23209 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prom ldentlHcatlon PERMIT NO.
Building Address:
23209
9 of o
nerocame: 16/r one: A A
7_ I66 CITY OF CUPERTINO-6UILDINC DIVISION
�o
Contracame: uc.N¢ APPLICATION /PERMIT (( /
L
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL CATFOORY CONTROL N
Archlted/Engineer. Lk,No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add.. PERMITISSUANCE ❑ ❑ N;`1
❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am Licensed under provisions of Chapter 9(commenc- APPLIANCES.RESIDENTWL JOB DESCRIPTION
Ingwlth Saction 7000)ol Dlvlalon3ofthe Bushes land PrefeseloreCode,and my
license b In fu (mooa effect. C• r,) PANELS
LDioense CLe Co scion / yr LCAq bA/G
UP TO 200
20 AMPS L W YQ
ARCHITECTS DECLARATION
Oa% I understand my plans shall be used as public record a. OVER I000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
E 6 Licensed PrefenWnal SIGNS ELECTRICAL
<<�
Z.
OWNER-BUILDER DECLARATION SPECIALCItCUIT/MISC
1.., Ihembyaffirmthat lcam exempt from the Contractors License Law for the
o9.. following reaeon.(Section7031.5,BusineesandProfessionsCER ode:Anycityor TEMP.METOR POLE INST.
F s' cmntywhichrequimapermittoco.tmd,alter,improve,demolah,orrepair
anystacture prior tolV lvsuance,alaorequires NeappLiant forsuch permitto
y POWER DEVICES
py K a file a signed statement that he Is Licensed pursuant to
e the provisions of the
Contractors Law(Chapter 9(mmwith Section
7000)of
Sµp.hNG R70L ELECTRIC
slon3ofthe Bugnesand Pro(aalo.Code)mthat he la themfromand VALUATION
yl the basis for the alleged exemption. Any violation of Section 7WIS by any OUTLEISSWITCHES-FD(TURES arno
0�
applicant for a permitsubjmapplicant are
s the applicano a civil pelty a nor mothan S(/ '0h
1 five hundred dollars(5500). I NEW RESIDENTIAL ELECER SQFT. STORIES TYPE CONSTRUCTION 1,as owner of the property,or my employees with k
wages as their so
compensation,will dothe work and thestmdureis not Intendedor offered for
V0sale(Sec.7044,Business and Profeselore Code:The Contractors License Law
5$ does not a pply to an owner of property who Wilda or improve thereon,and O(:C.GROUP RES UNITS
who does such work himself or through hisownemployees,provldedlhat each
improvements are not Intended oroffered forule.If,howeveq the building or TOTAL:
Improvement bsold withinoneyearofcomplebNtheowner-W Iderwill have
t"oden of proving that he did not build or improve for purpose ofsak.). QTy. PLUMBING PERMIT FEE FLOOD TONE APN
LJ L as owner of the property,am exclusively contracting with Boasted PFRMITISSUANCE
comreeon to co.troct the project(Sec.7044 Business and Professions Code:
The Contractors License few does not apply to an owner of property who ALTER-DRAIN&VENT WATER(FA)
Wilda or Improves thereon,and who contracts for such PNRcts with a
olatftctor(a)Icenxd pursuant to the Contractor'sLicense Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B &P C for this reason
Owner Date
DRAINS FLOOR ROOF,AREA,COND. SANTfARY Y_ N_
RECEIPT N
WORKMAN COMPENSATION DECLARATION �.N��.�P SCHOOL TAI( Y_ N
I hereby a(Orm that I have a mrtlflrate of consent to self-Inarc,ora RECEI4 N
certificate o(Workera Compevationlruurance me certifkdoopy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800.Lab CJ
PolleyN goo') — GAS EA.SYSTEM-OVER 4(EA) DINGRECEDIN
Com any BUILDING DIVISION FEES
LJCtAif ed copy Is hereby f nnu.hed. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
x�r CeiUled mpy Is filed with the city Inspection division.
GREASETRAP CERTIFICATE OF IXkT1PT10N FROM WORKERS' PAID
COMPENSATION INSURANCE SEWER-SANTIARY-STORM EA 300E 1' Date Recel t#
(Thlssedion need not be completed lithe Permit b for one hundred dollam
($lW)or less.) WATER HEATIRW/VENT/ELECTR ENERGYFEE Y_ N_
I certify that in the performance of the work forwhlch this permit Ia issued,
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of Callfomb.Date PAID
OZ Applicant NEW RESIDENTIAL PLMB. SQFf. Date Rccel t#
_Z O NOT/CE TO APPLICANT:if,after nuking this Certificate of Exemption,you
should become subject to the Workeri Compensation provisions of the Labor TOTAL:
r N Cade,you must forthwith comply with such provisions orthis permit shall W
j deemed revoked. BUILDING •E
m
W a CONSTRUCTION LENDING AGENCY SEISMIC FEE
d Iherebyaffirmthst there is a construction Lending agency for the performTOTAL: nELECTRIC FEE
MZ anceof the work for which this permit is issued(See.3097,Civ.C.) ;2.2 311PLUM6INC FEE
00
lender's Name
LL I— Lender's Add.. QTY.I MECHANICAL PERMIT FEE MECHANICAL FEEN—
O W ImdlfythatlhavemadthL appUutlonand tatethattheaboveinformation
1 lecorred.Iagree tocomply with all city and couD:
ntyordinances and date laws 19UZMU ISSUANCE FEES PAI
>. N relating tobulldingco.unction,and hereby authorizex
reprentativesofthh
I'_ Z city to enter upon the above-mentioned property for inspection purposes. ALTER ORADDTO MECH.
(We)agree to save,Indemnify and keep harmlem the City of Cupertino Date Receipt#
V
against liabilities,judgment,,cgstof xanti o t mayln anyway acwe AIR HANDLING UNIT(TO 10,0)0 CFM) SUBTOTAL:
agai Insl onseque/I/x ( ti oft permit.
..t,��
AIRHANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Slgmtum of Applicant/Conradot r site EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO lOQ(00 BTU) Date Repel t#
material as defined by the Cupertino Municipal Coda Chapter 9.12,and the
Ekalth and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
E3Yca No
Will the applicant 6r fu building occupant use equipment or devices VENTILATION FAN(SINGLE RESTD) ISSUANCE DATE
which emit havrdous air contaminants as defined by the Bay Area Air r pA I U
Qu Illy ManagementDtrid7 BOILER-COMP OHP OR 100,000 BTU)
Yrs No
me4have read the haz o materials requimmenb under Chapter 6.95 of BOILER-COMP(OVERIM,000 BID) FEB 20 1992
Cahfomla Health&Safety Code,Scotto.25505,25533 and 25534.1
u odersta nd that if the building does nW currently have a tenant,that It 6m NEWREBIDENTIALMECH. SQ.FT
respoability to notify theoe pantof the requirements which must be met TV C I ex
p r Issuag'ceo Ccrti(I eof anry CITY/•O�!'�,.IJP.tNd,IjAV
Owner or au prised agentDate ISSUED BVI/ 7_ -C r
TOTAL:
OFFICE COPY