23898 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PFR ITNO.
Building Address; 23898
1940 tzo,,Xar
Owners Name 1111 1 one: A
(3ncin +TW'TiflgTOn �}�• -p CITY OF CUPERTINO-BUILDING- IVISION —p
Contador'c Namn; .LIc.No: APPLICATION I PER IT Z
BUILDINQELECTRICALPLLTMBING- NICAL CATEGORY CONTROL#
Archited/Engineer. Lic.No:
QTY ELECTRIC PER 40:4
BUILDING PERMIT INFO
Address: l PP.R ITISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ihmcbyaffirn that l am licensed under provlalomof Chapter9(rommmo- APPLIANC45RE E L ]OB DFSCRBTION
Ingwilh Se on7000)of DiWsion3ofthe Busimmand ProfessionsCode,and my
license Is In full force and effed. PANELS
Lleman Class Lle#
Data jzmdradr
ARCHITECTS DECLARATION 1-Low
wm Zp I understand my plain shallbe used as public records. O SQ.FT.FLOOR AREA §/".lQ.FT.
Licensed Profemloml LFL L 4.1 p Z�
fn 63
OWNER-BUILDER DECLARATION IALCIIt SC3-(
T�' I hersbyafRrnthat I am exempt from the Contractor's Liam e law for the
pp Q following reazon.(Sedlon 70315,Bualnms and Profenlona Code;Any city or f
O Z F•W TEMP.METTiR PO INST, you V/ J (� G✓
countywhlch requlrsaperMttoconstmd,site$Improve,demollsh,or repair
.a anystmu mpriortoitsiwance,al,orcquirmtheapplimntforsuch pertNt to OWER DEVIC
yo. file a signed statement that he is licenced pursuant to the provisions of the
Ow Cmdractor'e License Law(Chapter 9(rommencingwith Section 7000)ofDivi-
H�O elon3ofthe Hudnmsand Profemlam Code)orthathelaexempttherefromand SWP4MIN LELECCRIC VALUATION
g the basis for the alleged exemption. Any violation of Section 7031.5 by any •1 �� D
2 OUTL SWITCHES[TXTURES L�
applicant fora permit subjedsthe applicant to a dull penalty a net morethan a!
o f nd ed ownerdelta.hepro AESIDENTIALELFCIR SQdT. STORIES TYPE CONSTRUCTION
I,s owner of the property,or he employees with wagm ate ffer sole
mpeneatlon,wllldothe work andthestmdure lana intended or offered for
Msale(Sec.7044,Business and Prof esio s;Code:The Contractors License Law - I
$ does not apply to an owner of property who Wilde or improves thereon,and
who doessuch work himselforthrough hlsownemployees,provided thatsuch /'0��4�4-----K�����-'es. RG L .UNITS
improvements are not Intended proffered for sale.](however the build Ing or TOTAL /Jj 1 1 1
improvementl,soldwithln oneyearofcomplebn,theowner.bu0derw111 have 1 V
tl�tiurdenwner proving of the phedidna excl orimprove for
......purpose QTY, PLUMBING PERMIT FEE a} n pPN
�J I,ate owner of the property,am exclusively conlraMing with Ilmnsed PERMIT ISSUANCE 4 aa�
rontradoa to construct the project(Sec.7044,Business and Professions Code:
The Cmdadora License Law dam not apply to an owner of property who ALTER-DRAIN k VENT•WATER RN
Wilds or Improves thereon,and who contracts for such p(ujeds with a
,,➢Il.t.�ador(s)licensed pursuant to the Contractor's License Law, FEE SUMMARY
L_I I am exempt under Sec. B k P C for this reason BACK FLAW PROTECT.DEVICE UTqI
DRAINS FLOOR,EDGE AREA,GOND. SANITARY Y N_
Owns Date RECEIPT N -
WORKMANCOMPENS TION DECLAR TI FD(TURES PER TRAP SCHOOL TAX Y N
❑I hereby affirm that T have o certificate of consent to copy
[teen ora RECEIPT'X
3800,L.riffloat.b o(Workere'Compensatlonlnsurance ma certified ropy thereof(Sec. GAS EA.SYSTBM-I INCA OUTLETS PARI,FEE Y N
380Q Lab CJ
1bllry p GAS F.A.SYSTEM-OVER 4(PA) RECEIPT p
MCCom any BUILDDINGINGDIVISION FEGertlfied copy is herebyfurnished.the city GRFASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy b filed with the tlty impaction division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANUARY-STORM EA$0011. Date Rete' t#
Qhlsaedlon need not be completed I(Ihe permit k(Drone Fundrcd dollars
($10))or WATER HEATER W/VENT/17 TR ENERGYFEE Y N
I cert Isse.)t N the perfomunreof the soak far which thin permit Is Issued,
I shall no,employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Workera'Compensatlon Laws of Cali(omla.Date PAID
OZ Applicant - LYCI t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW TI
W RESIDENAL PLMB. SQJTF.
FW should become subject to the Workers'Compematlon provisions of the Labor OTAL:
IrCode,you moat forthwith comply with such provisions or this permit shall be 1 GFEE d .Q
LU 7 deemed revoked.
0 CONSTRUCTION LENDING AGENCY SEISMIC FEE
a I hembyafflrmthat there lsammtrudion lending agency for the pedorm- ELECTRIC FEE
7 Z anreofth,wmkfmrwhkhthtspmmlt lslmued(Sec.3097,Civ.C.) TOTAL:
V O Lender's Name - PLUMBING FEE
LL I- LendereAddresn QTY. MECHANICAL PERMIT FEE MECHANICAL FE
OW Icertify that]have readthisappllcationand statethattheabova information
1 iscormd.I agree to comply with all cityand rounlymclinanomand state law, PERMIT ISSUANCE FEES PAID:
} W relating to Wilding construction,and herebyauthmize representatives of this _
)— U) city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH. Daft R Cel [#
— (Wo)agree to save,Indemnify an d keep harmless the City of Cupertino P
against liabilltka,judgments,"sand expenses which may in mywayao ue AIR HANDLING UNHCFO 10,00)CFM) SUB TAL•
again t mid City
I... us of the granting of this permit,
AIR HANDLING UNIT(OVER Ig000CIM) CONSTRUCTION TA
CONSTRUCTION TAX AID:
Signature of Applicant/Contractor
EXHAUST HOOD(W/DUCT)
HAZARDOUSMAT IALSDISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Dale Recei #
material as defined by the Cupertino Municipal Code,Chapter 9.1$and the -
❑t Yand Safety Cade,Section 75537(a)i HEATING UNIT(OVER 100,000 BTU TOTA
❑ a
Wllithex pplimnt orfutere building occupant use equipment or devices VENTILATION FAN(SINGLE REBID) ISSUANCE DA
which emit haeardous air ron(aminanta as defined by the Bay Area Air
a
bty Management District? BOILER-COMP OHP OR 100,0(D BTU)
171Yes No
have mad the hazardous materials requirements underChapmr6.95 of BOILER-CAMP(OVER 100,0000TU)
the California Health h Safdy Code,Sedimna 75505,25533 and 75534.I — PAID
understandlhatifthe Wildingd..tmrrenilyhaveatenanLthalitismy NEW RESIDENTIAL MECH. SQ.FT.
rmponsibllity to nalfy the occupant of the requirements which must be met '
primr to issuance aaCertlficate Oed"anry.
,u z JUN 2 5 1992
Owner or aulhorland agent to ISSIlEDOY
TOTAL:
OFFICE COPY