23582 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —,USE BALL POINT PEN ONLY
Building Project identification PERMITNO.
Buuding Addss:
e tD � faOZVe 6 ,Y4 23582_
^C O G/
• ams: one: A A
c CITY OF CUPERIIINO-BUILDING DIVISION ^1I��
can ctor• a Lic.No: APPLICATION I PERMIT � L /
�.
00111M BU[LDINGELECTRICALPLUMBING-MECHANICAL CATEGORYCONTROLN
Archlten/En neer. Llc.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: SW ' • S.T. M-6 ' PERMITISSUANCE aS' ❑ ��I 11 1:1LICENSED CONTRACTOR'S DECLARATION �J
I hereby affirm that l am licensed under provisions ofChapler 9(commen APPLIANCMRESIDENIIAL ]OB DESCRI'TIONr
ingwith Sec on7OM)of DiNsion3ofthe Businessand ProfmioneCade,and m
license is in ful lora and effect. PANELS ` V
Date ��
Date G I-HTECIP 201 1000 AMPS
UPT0200 MPS
ARCHITECTS DECLARATION
(j
00 r.. es
I understand my poselect be used u record.rerda OVER 1000 AMPS SQ.FI'.FLOOR AREA S/SQ.FT.
f Licensed Professional - SIGNS ELECTRICAL
6 IOWNER-BUILDER DECLARATION SPECIALCIRCUIT/M15C -
Zs, a Iherebya(Brm that latm exempe(romthe Contnctore License law la the
pO following reason.(Section 7031.5,Business and Professions Code:My city or 1 N
O Z t, TEMP.METER OR POLE INSi.
K q county whkh requiresa permit conamact,es the aprovgdemol6h,orreftto
Oy5 any a signeretatementshat he is
pursuant
to the
uch ions of
te pOyyp-R DEVICES — E D.
I N
a jj floe a actors statement that het Manses pursuant to the provisions o! the tl V
3µI. ContractorsLicense.shres Law(ChapterWSecdonherefof Divl- SWIMMING POOL ELECTRIC
I„U, O elon3o(theBusNeeaand ProfenlonsCode)arthat hela<xemptthercfromand _ A.11UATION
PgG$ the basis for the alleged exemption. Any violation of Section 7el3.5 by any OUTLE3SSWITCHE&FIXTURES
i applantforapem tsubjectstheepplicanttoativilpe.hyofnotmore Than
E five hundred dollars(S500). NEW RESIDENTIAL ELECTR
�n ❑I,as owner of the property,or my employees with wages as their sole E WOECONSTRUCTION
compensation,wllldothe wok and thestmature Is not Intended or offered for
Osale(Arc.7094,Busbuss and P afessi a Code:The Conmactor's Llceme Law
does not apply to an owner of property who builds or improves thereon.and
3^ whodeessuch wank himialforthreugh his own employees,provided that such OCC.GROUP RFS.UNITS
improvementsare not Intended or offered for sale.If,however,the building a TOTAL 7-00
ImprovementlesoldwilhinoneyearefcompietloMtheowner-bu0derwBlhave I,
t rden of proving that he did novo build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE
FLOOD TONE APN
Lf L act owner of the property,am exclusively com—ing with licensed ,
contrattore to construct the project(Sec.7044,Business and Professions Code: PERMIT ISSUANCE
The Contractor's License Taw don nae apply to an owner of property who ALTER-DRAIN&VEM-WATER(FA)
builds or Improves thereon,and who contacts for such p iajects with a FEE SUMMARY
�gR(fuYmrW licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B&P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
Owner - Date RECEIPT
• WORKMAN COMPENSATION DECLARATION PER TRAP SCHOOLTAX Y N_
❑I hereby affirm that I have a cer iflate of consent to self-Insurea, a FIXNRES RECEIT N
mmlfiateof Works Compematlonlm mnmoraamlfiedmpythemof(Sec. GAS EA.SYSTEM-1 INC.4OUTLETS PARK FEE Y N
3800.Lab CJ RECEIPT N
Compa
Porr'.licy GAS.EA.ESYSTEM-OVER 4(EA)ny BUILDING DIVISION FF.GS
1 �CytIfiefird copy b heed with the
city GREASE/INDU5TRL WASTE INTERCEPTOR PLANCHECKFEE
smiled espy V(fled with the tlty Inspection division.
CERTIFICATE OF EXEMPTION FROM WOR KERS' GREASE TRAP PAID
COMPENSATION INSURANCESEWER-SANUARY-SIORk4 EA 200Ff Date Recti t#
(rhis section need not becompleted if the permit Isfor ons hundred dollars
(SIM)or less) WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
I certify that in the performanceof thework forwhich this peal t Is 4sued;
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TRFATIN'G "
Workers'Compemaflon Laws of California.Date PAID
C• Z Applicant - NEW RESIDENTIAL PLMB. SQ]T. Date Recti IH -
Z O NOTICETO APPLICANT,If,after makingthla Certifla/e o(Exemption,you'
Fshould become subject to the Workers'Campcnsatlon provlslons o(the Leber TOTAL:
N Code,you rruat forthwith comply with such provisions or this permit shall be BUILDING
W > deeed revoked. -
m
IL C CONSTRUCTION LENDING AGENCY SEISMIC FEE
IherebyefOrm thattherelsacaneut an lendingagency for the perfortry TOTAL: ELECTRIC FEE l
7O anaofth.workforwhlch this permit is Issued(Sec.3097,Civ.C.)
U Lenders Name PLUMBING FEE
LL I- Lenders Address QTY. MECHANICAL PERMIT FEB MECHANICAL FEE
OW 1cerifylhat l haveread thisappliatlonand statethattheabovelnformation
C bcorest.l agree tocomply with al city and county ordinances and data laws PERMIT ISSUANCE FEES PAID:
>. relating to building construction,and herebyauthorue,representatives ofthis
W city to enter upon the abovnrentbrud property for inspection purposes. ALTER OR ADD TO MECH.
Z (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receiptil
V a galnst liabilities,jitifteners,"a and expenses which may In anyway acwe AIR HANDLING UNIT CTO 10,000 CFM) SUBTOTAL'
ata Wtsaldequel of Agra ntin Ma pemnit. AIR HANDLING UNIT(OVER 10,"CFM) CONSTRUCTION TAX "
CONSTRUCTION TAX PAID:
Signa re WrApplicanialContractor Date EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei tic
material as defined by the Cu perfino Municipal Code,Chapter 9.1 2,and the
I IeAth and SafetyCode Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU TOTAL
❑Yes No
Will the applicant oruNm building occupant use equipment or devises VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hazardous air contaminants as dented by the Bay Area Air
Quality Management Diatrle7 - BOILFA-COMP QHPOR 100,000 BTU)
'?have
No
?have read the bazt'rdous materials requirements under Chapter 6.95 of BOILER-COMP(OVER I OO,000 BTU) p �.71
the California Health&Safety Code,Sections 25505,25533 and 25534.I P /'a V
understand that lfthebuilding does not currently have a tenant,that it bmy NEW RESIDENTIAL MECH. SQ.Fr.
responsibility to notify the occupant of the requirements which must be met
prior to issuance ofaCertiOate ofOccupanq. {�p N4 2j8 1992 fY /.
Owner or authorized agent Date ISSUED tXa�T� F
.{'N"•7�`�rs
i TOTAL: 4a •Faff.l •NICs a�
OFFICE COPY '