22871 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
tlulldin Yrs ca Identl fkatIsnPERMIT NO,
Building Address: _ 22871
Owner s Name: one: A
(3z —✓ fS CITY OF NPERTINO-BUILDING DIVISION 10
—1, 6^ry
Contacmre Name: Lm.No: APPLICATION / PERMIT �[ �
Z(-/ BUILDING-ELECTRICAL-PLUMBING-MSCI IAMCAL CATEGORY CO
Architect/Engineer. Lic.Nu
BUILDING PERMIT INFO
n QTY ELECTRIC PERMIT FEE
Address: X �/ �' PERMITISSUANCE IJII
LICENSED CONTRACTOR'SDECLA ATION
I hereby alfkm thatlam lkmsed underprovWonsaf Chapter9(comunenc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwlthSec9on7000)of DiAMon3ofthe Businemand PmfmsionsC e,andm
license is In fail force and effect. PANELS ft�f'1�-/VN I
LicenseChs Lk.N VVI
Date Contractor
ARCHITECPS DECLARATION 301-10DO AMPS
pQ+ceO Zp I understand my plans shall M used as public records OVERIODOAMPS SQ.FT//.a11ILOOR AREA f/SQ.FT.
«Z , Licensed Profemlanal SIGNS ELECTRICAL 'Z"' S ills
OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC CJJ V
Ihereby affirm that am exempt team the Contractor's License Law for the
'Z9 p following reason.(Section 7Q11.5,Businem and Profemlons Code:Any dtyor TUMP.METERORPOLEINST. Ip
countywhkh requlresa permit loconalroct,alter,Improve,demolish,orrepair
q anystructure prior to its Issuance,alserequlresthcapplicem forsuch permit to POWER DEVICES
EE V ntfile a signed statement that he b licensed pursuant to the proWlom of the
Ole Coractor§License Law(Chapter 9(on.ruing with Section 7000)of Divi- SWIMN(ING POOL ELECTRIC VALUATION
Ut sion3ofthe Busin..sand Profemlom Code)orlhat he h exempt therchumand
p a 5 the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETs-SWITCHESFIXfURFS
Ebil applicant for a permctsubjecta the applicant to a civil penalty of not more tban
an, � five hundred dollars($500). NEW RESIDENTIAL ELECTR SQ. - STORIES TYIPE CONSTRUCTION
..p, ❑I,as owner of the property,or any employees with wages as their sole —
compensation,will dothe work and the structure is not intended or offered for
psale(Sec.70K Business and Pmfemlom Code The Contractors Urease Law
does not apply to an owner of property who Wilds or Improves thereon,and OCCGGROUP RIS.UNITS
who does suchwork himself or through hisown employees,provided that such
improvements arc not Intended croffered forsale.If,however thebullding or TOTA
Improvement Is said with In one yearofcomplelion,the owner-builderwill have
1 rdenof provingthatM did not Wild orimprove for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD/DNE APN
I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE —J
contractor to construct the project(Sec.7044,Businem and Profession Code: -
rs
The Contractor's License law does not apply to an owner a property who ALTER-DRAIN&VE -WATER(EA)
Wilds or Impraves thereon,and who contracts for such pSojects with a MFEE SUMMARY
cgpBractor(s111omsed pumuanttothe Contractor's License Law. BACK FLOW PROTECT.DEVICE OUTS I DE FEES
"I am exempt under Sec. B &P C for this mason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_
Owner Date RECEIPT 0 N
WORKMAN COMPENSATION DECLARATION FI%TURES PER TRAP / SCHOOLTAX Y_ N_
DI hereby affirm that I hive•certNate of...at to opythen,, ora RF-CETT X
MUO,I.eo(workers Compematlonlmurancematertifled copythereof(Sec. GAS EA.SYSTEM-i WC.40[IILETS PAWL FGE Y_ N_
3800,U6CO RECEIPT N
Policy N GAS F.A.SYSTEM-OVER 4(EA) BUILDING DI VISION FEES
Co
Cemfied copy is EA
hereby N ralshed. GRSE/WDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy la filed with the city Inspection division. '1..r PZS
GREASE TRAP PAID J
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE S -SAMTARY-STORM EA.300FT. Date Recel t#
(Thlsmdionneednabecompieted RtMper tbfwomhundr dolls ENERGY FEE Y_ N
(5100)orless.) WA TERW/VENT/ELEGTR f
lmnifythatinthcperformanmoftheworkforwMchthbpe its
I shall not employ any person In any manner so as to became su 'd t W Sy /TREATING PAID
Workers Compensation laws of California.Date
O Z Applicant NEW ENTI LPLMB. SQFT. Date Remi t#
Z O NOTICETOAPPLICANT:If,aNermaklagthb Cendiateof Exemption, -T `A
r N shwldbemmesubjecttothc Worken'Compematiunpmvbiomsofthe LaM a
Code,you must forthwith comply with such provisions orthis permit shall he BUIL DING FTE7„
_ deemed revoked. SEISMIC FEE
W CONSTRUCTION LENDING AGENCY
CL I hereby affirm that there@acomlroctlon leadingagency forlhe perform TOTAL ELECTRIC FEE
7 Z ince afthe work forwhlchthis permit k Issued(See.W97,CIv.C.) PLUMBING FEE
UO Landers Name QTY, MECHANICAL PERMIT FEE
IL h Lenders Addre.. MECHANICAL FEE
O W ludifythatl Mvercadthbapplimtlonandstatethattheabovelnformation I PERMIT ISSUANCE FEES PAID:
1 Voomct.I agree to comply with all city and county onTlnanm and trate laws
} N relating to Wilding construction,and hereby authorhe rcpresenlalivm ofthb ALTER OR ADD IO MILH.
r Z city to enter upon the above-mentioned property for Inspection purposes. Date Rfeeipt#
V _ (We)agree to Indemnify an d keep harmless the City of Cupertino AIR HANDLING UNIT(T010,000 CFM) SUBTOTAL:
against llablliees' gmentscosts expenses which may in anyway acorue
against said Cit oneequenc t orating ofthisperet qTR HANDLING UNIT(OVER t0,000CIM) CONSTRUCTION TAX
`/_—/ IXI1Al15T HOOD(W/DIJCTI CONSTRUCTION TAX PAID:
Slgmture A pliant/Conlin or Date
HAZARDOUS MATERIALS DISCLOSURE 000 BTU)
Wilitheappllanl or tuturebuildinguempant sloreorhandlchazardous HEATING UMT(f0100, _ Date Recel I#
materialasdefined by the Cupertino Municipal Code,Chapter 91Z andthc TING UNIT(OVER 100,000 BTU) TOTAL:
Health and Safety Code Section 25537(x)7
Cl Yes 0 No VENTILATION FAN(SINGLE AFSIU) ISSUANCE DATE
Will the applicant an future building occupant use equipment or devices PAID� A
which emit harardomalrcontaminants..defined bythe Bay Area Air BOILER-COMP OHPOR 100,000 BTU) r 7i V
Quality
I tyManagenent Dis1dNo
have read the haza oro materials requirements under Chapter 6.95 of BOILER-COMP l00,000BN) NOV = 6 1991
the Californla l lealth&Safety Code,Sections 75505,25533 and 35534. 1 NEW RESIDENTIAL MECH.—SQ FT
understand that If the Wilding does not corently have a tenant,that it Is my
responsibility to at lfy the occupant of the requlrensnts which must be met CIIY Ut GurrmHNU
Prior to issuance of a Certificate of Occupancy.
Owner or authorized agent Data TDTATL ISSUEDBY:A/
OFFICE COPY