23407 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro ed identification . PERMIT NO.
Building Address: - 23407_
o �a^rs� �c�
Phone: A
L0_11,U p CITY OF CUPERTINO-BUILDING DIVISION p Z
C tnul r.N me: /) 7 ^Lic.Nn: APPLICATION /PERMIT
,< Ca,. � s ` 4 BUILDINGELECTRICA4PLUMBING-MECHANICAL CATEGORY CONTROL#
Architect/Fogineer. Lie No:
QTY ELECTRIC PERMIT FEE BUILDING PER�MIIT INFO
Address: PERMITISSUANCE El 9 �y� 1:1LICF.NS ED CONTRACTOR'S DECLARATION V�
Ihereby
ctionaffirm 0)o(Di siw3licensd under ftheBuinprovisions offe amsr9de,and c APPLIANCESRFS[DENEAL JOB DFSCRU'C[ON
inenseI Infull 7000)af Divfect. (the Busineaand Professions Code,and my
license lslnfuB—(qr«�a le,IT. 547�� PANQS
License Class fj Lie#
Date CaI= UP TO 200ANIPS
201IODDAMPS
ARCHITECTS DECLARATION
�
Z Iundentand my pians ahallbe usedupubkc records OVER IOW AMPS SQ.FT.FLOOR EA f .FT.
CO
u Licensed Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPECIAL CR2CNT/MISC
i.., Iharebyaffirm that l am exempt from,the Contractor's License Law for the
ZO 'pQpp following reason.(Sectkm7031.S,Bualnnsand Professions Code:Any city or TEMP.METER OR POLE INST.
FSTAT countywhichmquiresaper tWcorutrunalteplmpmvgdemollsh,orrepair
qq'� 7Q any stmemns prior to its issuance,also requires the applicant for such permit to
Ol...Igned statement that he ls licensed pursuant to the provblors of the IV POWER DEVICES
�3 G Contntlor'sLicenseLaw(Chapter 9(commencing with Section 7000)ofDivi- SWENMINGPOOL ELECTRIC VALUATION
`SOS siobsnici eBueadlegndxemptlon.Any
fSmX 703LS by and
TS4Spi'' 9 the haab for the alleged exemption. Any violation of Sectbn 70315 by any OUTLETSSWITCFIFS ES
applicant fora permit subjects the applicant to a civil penaky of not morethan
five,hundred dollars(SM.
NEW RESIDENTIA SQFr. STORIES TYPE CONSTRUCTION
❑eaowner l of property,or my employmwith wages r 1Mirsole
compensation,caul doth work and ionstructure,Tb not Intended or offered for
.is(Sn.7B64 Business and Profealov Code TM ContraRors License Law
does not applytoanowner of property who Wilds orimprove,thereon,and OCC.GROUP RES.UNBTS
whodesssuchworkhimself orthrough hisownemplayees,provided that such
Improvements are not intended oroffered for sale.If,however,the building or TAI:
Improvement Issoldwithinoneyearofcompletlon,theowner-budderwlll have
t rdet of proving that he did not build or Improve for purpose of sale.). QTY. PLUMBING: FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
rontracton to construct the project(Sec. Business Professions Cade: T6
TM Contractor's License Law don not apply to an owner cif property who
Wilda or improve thereon,and who contracts for such ptojecb with a ALTER-DRAW&VENT-WATER(FA)
c'7Vctor(s)licensed pursuant to the Contractor.License Law. BACK FLOWPROTECT.DEVICE FEE SUMMARY
IJ I am exempt under Sec B As P C for this reason
DRAINS.FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
• Owner Date rB RECF71Ta
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP .(0y SCHOOL TAX Y_ N_
❑1 hereby affirm that I have•certiRrate of consem to self-inure,ora V RECERaE X
certlfc.teofWmI,miCampersation Insurance ora certified copy thereofesec. GAS FA.SYSTEM-1 INCA ODTLM PARK FEE Y N
3800,Lab CJ
Policy it — RECEIVE#
Com any GAS EA.SYSTEM-0VFRd(FA) BUILDING DIVISION FEES
�Cenified copy is hereby furnished. GRFASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
1PCertified copy bfiled with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCESEWER-SANTEARY-STORM EAL 200FT Date Recd t#
(this section need not be completed If the permit ls for on<hundred dollars
(fTER HEATER W/VFM/F].ECTR ENERGY FEE Y_ N_
100)orlssa.) WA
I certify that In the performance of thework forwhlch this permit Is blued,
I shall not employ any person In any counter so as to become subject to the WATER SYSTEM/TREATING
Workcrs'Compenvtianlaw.of Callfornh.Date PAID
-
0Z Applicant NEW RESIDENT[AL PLMB. SQFT. Date Reeei t#
Z O NOTICETOMPLICANT:ILafternukingthb Cenifkateof Exemption,you
.hould become subject to the Workers'Compensation provlsns of lothe Labor TOTAL:
CC N Code,you must forthwith comply with such provisions orthis permit shall be BUILDING
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
Il Z I hereby affirrnthat there b a construction lendingagenry forthe perform TOTAL: _Q!9 ELECTRIC FEE
once of Ilse work(orwhich this permit ls Issued(Sec.3097,CIv.C.) II�� PLUMBING PEE
(� O Tender's Name
LL I— M.dce.Addmsa QTY. MECHANICAL PERMIT FEE MECHANICALFEE
U Irenlfy that have read this application and state that the above information
O W isommct.I agree tocomply,with all city and county ordinances and state laws PFRMI'TISSUANCE FEES PAID .
r R relating mbulldlngcomtructlon,and hereby suthemn representative ofthb
F N city to enter upon the abovnmentioned property for kupection purposes ALTERORADDTOMECH.
Z (We)agree to save,indemnify an d keep harmJea the City of Cupertino Date Receipt#
(, against) IRtin, d nnnts,"sandexpenx_ chmaymanywayacerue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agar consoquance of ho o this permit. CONSTRUCTION TAX
AIR HANDLING UNTO(OVER IO,1100CIM)
AM rant/ ontractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HATARDOUS MAT AKal -C
OSURE
Will the applicant or future building occuor handlehazardous HFATINGUMT(TO100,000BTU) Date Reeei t#
material as defined by the Cupertino Murielhapter 9.12,and the
Iisalthand Safety Code Section25532(a)i FIFATING UNIT(OVER 100,000 BTU) TOTAL:
qI—I Yea MN.
Ill the applicant orfnum building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit havrdoua air contarnmar s as defined by the Bay Area Air
. Quality Management District? BOILFRCOMP0I1'OR100,00011TU) P A ' D
Ye Na
I
have read the hav materials requlmnents under CM1aper 6.95 of BOILER-COMP(OVER100,000 BTU)
the California Health&Safety Code,Sections 25505,25533 and 25536. I ItX^n 1 s)
t7
understand that lithe building doe not currently have a tenant,that it 6 my NEW RESIDENTIAL MECH. SQ.Fr MAR 1 1992
responsibility to notify the occupant of the requirements which must W met
prior to Lssua race of a Certificate of Om pa try.
CI- ;Y CUrcnllw�J
Owner or authorized agent Date TOTAL: ISSUED Byq ,
OFFICE COPY