23385 (2) _ -
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - - PERMIT NO.
Building Add 23385
s are: s one: p
CITY OF CUPERTINO-BUILDING DIVISION q
trador'e Name: ///'T� 7 APPLICATION / PERMIT E' `
v2 ,t� BUE.DINGELECSRICALPLUMBING-MECHANICAL CATEGORY CONTROL N
Arch t /Faglneer. Lic No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add her PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Iherebcti.nfflmthatlemaI.a3 fthcunder B.pms..d o(Chaptcr9de,andmc- APPLIANCFSRESIDENTIAL JOB DPSCRIPCION
IIngwlth5edlon 7000)al DlWelon3o(the Butlnessand Pro(ro ovCode,and my
f LI x,lsinfu rce and dfed. PANELS yyy...aaa
Date C6ss_ m% Lic '�
Date Contncto
ARCHITECTS DECLA ION 201-IODOAMPS
�qq�uu o:Zp Iurdcmtx.d my plans shall be used u publicremads. OVER IOJO AMPS AREA §/�.FT.
EIZ Licensed Professional 9GN5 ELFOTWCAL ^
<6 OWNER-BUILDER DECLARATION ,K■
a gpECIALCE2CNT/MLSC
7,s' Ihercbyaffirso that l am exempt from the Contndoh License law for the
pp following reaaon.(SMIon 7011.5,Business and Professions Code:Any city or
Oy' TEMP.MLTEROftPOLEINST. DATE
P� roantywhich rcqulrcsa permittomrotrud,Wter,improve,demolIsF,arrcpalr
any structure prlorm Its Issuance,also requireslhe applinntfor such permit to J
3 ll
file a signed statement that he Is mused pursuant to the provIsloau of the
POWER DEVICES
w
Contractor's License Taw(Chapter 9
(commencing with Section
of Dvl• NG POOL ELECC aBuNmndPMenlooCde) oemphe,f and SVIrIR
�AUON
G thebabtortealleged e . Any violation ofSectioa7eil.5 by any OUTLETS-SWITCHES HXTURES
applicant fora pearl(aubjectathe applicant to a civil penalty of
not rtnre than
five 1,as
dollars($500). NEW RESIDENTIAL ELECTR SQFr. STOW TYPE CONSTRUCTION
�n ❑T,ea owner ldot eworky,orhe employeswith wage es their sole
compensation,Business ad
work andthes Code: Is
ot Contrendedactors
or offered License,
Law
2 O u6(Sec. pply to anewandf property
Cod e:The or improves
Ureases Law
R£F dosnmapchy rnaw ?forth ghhisoW[Ids nemploymproideereon,and
whaatmch OCC.GROUP RFS.UNITS
EE fire xmts am not meended cough Mlsownempe. ,however,
Improvement issnld unhands yearoerect(ored Mthe nee b gder ilI have TOTAL; ' -
Improvement Iswldwlthlnoneyearafcompldbn,the ownervbullderwill have
thg burden of proving that he did not build or improve for purpose ofu6.). QTY, PLUMBING PERMIT FEE FLOOD ZONE )PN
LJ[as owner of the property,am exclusively contracting with licensed PFJtA1I7IS5[JANCE
mntractos ut
to carrud the project(Sec.76t4,Businm and Piefmions Code:
The Contractors License Taw does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or Improves thereon, and who contracts for such pipiects with a FEE SUMMARY
cQ3LI doHa)Ilmnsed punuent to the Contractor's License Law, BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B&P C for this reason
FFPq
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
Owner Date RECEIPT
WORKMAN COMPENSATION DECLARATION pp(NRFS PER TRAP SCHOOL TAX Y N
Of
hereby affirm that I have a mnificate of consent to self-Insure,or• RECEIPT N
38M,certitlLab o(Workery Comparuatlon]wunnce arattrti(ied copy thereo((Sec. GAS FA,SYSTEM-1 INCA OUTLETS PARK FEE Y N
Pok Tab C.)
On p RECBUILDING
N
GAS EA.SYSFFMAVER 4(EA)
Co ^y BUILDING DI VISION FEES
Certified copy 6 hercbyth the M.
city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certllied copy ls(IIsi with the city inspection divlelon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEMAP PAID
COMPENSATION INSURANCE SEWERSANITARYSIORM EA 200Fr. Date Reca t#
(Ihls session need no be completed If the permit ls for one hundred dollars
(§100)oify that
WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
Imam that In the performancenInan the work an as to
ce,0 permit ie baued, —
I shall not employ any Person In any manner at u to become mbjed to the WATER SYSTEM/TREATING
Worlicant ompensation laws of Glltorn6. Date PAID
Q Z Applicant
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.FT. Date RECEI f#
should become subject to the Workers'Comperurtiou provisions of the Labor TOTAL:
cN Code,you most forthwith comply with such provigme,or this permit shall be -V
> deemed revoked.
BUILDINGE
dC CONSTRUCTION LENDING AGENCY SEISMIC FEE r
Z
I hereby affirmthat there Is a construction lending agency for the perform- ELECTRIC FEE
anm of the work for which this permit 66aued(Sec.3097,Civ.C.) TOTAL:
V 4 Tender's Name PLUMBING FEE
LL H Lender's Add kree QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Tmrtify that l have ad this applIcat(anand nate thattheabove information
Iscorred.l agree to comply with all dtyand coamyordlnances and gate laws PERMITISSUANCE FEE$PAID:
} a relating to building comtnctloM end herby authorize reprcaan[ekvea o(thIs
F Ncity to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH. -
Z (We)agree to save,indemnify an d keep harmless the City of Cu pen No Date Reeei t#
V ago labllltlea,pdgmente,cons and expenses which may In any way accrue AIR HANDLING UNIT(To 10,900 CFM) -SUBTOTAL:
Int-CV
aga old City inc enco of Ilse granting of this permit.
2 AIR HANDLING UNIT(OVER 10'calac M) CONSTRUCTION TAX
Sigmlureof Ap cant Contractor Date EXTIAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willthe applicant or future building occupant store orhandle hazardous HEATING UNIT(M 100,000 BTU)
material as defined!bythe Cupertino Munlclpal Code,Chapter9,17,and the Date Recei t#
Ilealth and Safety Cod 1S5plewi5532(a)7 HEATING UNIT(OVER 100,00TBTU) TOTAL:
❑Yea No
Will the a pplicant or tun building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air comaminantses defined by the Bay Arca Air
Quality Management District? BOILER-COMP OHPOR 100,000 BTU) PAID
QYro
Te California
Healthe h
a sue rtukdaIs rcons 255565533 and 25534,
1 of BOILER COMP(OVFR 100,000 BTU)
theergamlaatifth&Smety Code,
not con 25505,25533 a undt,that I MAR - 6 1992
undenlandthmn notify
thldingdoesant of the
hick thatb met NEW RESIDENTIAL MECFI. YI,.17.
rsporeibllity to nilly then ant of the rcqulremente which must be coni
prior to uance of a Cert t tOccupapcµ
CITY Uh UuTcnIHlU j
Owner or aulh gent Date TOTAL.: ISSUEDBY: J A lKG
OFFICE COPY