23928 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building PmIxct Identification PE4MITNO.
BuBding Address: as' /� 1 23928
494 / ' /JY. 2, GP4 kips "
woe a one:
CITY OF CUPERTINO-BUILDING DIVISION L� Z
. Contractor's Name: LIc.Nm APPLICATION I PERMIT
• �l� BUILDING-E.FCTRICALPLUMBING-MFCHAMCAL CATEGORY CONTROL
Architect/Engineer. I.N Lk.No:
BUILDING PERMIT INFO
QTY ELECTRIC PERMTT FEE
Addreu /.,fbryy sPERAUTISSUANCEEl ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby afflrmthat lamlicensed under provlslonsof Chapler9(commmc APPLIANCESRESIDENTIAL JOB DESCRIPTION
ingwith Secbon7000)of Dlvision3ofthe Bustnassand ProfesslonsC"ode,and my / N
Lllos (oa and effect PANELS
... / E /
lcenx Clan LICY
Date Contractor UPT02DOAMPS
ARCHITECTS DECLARATION 701-1000 AMPS
ZI understand my planashR be used as public rrds. OVER IODO AMPS :I.
.FF.FLOOR
AREA� f/ FT.
O Licensed Professional SIGNS ELECTRICAL INALE
6 OWNEReBUILDER DECLARATION O M P U R
In SPECIALCIICUfT/MISC
7e, .Za owing ..rtntlsllano31.5,B .hxempt mthe ContractaE.m,Ceselawfmthe
(ollowing reason.(SMlon 7W1.5,Buslnm and IProfmlons Code:Any city or
F TEMP.METER ORPOLE INST. rs
� rountywhkh requirnapermi[toronahuct,alkr,lmprove,demolbh,orrepalr x "(/T
a anystmMmpeortoiblasuame,alasu
omqulmstheappllantforchpev tto POWER DEVICES AIG
fila a signed statement that he is licenced pursuant to the provisions of the
3"G Contranor'e License law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
sion 3 ofthe Business and Profmlona Cade)orthat he h exmpttherefrom and �sa•r„” -
Qthe basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHTSFIXTURES a.
applicant fora pennon subject the applicant toa civil penalty of not more than
five hundred dollars($500).
&as owner of the property,or my employees with wages as their sole NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
C compensation,will do the work and thestruaure is rot intended or offered for
5 M sale(Sec.7064,BuaNm and Profmiom Code:The ContnctoYs License Law
pn� F donal apply to an owner of property who builds or Improves thereon,and OCC.GROUIP RES.UNITS
,
FF:: whodoes such work himxQorthrough Msown employees,provided that such
Improvements are not intended proffered forsale.If,however,thebuilding or TOTAL: (�,
Improvement Id within omyearafcompldbNtheowner-bullderwill have
the burden of proving that he did nat Wild or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
M L as owner of the properly,am exclusively contracting with licensed pEgMIT 13.TIANCE
contractors to construct the project(Sec.7044,Buslnm and Pro(mima Code:
The Contmotara License Law does not apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)
builds or improves thereon,and who contracts for such Inojects with a FEE SUMMARY
�t[+ctor(s)llmnsed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
IJ I am exempt uncle Sec B k P C for this mason
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Dae RECEIPT N
WORKMAN COMPENSAT NDECLARATI N FO(Tuli PER IRT SCHOOLTAX Y N
❑I hereby affirm chat I have•mrtiBate of consent to se141neum,ora RECENT M
certificate olWorkem Comperustlon Insurance we mrtlficd copythemof(5ec. GAS EA.SYSTEM-I INCA OUTLETS PARK FEE Y N
39DO,Lab C.) RECENT N
Polley M
CGAS EA.SYSTEM.OVER 4(EA) BUILDING DI VISION FEES
C. any
ETCertlOed copy is hereby furnished. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified ropy b filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORK ERS' GREASETRVP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 20OFT Date R¢c¢i t4F
(Thlasectlon need nu be completed lithe permit la forone hundred dollars
($100)orlm.) WATER HEATER W/VFNf/ELECTR ENERGY FEE Y_ N_
I certify that In the perfomsnmof thework forwhich this permit Is ued,
I shall not employ any person N any manner so as to become subject to the WATER SYSTINMEATING
Workers Compensation laws ofCallfornla.Date PAID
OZ Applicant NEW RESIDENTIAL PLMB. SQ.Ff. - Date Recei IN
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provlalona of the Labor TOTAL:
CCN Code,you at forthwith comply with such provisions or this Parrott shall be BUILDING
IJJ > dmmed revoked.
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE
z Ihereby affirn that them is a construction lending agency for the perform TOTAL: ELECTRIC FEE 3^
anmoftheworkforwhi hthb permit fa lesad(Sec.3097,Civ,C.)
M Z L7
V O L.eiWer's Narna yl pvPLUMBING FEE.
LL 1— Landefs Addren QTy- MECHANICAL PERMIT FEE MECHANICAL FEE
OW Imrtlfythatl havereadthisappllotion and statethat lheabovelnfomutlon
a incorrect.lagma to comply with all city,and countymdlnanms and state laws PERMIT ISSUANCE FEES PAID:
�. N relating to Wilding corstructlon,and hereby authorize repmentallvesof this
f Z city to enter upon the above-m ntionad property for Inspection purposes. ALTER OR ADDTO MECH.
(We)agree to save,indemnify an d keep harmless the City of Cu Fortino - Date RC e1Ptk
V
against liabilities,judgment,costs acad expenses which may In any way acme AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL:
agausa said i m am-ol1M1e grant. of this permit.
jJ /� W9 AIR IiANDLINC UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
[J C� CONSTRUCTION TAX PAID:
Sig rept App HAZA DOUSor Date IXHAIJS"f HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE
Will the defined
by the
mertinobuilding ocmpantode, hhandle 93Z andoue HEATING UNIT(TO T00,OW B1lJ) Date Recei IM
material as defined by the Cupertino Municipal Code,Chapter 9d2,and the
l[nlth and Safety Cod�Sect1on 7553]G)7 � HEATING UMT(OVER IW,000 BTU) TOTAL:
Ibull the applicant or future building occupant use equipment or devices VEMILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Ain BOILER-COMP DFNDRI(10,000 B'IT)) Y" N I D
Quality Management District? "
4Y. o
haveread the
Health
a sets Code, cntIn.ementunderChaple4.1 of BOILER-COMP(OVER l00,OWBTU) JUL , 2 1992
the emta d t Health k Safety Code,Sec urr 25505,25S33 a tenant,and 75574.I
ne'posan tyro If the notify the ocgdoes nm cvmnllyhaves whichthat it troy NEW RESIDENTIAL MECH. SQ.FT
respo 'lRitymnoll(y the occupant of p.hey.requirements which mustbemet
Futuro lax of rtl to o(Oavpan�i -4- 7 •�_ t`'j'IY'CfF'L(,f F'CI1`111VV
Ownsf"orteraaauuutthonsed agent 'C�j) S-•/'L/ 'v Data ISSUED BY.. 1/.V
TOTAL:
OFFICE COPY