23783 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Bulldin Pealed Identification PERMITNO.
BWId Ing Addmso
23783
l
n¢r, ame: One:
CITY OF CUPERTINO-BUILDING DIVISION
C.nBe m. era; Lm.N.: APPLICATION / PERMIT
son BUILDING-ELECTRICAL-PLUMBING-MECHANICAL CATEGORY CONTROL N
rchite
-Act/ glneer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add., OPERMITISSUANCEbl_� EL�l PLUMB MUCH
❑ ❑ ❑
LICENSED CON CT OR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter9(comment APPLIANCES-RESIDENTIAL JOB 0E 101-1 ION
Ingwlth Seceon7000)of DiAMon3ofthe Buslasaand ProfeWon.Code,and my
1
lima.is in full to end effect PANELS `_
Licence Clan Lic.N V�s� y`C.�
Dat ontrador
t« -
ARCHITECTS DECLARATION h 1-1000 AMPS G
O I understand my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FL R AREA $/e.Q.FT.
Licensed Professional SIGNS ELECTRICAL
6 OWNER-BUILDER DECLARATION SPFLIALCIRCNT/MLSC
op,r Iherebyaffirt thatlamexempifromthe Cantrador's Li...Uwlorthe
ZOZ following mawn.(Section 70315,Business and Profmloa Code:My city or TEMP.ME1TR ORPOLE INSF.
p� county which requireea permittocomruck,alter,Improve,demdish,orrepair
anyatmc mpdmtoita aagalsorequimlheoppBantfasechpem tto POWER DEVICES
r file a signed statement that he b licensed pursuant to the provinions of the
3wyy Con/actor'sLicense Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION-H�O:J sion3 of the Business and PmIcBk sCode)mthat heb exempltherefromand ^ N- a
a.•�]] the basis for the alleged exemption. Any violation of Section 70315 by any OUILETSSWITCHFSFIXTURFS
O
applicant for a perndt subjectathe applicant to a civil penalty of net nnre than
$ RF T,as
dollars($S00J.ofthepro NEW RESIDENTIAL ELECTR SQ.FI' SIO TYPE CONSTRUCTION
�n
compensation,
as owner of the property,or my employees Is with wage as their dole
coIn(Sm.7044,
does
dothe work mdthe swcture boot intended or offered for
O We(Sec.Tilly to an owner fproperty who
Wild,Cimproves hemeLaw
t{r$$ dces naapplyman owner ofpropertyhisonempor improveseted that such
r RLS,UNITS
who dv:.Mxam ncB himself dedorwghhbawnemp howevewWeuildinueh �`.//
improvemenb are not Intended oro(fered(or dale.I(,however,thebuliding a A
Improvement issold within one yearo(compldion,the owner-budderw111 have
tlgjavden of proving that he did rout build or Improve for purpose of sale.), QTY. PLUMBING PERMIT FEE
LJ L as owner of the property,am exclusively contracting with licensed APN
contractee to construct the project(Sec.7044,Businessand Professloa Code: PERMIT1SSf1ANCE I
The Contractor's License Law does not appy to an owner of property who
build. or improve thereon, and who contracts for such prokds with a ALTER-DRAM Is VENT-WATER(EA)
ugatp.doral licensed pursuant to the Contractor*.License Law. FEE SUMMARY
LJI am exempt under Sec B k P C for thin reason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,ODND. SANITARY Y N
Owner Date RECERTN
WORK MAN COMPENSATION DECLARATION FD(il1RF_S PER.TRAP Sp{OOLTAX Y N
❑I hereby affirm that I have acertificateInsue of concent to opythrem,ora RECEIPT N
Moa'L.bc.)certifirade.frker%Cmnperwllonlaunnreora rerti/lcd ropythereof(Sec. GAS EA.SYSTEM.1 INCAOUTLETS PARK FEE Y N
Polis Lab C.) RECEIPT N
Policy M
CoGAS EA.SYSTEM-OOVER (EA)
BUILDING DIVISION FEES
LgCOed
copy at hereby famished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy Is filed with the city inspection division.
CERTIFICATE OF IXEM PTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARYSTORM EA 700FT Date ReceI of
Rhin section need net be completed If the permit b forone,hundred defiant
(slm)arlyth WATER HEATER W/VENT/eLrr.TR ENERGYFEE Y N
]snot thato the person
Ianymof the wekforwMrh this pemdt Is blued,
I shall not employ any person In any manner a ae be me Abject to}(,e WAIL!SYSTEM/TRFATINC
Workers'Cicant om nation law.of Cal(i,,,f'QQQmmmb.Date y PAID
O Z NOTI ETO�PLI Anea/ ��ibCi B�te�o`f Exem ion, ou NEW�DENTIAL PLMB, SQ.FC. .Date ReceI tin
Z O 1,ager nw.4 a Pt Y
should become subjcd to the Workers'Compensation provisions of the Labor TOTAL:
Q
Code,you=at forthwith comply with such provisions orthbpermitshalibe U D •.T"-+Fie9
W y deemed revoked.
a c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby afflmnthat there b a construction tendlegagenry,for the perform- TOTAL ELECTRIC FEE
Z anceof the work(or which this permit b fiesued(See.3097,Civ.C.)
V O Leona,'.Name PLUMBING FEE
LL F- Lendre.Addreas QTY. MECHANICAL PERMIT FEE MECHANICAL FEB
O W I certltythat l have read thisappHatlonand statethat theevelnformmio
bon
1 brorrect.Iagreetoc.mlth
plywaHcityand countyordinanceeand slatelaws PERMIT ISSUANCE FEES PAID:
>. 0. tobulidingronstmction,and hereby authorize representative ofthts
F N city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD T MECH.
? (We)agree to save,indemnity an d keep harmless the City of Cu pertiva Date Receipt#
V agaHut liabilities,judgment.,cost...d expenses which may in any wayacerue AIR HANDLING UNIT CFO 10,000 CIM) SUBTOTAL'
against aid City in consequence of the granting athis permit.
AIR HANDLING UNIT(OVER I0,IX70 CFM) CONSTRUCTION TAX
sigrutua of pprat/Contractor Date EXHAUgTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
MDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATINGUNIT(TO100,000117U) Date Reeei t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and SafetyCcd�di.n 75537(.)7 HEATING UNIT(OVER Iffy"BTU) TOTAL:
❑ Yea No
Wllllie applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RE5ID) ISSUANCE DATE
which emit hazardous air contaminants as deRned by the Bay Area Air yk
Quaily Management D21&Act? BOILER-COMP QHVOR 100,000 BTU) PAID
4Ye No
h.wmadthehat�usmaterialsrequlmmenbunderChapter6.95of BOILER-COMP(OVER 100,000 BTU) (�(�q
the Califomla Health&Safety Code,Sections 75505,75533 and 15534.I JUN -5 1992
understand that lithe building does not currently have a tenant,that it is my NEWRESIDENTIALMECH. SQ.Fr
responsibilityto ndiy the occupant of the requirements which must be met
prior to issuance of a Certificate of Oaupanry. V�;pphhlW�
s\' CPIT Wr
Owner.raul cad agent Data IRSIIEDBY: J
TOTAL:
OFFICE COPY