23946 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PFRMITNO.
Building Address: 23946
nera ama:�� L %jot � � A
�.4Pd C4va"T-0 C.o. CITY OF CUPERTINO�BUILDING DIVISION r���N7
!tndara Nam/e:• Lie.Na APPLICATION /PERMIT C— .
F� Li1�N T-L 7 � BUILDINGELECTRICALML BINGMEC Nl AL CATEGORY CONTROL N
Architect/Engineer. Lic.Na.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
AddresBZOZ ,4 QPEfth9TISSUANCE ElIQI 1:1 ❑
LICENSED CONTRACTOR'S DECLACLA RATION L/C7
I hereby affirm that lamgcrneed under providers at Chapter9(mmmrnc- APPLIANCFSRESIDENTIAL JOB DESCRHxI'ION
Ingwe I.I.full.. )cat Divffort. thegurlassandProleraloneCode,and my
LiceeebInfuH force andtfect. PANELS
Dame Cbss LIaN
Dade.Contractor UP TO 2DQAMPS
ARCHITECTS DECLARATION 301-1000AMPS
WO Tundentandmyplamsh Hbeuwdupubecrecwds. OVER 1000 AMPS y~• I !g.
tk
9GNSELECTRICAL i
Licensed Professional OWNER-BUILDER DECLARATION / t G�,�J N
!ten IB SPECIALCIRCUIT/MLSC ` j
F. I hereby of@m that lam exempt fromthe Contractors License law for the
Zp foHowing reaeon.(Eediun 70115,Business and Pmf=Wm Code:My dty or �� 1� G
OZF•e TEMP.MEfFR ORPOLE]NST. D E . 7
!V
P� counywhlch requlreaapemdt toconstmt,almtlmprove,demolbh,orrepalr
anystmMmpriorwitsbuance,a) mquimslheapplimnttasuchpert tto Ip1ygR DEVICES JI
TNG file a signed statement that he b Licensed pursuant to the pmvblons of the
SOwl, Contractor'sLicense Law(Chapter 9(mmmencing with Section 7000)of Divi. SWIMMING IDOL ELECTRIC
OS sion3ofthe Busts amdPref.W.Code)orthahebemmpttherefromand VALUATION
6 the basis for the alleged exemption. Any violation of Section 70115 by any OUILETSSWITCHESFlXTURES
q
applicant for a permit sublets theappncam too civil penalty of not more than
five hundred dollars M100). NEW RFSIDENTW.ELECTR SQ.Ff. STORIES TYPE CONSIRIICTION
< ❑I,as owmr of the properly,or my employees with wages as their sole
mmpensatlon,will do the work and the structure Isnot intended or offered for
q sale(Sea 7044,Busims.and I mfe.eions Code:The Contractors License Law
don nm apply to an owner of property who Wilds or improve thereon,and OCC.GROUP RES UNITS
E whodassuchwork hiceselforthrough Naownemployers,provided thatach
Improvements are not intendedoruffered for sale,If,however the Wllding or ToP
Improver nt Iseaidwlthlnoneyearofcompitlon,theawner-bu0derwBlhave -
tlxrrdenofpmvingthathedld nm Wild or Improve for purpose ofcale.). QTY, PLUMBING PERMIT FEE 'FLOOD ZONE APN
LJ I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE r'
mntntan to construct the pmjed(Sec.7044.Business and Professbm Code:
The Contractor's License Law does net apply to an owner of property who ALTER-DRAIN&VENT•WATER(EN
Wre
ilde or Improver theon,and who contracts for such pip"with a FEE SUMMARY
CgR(�actor(.)banaed pursuant to the Contnder's License Law. BACK FLAW PROTECT.DEVICE
L�I am exempt under Sec. B &P C for this reasonOUTSIDE FEES
Owner Date DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
• WORKMAN COMPENSATION DECLARATION RFC®'1'N
FD(TURE&PER TRAP SCHOOL TAX Y_ N
❑I hereby ffirorke that I have o Insu a c of consent to copy
thereof
or RECEIPT N
a00,Lab otWorken'Compematlonluurana as certl(Ied spy thereo((Sec. GAS EA.SYSTEM-1 INC40UTLETS PARK FEE - Y N
poll Lab C.) RECE PT M
Poll M GAS EA.SYSTEM-0VERd(EA)
any BUILDING DIVISION FEES
ertlfied copy b hereby filed
the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
❑ ertined mpyb(lied with the ty Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCESEWER-SANTTARY-STORM EA 300F1' Date RCCCI f#
(Thissectlon need not be completed lithe permit b for one hundred dollars
($100)orless.) WATER HEATER W/VENT/ELFCTR ENERGYFEE Y_ N_
In, Ifythat N the performance oflhewurk forwhIch this permit is broad,
I shall nm employ any person In any manner n u to bemnr arblect to the WATER SYSTEM/TREATING
Workcri Compensation laws of California.Date PAID
Z Applicant NEW RESIDENTIAL PLMB. SO.1•T. Date ReceI t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
I. W Code,you swat forthwith comply with such proridons or this permit shall be -
BUILDING FEE
LU j deemed revoked.
CL C . CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby afnrmthat there b co
a mtmtlon lending agency for the perform- TOTAL: ELECTRIC FEE
L) Z ance ofthe work for which this permit uedCO(Sec.3097,Civ.
(„) O b W
LsMer'.Nio, PLUMBING FEE
LL F Leedar•.Addreaa - QTY. MECHANICAL PERMIT FEE
O W I certly thatlhaverve thbePpHationard Yatethatthe above information MECHANICAL FEE
(i bmncci.lag m comply withallcityand munyoedlnanasend Yate laws PERMIT LSSUANCE FEES PAID:
} N relatingto Wil ing comtmction,and hereby authurire representatives ofthb
(_ Z dtyte enmrupo eabave-mentbnad property la Wpection Purposes. ALTER OR ADD TOM�H. Date ReeCl (#
V aalrac)ab�lltle dk
ms eandexan d�eneea whlc.the h nu Clan two pertino acaue AIRIiANDLINC UNI"1'(T010000CFM)g (u x y y SUBTOTAL:
d City nece of the granting of t] pe B.
1 6 9 Z AIR HANDLING UNIT(OVER IO,ODOCFM) CONSTRUCTION TAX
tureof APPH /Conmcior rc E7(HAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
A RDOUS MATERIALS tatom or RE
Will the appH rat future Cupertino
Municipal
Yore hahe pten 9.hvardoua HEATING UNIT(TO l00,f100 BTU) DBIC RCCeI t#
Health
and define he Cupertino Municipal Cmde,Chapler 9.1 2,and the
Health and Safety Cade Section 75532(a)7 HEATING UNIT(OVER 100,000 BTU)
!-1 Yu No
Hlthe hasard usa tore Wilding occupant use theequipmentArea
VENTILATION FAN 6INGLE RESID) ISSUANCE DATE
which emitNvrdoua air mntaMnanta as defined by the Bay Area Ab• q ,alityManagementDistrict? BOILER-COMP OR100,0(UBTU, P A O ^
YL hay- ❑!�!No L
I have mad the hazallous Raterlals requlrcments under Chapter 6.95 of BOILER-COMP(OVER 100,0008TV)
the California Health&Safety Code,Sections 25505,25533 and 25534.I
n
understand that ifthe building donm currently have a tenant that it is my NEW RESIDENTIAL MECH. SQ.R JUL =8 1992
mor i.ex.to notify the occupant otthe requirements which must be net
Prior to Issuanre of i y the ccu ant oupancy.
Owner or authorlud agent Data TOTAL: ISSUED BY'--raw
OFFICE COPY