23319 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proed Identification PERMITNO.
Building Address:
i. I i (o2 (1 ,r4JcS ou At�� E�ct6�.Sia►a� 2 3 319
where aces: _ hone:
Rn R L� a'J—'a4'{ CITY OF CUPERTINO-BUILDING DIVISION "�
cantraanr(°_[J LcNa: APPLICATION / PERMIT
• 'T ' Ze- 4O BLnDINGELECTMCALPLUMBING-MECHANICAL CATEGORY CONTROLM
Ash es/Engineer. Lk.Na
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address:
PERSBTISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
IhthSy ll70that lam Bcm3.fthunder.g.provisions dpmfhsM..r9(m..d APPLIANCESRESIDENHAL JOB DESCRU'EtON
It...I I.fon7000)of d effec n3o(the Butlneuand ProfesslonaCode,and my
lienee b in ha urs and effect. PANELS
License Claes - Lk.X YlJ(n ZrI I
Contractor UP TO 200 AMPS
ARCHITECTS DECLARATION 201-1000 AMPS
p❑±M zz I understand my plans shall be used u public records. OVER70DOAMPS ���QQQ {���OQ�R Alb! D - .FT.
F�F Licensed Professlansl SIGNS ELECTRICAL / • C
«< 'E3
OWNER-BUILDER Iamex mptfro DECLARATION SPECIALCIRCUIT/M64C p M P U T R
z'" tt�ga IherebyalBrmtFullam exemptfromthe Contradot°Llmnm lawfor the )
oo�� following reason.(SeMon 70315,Business and Professions Code:My city or Y a I/ f
OZ" TEMP.METER ORPOLE INST. - ! Y[ i
PE aiuntywhich rcqurenapermhtomnstvct,alte.lmprove,demoWh,or repair
S anystmR mptl tolbl ancemis requimtheappBsntforsuchpermltto POWER DEVICES DATE
G 0. file a signed statement that M b licensed pursuant to the provisions of the
3w Contractor'.License law(Chspter9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
OJ don3 ofthe Bu°Ines°and Profeulens Code)orthat he bexempttherefromand
<S the basis!or the alleged exemption. Any violation of Section 70315 by any
applicant turn permit subjects the applcanito a civil penalty of no..than
OIJTLETSSN7TCI{ESFIXTURES
live hundred dollars(SM.
�n ❑I,as owner of the ro NEW RESIDENTIAL ELFCTR SQFf. STORIES TYPE CONSTRUCTION
p party,or my employees with wage a Were sole
comp c.704,B..Wl do We dProfrel..Cork and the dureis not Intended oroffered for
O c1.cs not 7064,to alnowner Professionsho Wilds or improves thereon,
hereonAce.lad
$ does does
apply loan owner ofpropertyhisOm em oyes,provided
uch OCC.GROUP RFS AMTS
whodoea artsch am workhimselfed oorthrough hleowne.If,hone,pro thein that gar
Improvement arc not Intended proffered torsion.If,however,thebuikll have TOTAL:
Improvement bsoW withinoneycarolcomplsiorytheowher-bullderwlll have
the burden of prot Wild proving that he did cold or improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOODZONE APN
IJ Las owner o!the Property,am exclusively contracting with licensed PERMIT ISSUANCE .
comadors to construct the project(See 7061,Business and Prolessiom Code:
The Contractors License Iaw does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds ur Improv.therm.,and who matrass for such plojecv with a
cgp[fad,.(.)licensed pursuant to the Contractors License Law. FEE SUMMARY
I�I am exempt under Sm B k P C for this recon BACK FLOW PROTECT.DEVICE OUTSI UP FEE 5
DRAINS 11.0011,ROOF,AREA,COND. SANITARY Y N_
• Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES-PER TRIM SCHOOL TAX Y_ N
❑I hereby affirm that I have a certificate of concent to salt-Inwrc,ora REJ=N
certificate efWorkeri Compewtlonlruunnmora srifled copythemof(Sec. GAS EA.SYSTEM-1 INCAOULITS PARK FEE Y N
3800.Lb VII. RECEIPT M
Po11ryN Y 9 aye GAS EA.SYSITMAVER/(EA)
Com anvJ(,L.Dy1n(.(�OF QFrnTV BUILDINGPT DIVISION FEES
[JC rtlRed copy is herbyfumished, GREASE/INDUSM WASTE INTERCEPTOR PLANCHECKFEE
QCertiRed copy b filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA MEET. Date Reeel to
(Thlssesion need at be completed if the permit is forom hundred dollars
(5100)mleu.) WATFA HEATER W/VENT/FlFC'TR ENERGY FEE Y_ N_
I certifythat In the performs.of the work farwhlch this permit Is blued,
I shall not employ any person In any manner so as to became subject to the WATER SYSTEM/TREATING
Workeri Compeneationlawsol Callfomh.Dale PAID
OZ Applicant NEW RESIDENTIAL PCMB. SQFf. Date Recei tf(
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
should become subject to the WorkeraCompewtlon provision,of the Labor TOTAL:
N Code,you mast forthwith comply with such provisions or this permit shall be BUILDING
IL 5 deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
(L ° Ihereby affirm that there b a constvdlon iendlegagenry for the perform- ELECTRIC FEE
0 once ofthe work forwhich this permitb Issued(Sec.3097,CIV.C.) TOTAL:
(,) _ Lenders Name PLUMBINGFEE
U. Lender.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FE
OW I certifythall law read this appliationand statethatlheaboveleformatlon
fl bmrmd.lagreetocomplywlthaildtyandmuntyordlnanm..rdshimlaws PERMIT ISSUANCE FEES PAID:
W relating to building construction,and hereby authodu representatives of this
cit to entero n the above-mentioned property,for inspection ALTER OR ADD TO MECH.
~ ? y(We)agree save,Indemnify an d eearmless the ityo rtmo Date Recei t#
V against llabilltios,}adgmmdu,coesand e.Pat.which may In any way accrue AIR HANDLING UNIT(T010,000 CFM) SUBTOTAL:
aga last said City In consequence of the granting of this permit. AIR HANDLINGUNIT(OVER 10,000 CFM) CONSTRUCTION TAX
"'° '� - ��7-1G CONSTRUCTION TAX PAID:
Sig t/ actor
Data EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE
HM1a pilantorfuture building occupant store or handle harardous HEATING UNIT(70 110,000 BTU) 'Date ROtei Ile
material a°delved by the Cupertino MuNdpal Code,Chapter9.IZ and the
Health and Safety Code,�+-Sl,Mion 25532(x)7 HEATING UNIT(OVER 1041,000 BM TOTAL:
Yt.
No
❑Wil the applicant arfutore building oserpam use equipment erdevlces VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit havrdous air contandrameas defined by the Bay Area Air
Qjj;IlftManagement DistricT BOILER-COMP PHP OR 100,000 BTU)
QYesNo
(have read the b.Q.,materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) P A f
the lcalilornb Health k Safety Code,Sections 25505,25533 and 75534.1
understandthaI lithe building does not currently haveatenant,that It b my NEW RESIDENTIAL MECH. SQFT
responsibility to notify the occupant ofthe requirements which most be mel FEB 18 1992
prior to Issuance of a Certificate o(Occupancy. -y^
Owner or authorixed agent - - - Date ISMlED
TOTAL:
OFFICE COPY