23920 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Budding Add o S o CLLYQJCF.., vTe - - L -23920
wnera one: rM A
CITY OF CUPERTINO-BUILDI G DI ON
Contractor's Name: / Lk.Na. APPLICATIO P R T
k
t. 1 Gbh BUILDING-ELECTRICAL MECHANICAL RY C LJ�
y.y I'Amhlt Enneer. Lic.Na 6
fir'#•-R311.. ) 4ft QTYP RMIT BUILDING PERMIT,INFO.
- Address: G /LS TI A ❑- ❑ ,.❑
LICENSED CONTRACTOR'S DECLARATION
Thereby afflrmthat l am licensed under provisions of Chapter 9(.cr I AN RESIDE JOB DESC IION -
Ingwith Section 7(xD)of Division 3 ofthe Bupnessand PrefeaslonsCode,and my
IlmnseislnfullforceandeffeR. P - _�1/\O�
,loan.Class Lle4 Ro ,
Data Contractor UP TO M AMPS ,
ARCHITECT'S DECLARATION 701-1000 AMPS
ce0"Cl- l understand my pl...hall be used as public records. - OVER 1000 AMPS N.
SO EA ^, S+{SQ.FL
t, Licensed Professional SIGNS ELECTRICAL ('� 1^V I
«<�Q 6i OWNER-BUILDER DECLARATION SPECIALCIRCUIT/M1SC 1:� �(
s., , owing meamn. thaton731.5,Biro ossa Co.tndoos Licenx Law fort he _ � a _
O Per following Code:Any tltyyr TEMP. OR POLEINSr. (a//•�2 f
A,Sy anystm ich mpdortol pe mit anct ao requ,altenlmprovntfor ch, er ttr �/ /
q .a anya su signed
stammalte that
he b,also mgmrersuant to the revisions;of t e I'(JWER DEVICEq G e�
file a signed statement that he b licensed pursuant to the provisos of the '
ConlrutoreLicense Law(Chapter 9(commencing with Section 7000)ofDwi. SWINMNG POOL ELECTRIC VALUATIO
OGG sion3ofthe BusincssandPdf.I.mCode)orthathebexempttherefromand
H S2.a the basis for the exemponAny ti : Aviolation of Section 7031.5 by any '
i o5 e a - OUTLE7SSWITCHFSM% 115
fiveapplicantdred fora pemNtaobj<s the applicant teat civil penalty of net merethan
five hundred delis.($500)..; - NEW RESIDENTIAL ELECTRSQ.FT. STORIES TYPECONSTRUCTION
QI,ac owner of the property,or my employees with wages as their sok
�7 compensation,wBldothe work and thestmeture b not intended or offend for
,1 O sale(Sec.7044.Business and Professions Code:The Contractors License law
q '$ does not apply to an owner of property who builds or Improve thereon,and OCC GROUT' M.UNITS
whodoessuchwork himself orthrough hist s
ownemployees,provided that
Improvements are not Intended oroffered for sale.If,however,the building or NOTAL:
Improvement is sold with In one yearofcompletlo4 the owner-budderwill have - -
t1)R.¢urden of proving that he did not bund or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE �'FLOODZONE APN
"4 as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
..trade.to construct the project(Sec.7044,Business and Professions Code:
The Cont.cto's License Law does not apply to an owner of property who ALTER-DRAW&VENT-WATER(EA)
Wilds or Improves thereon, and who contracts for such pojeds with a FEE SUMMARY
cgN(actor(s)Demand pursuant to the Contractor's License Law. BACK FLOW PROTECT.
LJI am exempt under Sec. B&P C for this reason
�{�y�� DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
f��'C+1 Owner' - Date RECEIPT#
' /1M1 WORKMAN COMPENSATION DECLARATION FIXTURES-PER TRAP SCHOOLTAx Y_ N_
A❑I hereby affirm that I have a.rtiBcate of consent to self-insure,or a RECEIPT If
�JJ certificate cfWorkerVCompamgIxrn Insurance ora certified copy themoff5cc. GAS EA.SYSTEM-1 WCAOUTLEIS PARK FEE Y N
�s'.ac.04 3800,UbC.) RECEIPT#
Policy GAS EA.SYSTEM-OVER 4(EA) BUILDING DI VIS ION FEES
' Com any
Genlfied ropy 6hereby fumbGREASE/INDUSIRL WASTE INTERCEPTOR hed. PLANCHECK FEE
. Ccrified mpyis,filed with the city lnspedlondlvision, I
CERTIFICATE OF EREMPTION FROM WORKERS' GREASE TRAP '• PAID
COMPENSATION INSURANCE SEWER-SANITARY-5]ORM EA 70000 Date. RCCCI t#
(Thbsectien need not W completed if the permit b for..hundred dollars
(51fU)er less.) wATEa rrFATER w/vENT/ELECTR ENERGY FEE Y_ N_
I certllythat in&performanceof thework forwhlch this permit b issued,
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensatlon Laws of California. Date PAID
-
0 Z Applicant NEW RFSIDFNTIALPLMB. SQFT. Date' 'Remi t#
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
should become subject to the Workers'Compenvtlen provisions of the Labor TOTAL:cc
fA Cod,you at iorthwith comply wlthmch provblom orthb permit shall be BUILDING b
seemed revoked. . SEISMIC FEE .j
W CONSTRUCTION LENDING ACGNCY '.
Il Ihereby affirm that there b a construction lending agency for the perform ELECTRIC FEE
Z , once of the..,k for which this permit le Issued(Sec.3097,Civ.C.)
L) O ITOTAL:
.endera N. PLUMBING FEE
H Lenders Address - QTY. MECHANICAL PERMIT` FEE MECHANICALFEE
LL U I certifythat l have read thin applicationand state thattheabove information
O W incorrect.I agree to comply with all city and county ordinance and pate laws PFRMITIRSUANCE. FEES PAID:
} 6 - relating tobuilding construction,and hereleyauthorlureprnemativesofthb
W it t t upon the above-mentioned forW lion purposes. ALTER OR ADD TOMECH.
F Z city to enter p property a purCu Date Receipt#
_ (We)agree to save, ants,' (y and keep harmless the City of Cupertino AIR HANDLING(IMT(TO 10,000 Q�M)
against liabilities,judgments,'"s and expense which may in anywayaccrue ' SUBTOTAL:
agelretsaid Cl , neaqucnc he anti.g°f this permit CONSTRUCTION TAX
�"EjG` -� AIR HANDLING IINI'1'(OVER 10,000CFN)
Signature !Applicant ractor Date ExHAl15'r HOOD(w/DUCn CONSTRUCTION TAX PAID:
HA0110OUS MATERIALS DISCLOSURE
Will the applicant orfumm building occupant storeor handle haeardous HEATING UN (TO 100,000 BTU) Date Reuel t#
material as defined by the Cupertino Munlcipal Cale,Chaptcr 9.17,and the
Hehh and Safety Cade Seedon 75537(a)? HEATING UMT(OVER 100,000 BTU) TOTAL:
❑Yea I]No
Willtheapplicant or future building occupant use equipment ordevices VENTILATION PAN(SINGLE RESID) ISSIUUAACF DATE.
which emit hanrdous air centamir.nts as defined by the Bay Area Air
Quality Marugenumt District? BOILER-COMP OFT'OR 100,"BTU) s
4I'�I Ye No JUL 2 4 1992
haveread the banNous materials requirements under Chapter 6.95°! BOILER-COMP 100,000 BTU)
the California l Iexlth&Safety Code,Sections 25505,25533 and 75534.1
understand that if the building does net currently have a tenant,that it b my NEW RESIDENTIAL MECH. SQ.F'r
_ rapmasibilitytonotify the occupant ofthe requirerrcntswhich most bemet CITY Ur l.Urenul+v
prior to Issuance of a Certificate m Occupancy. '
Ownererauthoriud agent Date r ISSUED I4Y: �p�� [I
TOTAL:
OFFICE COPY