23268 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buudin Pm'c I Idemmeatlon 7 PERMIT NO.
B°Ild`ng Address: 23268
gr � sy
ame: one: A
TE
a3 CITY OF CUPERTINO-BUILDING DIVISION _ ���
FA en or a Lie.N : APPLICATION / PERMIT
BUILDINC-ELECnUCALPLUMBINGMEL']IANICAL CATEGORY CONTROL CONTROL
rchitect Linc.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:
PERhIITISSUANCE ❑ ❑ El
CONTRACTOR'S DECLARATION
I hereby affirm that am licensed under provisions ofChapter9(conunme APPLIANCES-RESIDENTIAL ]OB DESCRIPTIONingwlth Sation7D00)of Divtlnn3oftheBwiassan mfeatonsCode,and
licence is inddfect. PANELS
Licen b LICK /��f//17I�/aC
Date Contractor d�J
ARCHI]M R N 701-I WO ANTIS
`G COGa
I understand my plans shall be used public records. OVER IODO AMPS SQ.FT.FLOORAREA S/SQ.FT.
E Licenced Professional SIGNS ELECTRICAL
<a� OWNER-BUILDER DECLARATION SPECIALCBICIIIT/M15C LED ' N
7 f'yd 7 I hereby adRren that l am exempt fron the Contractor's Lirense Paw f«the
pTEMP.METER OR TOLE INST.
following P 4.1 T E R
Fu1 ewntywhichmquimsaper ttomrotmdalter,Unpmvedemollah,orrepalr
�E�[�'� anystructure prlortolts Issuance,also requiresthe applicant forsuch permit to
K 1 file a signed statement that he is licensed pursuant to the provbiom of the POWER DEVICES
Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC DATE Divi-&Z4�-'-�
sion3 ofthe Business and Pro(esslom Code)orthat he b exempt therefrom and ATIOON
id
JJ the basis for the alleged exemption. Any violation of Section 7QHS by any OUTLETS-SWITCHESFIXTURES �l l^ OV
<� appbuntforaper taubj<stheapplicanttoadi 1pemltydnmt mthan
five I,aso nerlofthepr. NEW RESIDENTIAL ELECTR TORIES TYPE CONSTRUCTION
I,as owner arthe property, SQ.FT.
❑ p perry,or my employes with wages a there sole
C7¢ compensation,wllldothe work and the s0ucmrc boot intended or offered for
O sale(Sec 70K Business and Pmfeaiom Code:The Contractors License Law
�$$ does not apply toan owner a property who Wilds or improves,thereon,and
OCC.GROUT' RfS.ONDS
whodoessuchworkhimseif orthrough hbownemploy«s,provided that such
Improvement are not Intended oroffered forsale.If,however,thebuildingur TOTAL:
improvement bwld withtomyearofcompldtomtheowner-builderwlll love
t"rdenofproving that he did nmbundorimproveforpurposeofsale.). QTy, PLUMBING PERMIT FEE [.T-OpDpONrE nPN
L_j 1,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to roretruct the project(Sec.704,Business and Professions Code:
The Contractor's License Paw does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon,and who contracts for each p(ujem with a
on ctorts7 Bcenxd pursuant to the Comnctor's License Law. FEE SUMMARY
LJ I am exempt under Sec. B&P C for this rcawn BACK FLAW PROTECT.DEVICE Q1ITelDF FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N
Owner Date
ORmNAN COMPENSATION DECLARATION RECEIPT 0F�UgpS-PER TRAP SCHOOL TAX Y— N
e
rcby affirm that I have a certificate of consent self-hums,ora RECEPTM
(tate of Workers Compeaatlonlauranreoracerti(led copythpythercof(Sec. GAS F.A.SYSTEM-]INCAOUTLETS
3800,Lab CJ PARK FEE Y N
Policy p RECEIPT p
Com any re t GAS FA.SYSTEM-OVER 4(EA) BUILDING DI VISION FEES
�CenIT s here 'Kedr I
GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHE•CK FEE
n('p(Pfled copy t filed with the the dry inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETBM PAID
COMPENSATION INSURANCE SEWER-SANITARY STORM EA 200FT Date Rc(mi tM
(lblsaectbelon need not complctN If the permit b for one hundred dollen
(f1 I mnifcss.) WATER HEATER W/VENT/ELECM ENERGY FEE Y N
I rent employ
the person
in any m nner an as to
brooms,
smit is to theed, —
I shall not employ any person In any manner at a to become eub)ect to the
Workers'Campenalion Gas o(GWATER SYSTEM/TREATING
llrornt. Date PAID
O Z Applicant
Z O NOTICE TO APPLICANT:IL after raking thin Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.FT, Date Remi tic
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
C N Code,you moat forthwith comply with such prounion orthb permit shall be BUILDING •E
W > deemed revokad.
CL C CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyaf0rm that there b a construction lending agency far the perform ELECTRIC FEE
7 Z an«ofthe work forwhich this permit is bored C5ac.3 ,CIv.C.) TOTAL:
L) O lender'.Name 09/ PLUMBING FEE
LL ~ lender's Address QTY. MECHANICAL PERMIT FEE
O W Icertify thstl have read this application and statethat(heaWw information MECHANICAL FEE
lscorrect.l agree to comply with all ehy,and countyordiances and state laws PERMITISSUANCE FEES PAID:
>. IL relating to building construction,and herebyauthoriaereprecentauvso(this
F Z city to enter upon the abovcmentioned property for WpMlon purpoces. ALTER OR ADDTO MECH.
gr to save,indemnify and keep harmless the City of Cupertino Date ReaeiptN
rethabi 4re,jrdgments,ccAsandexps asewhichmayinanywayacaue AIR HANDLING UNR(TO 10,000 CFM) SUBTOTAL:
ata consayuenre oft tmgnr this d
AIR HANDLING UNIT(OVER 101"CFM) CONSTRUCTION TAX
gnatvre of Applicant/C ctor oL CData E%]1AUSI'HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle ha ardous HEATING UNIT(TO 100,MO BTU) Date RCeei IN
material as deflmd by the Cupertl MunidpalCode,Chapter9.1$andthe
flcalthand Safety Code 'erf25572(a)7 HEATING UNIT(OVER IDg000 BTU) TOTAL: 1e
ED Y. o
Will the applicant or eent, ui ngoccvpan,use equlpmnnt or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit harardouaalr com ant as de fined by the Bay Area Air _
Quality Management Dist us BOILER-COMP OHP OR 100,000 BTU) D
4
have ad the haa Code,Se tions 25505, under Chapter 6.95 of BOILER-COMP(OVEi IDJ,000BN)
the nlaFlcalth&SafetyCode,Sect1oa75505,2g537and7SSJ6.I
AL MECH. SQ.FTFEB 2 5
' and rsta dthat ifl building not currentlyh Boast.tlutitlsmy NEW FEB 1992
rs Rity ton the ant a Ire swhkh mustbemd
pe ixuance r ce r ry.
CITY OF CUFthI64'J
ser authorlsd agent D e ' / ��s
TOTAL:
OFFICE COPY