23216 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Acidmas: 23216
/oi RIH �,
A A A
C /FF 1 N� one. CITY OF CUPERTINO-BUILDING DIVISION
contanLo awme: Lia,No Z
APPLICATION / PERMIT
/) IV164, /f 4 BUILDING-ELECTRICAL-PLUMBING-MECHANTCAL CATEGORY CONTROL
hhed/Engineer. Lic.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE F-1 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(rommenc- APPLIANCESRESIDENTIAL JOB DFi RIPION
ingwilh Srcnon7000)of IAvlsion3 ofthe Buslnessand ProfessionsCode,and my
license Is In fel fora and died. PANELS
Llansc Glasse a[ IAll ic.. 26A 9�s CNNG mor tN 7R /9-M
Date Contndor &A4: UP TO 200 A&MS
ARCHITECTS DECLARATION 201-1000 AMPS
c)2. I understand my plans shag be used as public moral.. OVER 1000 AMPS SQ.1.7.FLOOR AREA WSQ.Ff.
�y
4 6 Licensed Professional SIGNS ELECTRICAL � IN
6 w OWNER-BUILDER DECLARATION rr (�
�n °lit SPECWLC4RCIBT/MLSC ' e 'T E
f. y owing raf@mthatlamexempt 31.5,B(romthe Contractor's License Law for the utL/J' 16.�.r K
Zor
O Z�@ followingreason.(Section
rmit to Business and rimprove, Code:Anycttyir TEMP METER OR POLE INST.
F� cwnty which requlraapemdtroconstcoat,alter,lmprove,dertnlbh,orrepalr
anysimcnies pdortoiblssuance,alsorequirestheappRantforsuchpermitto POWER DEVICES
Vfile a signed statement that he is licensed pursuant to the provisions of the
3a� ContractorsLicense Law(Chapmr9(mmmencingwith Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
O aon3 Orthe Business and ProfessionsCode)orthat he is exempttherefromand /`
the bash for the alleged exemption. Any violation of Section 7011.5 by any OUTLETS-SWITCHES-FIXTURES ` t Q 0
ESO appllant fora permB sebyrtsthe applicant to a civil penalty dna morethan `.J 00
five hundred dollars($500). NEW RESIDENTIAL ELF-CTR
7 M1,as owner of the property,or my employees with wages as their sole �'�' STORIES TYPE CONSTRUCTION
compensation,wdldo the work,and theatmeture le net Intended or offered for
5 O sale(Sec.7044,Business and Professions Code:The Contrad.e.License Law
$� does not apply to an owner of property who Wilds or improves thereon,and OCC.GROUP RFS.UNITS
who does such work himself or thnwgh hisawn employees,provided that such
Imp averrentsam nes intended or offered for sale.If,however,the building or TOTAL:
Improvement lssold within one yearofcomplaion,the owner-builderwill have
tlIcjrard en of proving that he did nes build or improve for purpose of ule.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L a.owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.70M Business and Professions Code
The Contradoes License Law does not apply to an owner of property who ALTER-DRAIN k VEM-WATER(EMbuilds or improves thveon,and who conned for such ptojeats with a FEE SUMMARY
,➢lfador(e)licensed pursuant to the Contractor's Llanse Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under See. B h P C for this masonOUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY V N_
Owner Date RECEAT p
WOR KMAN COM PENSATION DECLARATION FD(TURES PER TRAP SCHOOLTAX Y_ N_
01 hereby affirm that I have a certificate of consent to self-insure,ora RECEIPT g
certificate of Worken'Compenutlonlrourana ora artlfied ropythereof(Sec. GAS PA.SYSTEM-1 INCA OLIMETS PARK FIT Y N
3800,lab CJ .f '�11 I REG I=- N
I'oliryp GAS EM
FA.SYST -OVER4(EA)
Com env .r M� FIE-IC.IITl�rS�FI'� BUILDING DIVISION FEES
�cemnea ropy iynereby famished. PLANCHECK FEE
,g5chE
ifled copy is filed with the city impection division. GREASE/INDUSfRL WASTE INTERCEPTOR
'tel CERTIFICATE OF EXEMPTION FROM WORKERS' GR£ASE7RAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-SR]RM EA 200FT Date Recei tit
(rhlssedlon need nes be completed lf the permit is for one hundreddollars
(SIB(>orloss.) WATEt HEATER W/VFM/dECTR ENERGY FEE Y_ N_
I medythat in the performanaof the work forwMch this permit is Eseed,
1 shall not employ any person In any manner so as to become subject to the WATER SYSEEN/TRFATTNG PAID
WorkersCompensation Laws of Cal forma.Data
0 Z Applicant NEWRESIDENIALPLMB. SQ FT. Date Recei tN
Z O NOTICE TO APPLICANT:If,after making this Cerifiale of Exemptien,you
FN should berome subject to the Workers'Compensation provisions of the Labor TOTAL:
CC Code,you moat forthwith comply with such provisions or this permit shall be BUILDING FEE
W j deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL ° hereby affirm that there Ls a construction lending agency for the perform TOTAL: 1� ELECTRIC FEE
Z sure of the work for which this permit is issued(Sec.3097,Civ.G .JP
02 Lender's Name PLUMBING FEE —2,2.,v
U. cndera AddressQTY. MECHANICAL PERMIT FEE MECIiANICAL FEE
U ludifythatlhavemadthbappliationandstatethattheabovelnformalon
0 W Iscomet.I agree to comply with all dry and countyordinances and state laws PEAMITISSUANCE FEES PAID:
} S relatingtobulldinge nstmetion,and herebyauthodzerepresentativaofthis
F Z city to enter upon the above-mentioned property for inspection purposes. ALTFRORADDTOMECH.
_ Date Receipt#
(We)agree to uve, ,mg,oxdty an a keep harmicv the in a of Cupertino
0 agaWtllabllitla,jadgmenc�mat net expense which may In anyway accrue AIA HANDLING UNIT(f010,000 CFM) SUBTOTAL:
/agAnagalrututd4C�itz�wcon.+mGkn lathe gra iAIL4 permit.
�'ir((h Yy((// MRHANDLINGUNIT(OVER10,000CF.N) CONSTRUCTION TAX
I VA
SI—gwGtua of Appllant/Cotractor Date IXHAUS'r HOOD(W/DL1CT1 CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant store or handle havndous HEATING UNIT(TO 100,000 BTU) Date ReceI to
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I lealth and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
\
F-1YenNo .
\\) Will the applies nto futu occupant opant use equ 1pmcnt or d evices VENTILATION FAN(SINGLE REBID)
mim 1$$[J/hNEC�IJATE
ichethavrdoircontaminants as defined by the Bay Area Air
QManagement
Quality Management District BOILER-COMP DFR'OR 100,000 BTU)
Yes
4have read the haze ous materials rsquimments under Chapter G95 of BOILER-COMP(OVER 100,000 BN)
L FEB 24 1992
the California I leallh k SafetyCode,Sections 25505,25533 and 25534. 1
1 understand that if the building does not mrrently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.IT.
I
responsibility t am
iry the occu a At of the requirements w rch must be met
pdor to Lssuanm da di(Tca aro cy. CITY L('
Owner or authod lid agent Data l
TOTAL: ISSUEDBY.
OFFICE COPY