23372 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification, - - -PERMIT NO.
Building Addre.a:
5 23372
nems 111honc
�1t.v� 1 CITY OF A
CA. �C.NP S CUPERTINO-BUILDING DIVISION
Co 'a ams: Ic.No: '• ,� �— Z
?O,XtO a M., H� APPLICATION / PERMIT
i grchi/M neer APPLICATION
CATEGORY - CONTROL«
III / Lk.No: .
BUILDINGPERMIT-INFO
.'QTY • ELECTRIC PER FE
Address:
•y PERh11T ISSUANCE ,CD � D„ ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm that I an,licensed under providonaof Ch.pter9(commenc APPUANCESRESI L ]OB DESCRIPTION,
ingwlth Senion7000)ofDiviNon3ofthe Busineseand Pmfeselon.Code,and my t
license ie In full! and effect., 11p�I'J`I PANELS '
Licen
Date Contractor !/L a..n/.
ARCHITECI•S DECLARATION 30
qu0G Iuntlentand my pians sha0 be vied as pubbc reromda - O SQ.Fr.FLOOR AREA - $/SQ.Fr..v
O l
Fi l Licensed Prof.bwl _ C TRICAL - /'Q
:zFGGGG'a- uuuSSS OWNER-BUILDER DECLARATION SEECIALCQICUIT/MISC
o ]hereby-(@mthatlamexempt(romthe ContraRor'e Licemelawfmthe
following reason.(Section 7011.5,Business and Professions Code:Any city or '
P� Wj county which requires a permit toroimtruct,alter,loprove,demolish,or repair •pip METER OR POLE[NST.
.� any structure prior to its ksuance;also requires the app0mnt for such permit to
file a signed statement that he is POWER DEVICES licensed pursuant to the provisions of the _ il -
3pw Contractors License law(Chapter9(commenWg with Section 7000)of Divi- SWIMMING POOL ELECTRIC. `'
shm 3 of the Business and Professions Code)mthat heleexempttherefromand VALUA ON D
the basis for the alleged exemption. Any violation of Section 70315�by any t a
applicant fora permit subjects the applicant to a civil penalty of not Qmthm OUTLETSSWHCHESFIXTURES•
lidred dollars($.SM.
eNEW RESR3ENTIAL ELECTR SQ O
�n I,as owner of the property,or my employees with wages as their sole STO FS TYPE CONSTRUCTION
mmpensation,wBldothework,andthestruciure I.not Intended or offered for
O sok(Sec.7044,Business and Profession Cade:The Contractor's License Law
i $ does not apply to an owner of property who Wilde or improves thereon,and -'
who doessuchwork himseRorthmaugh hismwnempleyess,provided thatsuch ,�..y4 OCC.GROIIIs RFS.UNITS '
Improvements are not intended or offered for sale.If,however,the building or TOTAL: Zls'Z'O
Improvement is sold within one yearolcompletion,the owner-builderwili have I
to ben of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PER FEE -- )r[-OpD SNE gpll
L,J t as owner of the property,am exclusively contracting with licensed PERMI7755UANCE
ommumm to construct the project(Sec.7044,Business and Professions Code: -
The Contractor.License Law does not apply to an owner of property who
Wilds or improves thereon,and who contracts for such p(ojectn with D
<gR(pRor(e)Bansed pursuant to the Contraaob License Law. BAIX FLO '[, FEE SUMMARY
I am exempt under.Sec. ,B k P C for.this reason - - -
Owner •� Date -r . OUTSIDE FEES
DRAINS SANITARY Y_ N_ '
WORKMAN COMPENSATION DECLARATION RECF1Pr«
❑I hereby affirm that I have a certificate of consent to self-Insure,or a FD(TURES SC[ L TAX Y N
cemitlmtecfWorkers'CompemaHonlmunnmorawdifkdmpythereof&S . RECEIPT«
3500,Leh CJ GAS-FA.SYSM'MI WCAO PA FEE' Y N
Pmiry« d351a6—OZ .,..RECEIPT«
Com anv tK w.—i..F GASEA,SYSTFAt-OVER6(EA)
BUILDING DIVISION FEE
Certified copy Is hereby famished.
UCertitled copy Is(Bed with the city Inspection division. CREASE/INDUSDtL WASTE INTERCEPTOR PLANCHECK FEE - S tin CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE - '
(rhlswdionneednmbecompletedlfthepert tisforonehundreddollan SEWER-SANITARY-STORM EA.20OFT. Date t#
($100)oifyth WATER HEATER W/VENT/ELFCTR ENERGY FEE
Ill net cop In the performance of the work so as to this permit Is issued,
I shall not employ any person In any manner se u to b me subject to the WATER SYSTEM/TREATING
Worlicant mpensatlon Laws of California D p D
Z 0 NOTICE co es s�t M:IL e k omPer ationlprovis Exemption,you IJLW RESIDENTIAL PLMB. SQ.Fr. Da R 1 t# .
•F N should become subject to orkeme'Compematlon provblon of the Labor TO L:.
Code,you mu at(orthwlt mm plywithsuchprovlalonorthlepermitahanbe BUIL 'D
W > deemed revoked. _ ',
,S p CONSTRUCTION LEND] CC� - - SEISMIC FEE .;
'I
hereby affirm that there is roma[ nknl�dingagersy(ortM perform- _ TOTAL: 1. ELECTRIC FEE
M O a..
of
work for which this t is Issued(Sec.3097,Civ,C)-
V L der.Add PLUMBING FEE
U. E Le
ender.Address Qrlf• MECHANICAL PERMIT FEE MECHANICAL FEE i-
O W Imuifythatlhavereadthisapplicationandk.tethattheaboveinfornutian
i,omroct.I agmeto complywith all city and county ordinances and state laws PERMITISSIIANCE FEES PAID:
} N relating to building mmtruction,and hereby authorize representatives of this. -
H Z city to enter upon the above-mentioned property for bapeciion purposes. ALTERORADDTOMECH.
(We)agree to save,indemnify an it keep harmless the City of Cu peltins, Date Re eipt# '
against liabaltks,judgments,coatsand expenses which may In anywayamme AIR HANDLING UNIT(TO 10,000 CFM) $UBT TAL•
agaWbald City In sequence o(the granting of this permit'
AIRHANDLINC UIa1T'roVFE10,BBOCM .CONSTRUCTION TA
Signature Applicant/Contractor Date EXHAUSTID,(W/DUCT)_ CONSTRUCTION TA PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant nefuture building occupant store or hand ie hazardous HEATING UNIT(TO 100,000 SM
maDate ,'BBC2 t#
terlal as defined by the Cupertino Municipal Code,Chapter 9.12,and the - '
Health and Safety Codsjection 25532(.)7 HEATING UNIT(OVER 100,000 BTU) TOT L:
F1 Y. It��u No
occupant the applicant or tare building pant use equipment m devices VENTILATION FAN(SINGLE RESID) ISSUANCE DA
which emit hazardous a r contaminants as defined by the Bay Area Air - PAID D
Quality Management District? - BOILER-COMP(3Fff'OR 100,000 BTU)[ H
IhYas NoI
have read the haz nus nate mals requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)'
the California Health 1 .
�fety Code,Sectbna25505,75533and2S534 [ - MAR1992'
understand that if the building does not currently have.tenant that it le my NEWRESIDFI-MALMECH. - SQ.FT.
responsibility to Ally the occupant of the requirements which must be met
prior to Issuance of Celfificate of Occupancy, - I - - IVUf Cfi 111V1/
a/I_L�'�C rj.',J 'CII Y
9` '
Uvnerma lad agent Dam— - ISSUED 6Y:� V.. 11L
TOTAL:
OFFICE COPY