I have a certlBcate of consentm ul(-Inwre,ora RECEIPT N
certificate of Worken'Compeman°n Wurance or a certifled copythereaf(Sec. GASYSTEM-1 PARK FEE Y N
3800,Lab C.) S F.A. 1 .4RECEIPT N
Comty N
rcGAS EA.SYSTEM-OVER a(EA)
BUILDING DIVISION FEES
e ified copy is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCFIL•CK FEE
❑Certified copy b filed with the city Inspection division.
CERTI'll OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200ET. Date Rewi t#
(chis section need net W completed If the permit U fororo hundred dollars
WATER HEATER W/VEM/ELGCTR ENERGY FEE Y_ N_
I certify that le the performance of thework for which this permit Ia 4sued,
I shall not employ any person In any manner an as to become subject to the WATER SYSTEM/TREATING
Wo-lu,.'Compensation laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
Z O NOTTCETO APPLICANT:If,after making this Certificate of Exemption,you
HN should become subject to the Wmkers'Comperuitlon provisions ofthe Labor TOTAL:
Code,you=at forthwith comply with such provisions critics permit shall be BUILDING EE
LU > deemed revoked.
G CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 Ihereby affirm that there is a construction lending agency forthe perfor ELECTRIC FEE
7 Z ante ofthe work for which this permit is Issued(Sec.3097,Go.C.) TD PLUMBING
(� O Lenders Name
IL F Leaders Addreu QTY. MECHANICAL PERMIT FEE MEC F8 Com_
O W Iartlfythatl havemaithaappliotionand state thatthe above Information 1
bcormet Ice ee to comply with all city and county ordinances and state laws L PFRMTIISSUANCE FEES
} D. relatingm 1 ingcomtruction,and hereby autborion rep.7matives of this
H Z city to en ru nthe above-me sed pmperty for Inspect purposes. ALTERORADDTOMECH.
(We grc to uve,Inde n d p harmieu the City of Cupertino lC RecMPt#
V agalns ubl' figments and nses which rtuy In anywayacaue AIR HANDLING UNTI'(TO 10,000 CFM) S BTOTAL:
gai C of amingoRhis permit.
AIRHANDWNGUNIT(OVERI(%(K)0CFM) CONSTRUCTIOJ TAX
Sjuroreiiif ml- Date EXHAUSTHOOD(W/DUCn CONSTRUCTIO TAX PAID:
HAZARDOUSMATER SDI OSURE _
Will the applicant or futumbullaing ant or handle havrdom HEATING UNIT(TO 100,000 BTU) Date RCCci t
materul as defined by the Cupertino"
pal Code,Chapter 9.1 Z and the
Flealth and Safely Codr SMlon 7553Z( HEATING UNIT(OVER 100,000 BTU) TOTA
❑ Yes �]No
Will the applicant orfutum building occupant use equipment or devices VENTILATION FAN tSINGLE RESID) ISSUAAljPATr
which emit haurdous air contaminants as defined by the Bay Area Air � '
Quality Mane at District? BOILER-COMP OHPOR 100,000 BTU)
Yu No
have dt hazar , arate' Is requirements under Chapter 6.95 of BOILER-COMP(OVPRIDQo00111L) FEB '1
the Califo is H ffi k Safety C e, ions 25505,25533 and 75534. I J�6 B 2 5 1992
underste dth ift uildin oe a currently have atenany that It is my NEW RESIDENTIAL MECH. SQ.FT
cope 111 fy the p oft requirements which must be met
pr r r rti f anry. CITY OF CUPtnurvv
Ow c or au oriuda est Date
T ISS(EDB /�
l
OFFICE COPY