22430 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES ' USE BALL POINT PEN ONLY
NuildInX Pro'en Identification - -- PFItMITNO.
Building Address:
Lg.-e- 22430
�+ A A
CA^' mek'e akeA� ZSS' ( Z3y CITY OF CUPERTINO-BUILDING DIVISION �It
' c ayF �me:DN uL 11a��8 APPLICATION I,PERMIT
U EECTR l
ULDINGCALPLUMBING-MECHAMCAL CATEGORY CONTROL N
hitad/Engineer: Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:/42 O O/ PERMITISSUANCE ❑ ❑ ❑ ,
LICENSED CONTRACTOR'S DECLARATION -
IMrcbyaffUmthatlam Bcenxdunderp.Wonedf Chapter9(rommenc APPLIANCESREADENTIAL JOB DESCRIPTION
fingwitlicamah iftfut 700p)oaDivifect, fthe0u.lnessand Prv(nslonsCode,and my PANELS
liana b In fu (o d affect,
p. O
Llan Cls L Lich 3 -
pale- )— - GORlrader
PS
ARCHITE as pubbATION OVER
O000 AM
qO7 lundentand myphta shaBbe used vpublic records OVER 1000 AMPS - SQ.FT.FLOOR AREA 5/SQ.FT.
qWI+�u O
Licensed Proleasbnal • SIGNS ELECTRICAL.
<<�Q OWNER-EUILDER DECLARATION SPECIALCIRCUIT/MISC '
I herebyaffirm thatI am exempt from the Contractor's License Law for the '
following reason.(Section 7031.5,Bminenand Pm(enshmns Code:Any cityor TELvIp,ME=OR POLE INST.
county which retuiresa permit reconstruct,alter,improve,demolish,orrepair
On any structure prim to its lsouance,alsorequires theappliant(orsucs permit to POWERDEVICES -
Ne a signed statement that he Is licensed pursuant to the provbionet of the
u,�. Contndori License Low(Chapter 9(comerencing with Section 700D)of Divi- SWIMMING POOL ELECTRIC
';O sion30(the Business and ProfessionsCode)orthat he bexempt therefrourand VALUATION
the baeb for the alleged exemption. Any violation of Section 70315 by any OUTLETSSWITCHESHXTURES
OGS
applicant fora permit subjects the applicant to a civil penalty of not more than
I5]
five hundred dollars(S500). NEW RESIDENTIAL ELECTR FT.
.. ❑I,as owner of the SQ' STORIES TYPECONSTRUCTION'
property,d my Isswithwages r tbetrsole
1=7.Q wm(Sce.70KBuldois and Prhe wenk,andthes Code:
ntractintenr'orcanse Law
5�❑ dofor
as es e not 71Ry to ainow owner
f property
Code:TM or Improves
mp eves Liree slaw
(?j $
who does
apply loan owner ofp rough who nam oyev,provided
- OCC.GROUP RES.UNITS
o whodoements are not ntelorthroughhlsowne.If,hoespr,the Wilding
or
Improvements sold intended year rofferecl
etion,sale.the oweveg deer ill have TOTAL: '
Improvement bsold within one)rear tbuild or Int thee for
purpose
of shave
t ben of proving that he did not build or Improve for purpose of salc3. QTY. PLUMBING PERMIT FEE FLODDTDNE APN
�1,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contracron to construct the project(Sec.7016,Business and Professions Code:
The Contredor'e License Law don not apply to an owner of property who
Wilds or improv s-thereon,.and who contracts for such projects with a ALTER-DRAW&VENT-WATER(FA)
c ador(s)licensed punuau<to the contractor's License Law. BACK FLAW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec B k P C fee this reason '
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N
• Owner - - Date RECEITN
WORK MAN COMPENSATION DECLARATION FTXTIIRFS PER TRAP SCHOOL TAX Y_ N_
❑I hereby affirm that I have a rertl0ate of consent to ulf-Inwre,ora RECEIPT N
certiflate of Worken'Compensatlonlnsurana ora certifkd copythamuf(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FTE Y N
3800,Lab C.)
Poliryj C_/. � �L N RECEIPT p
Cam n /ID' ( ZGN GAS EA. BUILDING DI VISION FEES
Certified copy Is hereby Turn] ed. ,e CREASE/INDUSTRL WASTE INTGRCEI'TOR - PLANCI'IECK FEE s
❑Certified copy b filed with the city mapre int division. •• ,
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER SAFIITARY STORM EA 2(IOF7 SvQp Date Remi t#
(This to need not beeompleted lithe permit Ls forone hundred dollars
(5100)rtifyt.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
1 artily that o the performance any
m wmk so as to become
penult b booed,
I shall not employ any person In any manner at as to become subject to the WA.�SYSITM/IRFATING
Worken'Compenvtlon Laws of Glllomla.Data PAID
0'Z Applicant NEW RESIDENTIAL PLMB. QF. Date Reoel t#
Z O N'OTICETO APPLICANT:If,after making this Certificate of Exemption,you -
Hshould become subject to the Workers'Compensation provisions ofthe Labor TOTAL:.
tY W Code,you must forthwith comply with such provisions orthis permit shall be BUILDING
W > deemed revoked. .
CONSTRUCTION LENDING AGENCY. SEISMIC FEE
O. I hereby affirm that there Is.mmtrudlon lending agency for the perforrtr ELECTRIC FEE
3 Z arm o(the work for which this permit is Issued(Sec.3097,C1v.C.) _ TOTAL: 00
U O lender'.Name - PLUMBING FEE . DD
LL H Lenders Addma. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I cenifythat l have readthb application and aatethattlee above information
4 lscoma.I agree to comply with all city and county ordinances and state laws PELtMITLSSUANCE FEES PAID:
>. relating to building construction,and hereleyattherricerepresentativesofthb .'
V) city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.
(We)agree to save,indemnify an d keep harmless the City of Cu pedino Date Receipt#
V against llabillties,' cigmens,cotexpenses which nay in anywayaccrue AIR HANDLING UNIT ITO 10,000 CFM) SUBTOTAL:
�
gat clCity, n e enex of the granting of this permit. -
l AIR HANDLING UNIT(OVER IO,000GEM) CONSTRUCTION TAX
IgWrature of Apples/nnttt//Contractor / Date 7 EX
/Contractor HOOD IN/DUCT) CONSTRUCTION TAX PAID: -
HAZ R DOUS MATERIALS UI SCLOSURE
Will the a pplicant or It re building occupant store or hand le hazardous HEATING UNIT(TO 100,0D)BT U). Date Recei t#
material as defined by the Cuperd no Municipal Code,Chapter 9.17,and the
]iealthand Safety Coderxx&dbn75533(a)P HEATING UNIT(OVER 100,000 BTU) TOTAL: ,�
E3Y- •. M No -
Wllltheappliantorfuture building occupant use equipment or devices VENDLATION FAN(SINGLE RESID) ISSUANCE DATE
which emit havrdous air conUodears as defined by the Bay Area Ab O�
Quality Mavgcment District? PHPOR IOO,IXD BTU) IC
'Yea No
have read the h.Y materials raqulremceds under Chapter6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health 6 Safety Code,Sections 75505,75533 and 75534.1 JUL 1 1991
understand that lithe building does not currently have at....I,that it is my NEW RESIDENTIAL MECH. SQAT.
respomlbility to notify the onvpant of the requlrementa which must be met _ /sa
prior to Lesuance of a Certificate of Occupancy. VI
ly Of
Owneror authonwda t Date
gen TOTAL: ISSUED UY>\
OFFICE COPY