22967 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identlficatlan PERMITNO.
Building Address:
G22967
2^q 6 7
G{J,J
oars ams: (+ }-,. hone:
N J JG C Ur CITY OF CUPERTINO-BUILDING DIVISION 1 e� A
G ` N ��+ LIc.No: APPLICATION / PERMIT I f` t ` a
� BUILDINGS,ECTRICALPLUMBINGM HANICAL CATFfARY CONTROL p
Architect/Eogineem LM.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addreas:�J��S,,1•V JVM1a pSLVtITISSUANCE g--
❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm that am licensed under provisions of Chapter9(commenc APPLIANCES-RESIDENTIAL JOB DLSCRIPITON
Inose11 to
70W)of Dlvleimn3o(the BuslnessandlarofesslonsCnde,and my
Ilcense is In fu)t to an cited. r.., ..,,� r r PANELS
License CI C� Lk.tr_7"}T},S d
e Contractar�, UP TO 2DO ANTS
ARCHITECTS DECLARATION 20140DO AMPS
q�aMZQQ I understand my pies shall be used as public records. OVER I000 AMPS ^SQ,FAT.FLOOR AREA S/SQ.FT.
k z Fd Licensed Professional SIGNS ELECTRICAL \ II�—n� �. '
Z a y ` OWNER-BUILDER DECLARATION SPECIALCIMCUIT/MISC ,' �� T E
l here's affirm that l am exem from the Contractor's License Law for the
O$F p following reason. that
70'31.5,Business and Professions Code:Any city or TpAMp,METER OR POLE INST. ' �'
pS tu�Jl countywhkh requires a permit to mtutmct,alter,improve,demoloh,orrepair
$ anystm=mpeortoltstsauame,abomquimatheapplimntfornuchpermitto �•G/
O lire a signed statement that he is to pursuant the provisions DEVICES
ioof the -
�Oy Contractors License Law(Chapter 9(commencing with Section 7000)of Divi- ...�P
a 'on 3 ofthe Business and Pod.winse Code)or that he 1. ",pt therefrom and TSWIMMING POOL ELECTRIC k5yflVALUATION
'--11 the beats for the alleged exemption. Any ,violation of Section 70315 by any
< appBcmt for a permit sub*Uthe applicant to a civil penalty of not rrore than OUTLETSSWITCtESFIXTUR
O five hundred dollan(S500).
�n ❑L as owner of the roe NEW RESIDENTIAL ELECTR_SQFT. STORIES TYPE CONSTRUCTION
p-party,or my employees with wages as their sole
compensation,will do the work,and the structure isnot intended or offered for
q sale(Sec.7044,Business and Pmf.loro Code:The Contractors License Law
$ does not apply to an owner of property who Wilds or improve,thereon,and {
who doessuch work himself or through hisbwn employees,provided thatsuch OCG GROIIia RFS UMTS
improvements are net Intended oroffered forsale.If,hcuo,W4 thebullding or
improvemenHssoldwithinonerarofcomplebgtheowner-W Bderwlll have
thalZurden of provingthat he did not build or improve for purpose ofsaleJ, QTY, PLUMBING PERMIT FEE FLOOD TONE APN
LJ{as owner of the property,am exclusively contracting with licensed PERMTC ISSUANCE
ocomed0n to construct the project(Sec.7044,Business and Professions Code:
The Cmdeactor'e License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilda or improves thereon,and who contracts for such pm*U with a
acror(s)ucenand pursuant the Contractors License Law. RACY FLOW PROTECT.DEVICE
FEE SUMMARY
I am exempt under See. B&P C for this reason
OwnerDRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Date p
WORKMAN COMPENSATIONRECEIPT DECLARATION
!Ell hereby affim that I have.a certificate of consent to self-Insure,ora 171X'IURES PER TRAP SCHOOL TAX Y NRtLEIPT N
certl0uteofWorken'Comper tioalmumnmoramniftedmpythereof(Sec. GAS-EA.SYSI.Q.i1INC.40UILETS PARK EPEE Y T
3800,Lab CJ
Policy b - RECEIPT p
Com any - GAEA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
ECS ertified copy is hereby the city GREASE/TNDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy ts(Bed with the airy inspection division, ,
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP URA IPAID
COMPENSATION INSURANCE
(Thlasecilanneed nmbe compliedSts(pronehundred dollen SEWSbSANF ARY STORMEA 200FT Date Recel t#
($11D)orlenJ WATER HEATER W/VENT/ELECTS ENERGY FEE Y N
Icertl(y that In the performance of thework(orwhich this permit la issued, —
I shall not a loy pens In any nner eo ee to co ' to the 1YA7�S1,S:IEM/TREADNG
Workern C e nIa s !Gail( a.Date 1 PAID
O Z Applicant NEW RESIDENTIAL I'LMB. SQFT. Date Recei f#
Z 0 NOTICE I A :If,a e king this Certificate of Exemption,you
should bam subject to the Wor n'Compersation provision:ofthe Labor TOTAL:
N Code,you moat forthwith comply with such provisions orthts permit shall be W BUILDING> deemed revoked. -
CL f] FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
lherebyatfirm that there is a construction lending agency for the perform- TOTAL: ELECTRIC FEE
M 0 aom.ftho wmIxfof whichthis permit ts Issued(Sec.3097,Civ.C.)
V _ Lader',Name PLUMBING FEE
IL I— Landerspddress QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Imrtify that have read this appBcetion and stamthat the above Information
1 ismrred.I-pmWcomplywithallcityand coomyordleancesand state laws PERMIT ISSUANCE FEES PAID;
W relating tobulldingmmtiuctlon,and hereby authorize representativesofthis
-(— Z city to enteruism the above-mentioned property for Inspection purposes. ALTEROR ADD TOMECH. Dare - Retei t#
111thaappIi,�)tcvh1tcmb
M
Indemnify an d keep harmless the City of Cupertino P
gggqqqseeeeeammnmms1pppppp ostaandexpenswhlch yloanywayaceme AIR HANDLING UNIT(TO 10,ODO CFM) $U$TOTAL:
nceo egraotingofthlap coniI.' � AIR HANDLING DMr(OVER 30,000CFM) CONSTRUCTION TAX
/Conte or Data EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PA IRDOU MATERIALS DISCLOSURE(ding occupant store or handle hazardous HEATING UNIT(TO 100,OW BTU) Date ROCeI (#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and SafetyCade SBoJcr 25532(.)2 i HEATING UNIT(OVER 100,000 BTU) TOTAL'
n Yea No - ��..yy
'Cyril the applicant or future Wilding occupant use equipment or devices VFIIMATION FAN(SINGLE RESID)
mi
which et hazardous air contaminants as defined by the Bay Area Air �Syly DATE
ally Management District? BOILER-COMP QHP OR 100,0(0 BTU)
' Yea gua - Nov 12 1991
T1�averead Health
a sets Code,Se requirements under Chapter G95 of BOIER-COS1P(OVER 1(10,000 BTU)
the If-role tl tkalth&Safety Code,Sections 25505,25533 and 25534.] ,
understand that[(the Wildln does not mrrentl heave a tenant,that it ism NEW RESIDENTIAL MECH. FT day �a
responsibility to orally the occupant of the mguiryements which must be mei CAY OF CUPttSI INU
prior to Issuance of a Certificate ofOccvpanry. \�\../s.}��^+•��`�Y��
Owner or Both Tired agent Data ISSUEDBY: VVi� `•1S aV���4
TOTAL: '
OFFICE COPY