23487 (2) APPLICANT TO FILL IN INFORMATION,WITHIN RED LINES — USE BALL POI IVT PEN ONLY
Building Pm'ed Identification PERMIT NO.
Building Address: �L
/ ed �„�+ rTN(JL./ 23487
O,ner s, core: a,t hone: / - - A,
—1111�A, NbVe cr ?,2 j CITY OF CUPERTINO-BUILDING DIVISION
ono-acmraName: - - uoNo: APPLICATION it PERMIT
BUILDINGS.ECTRICALPLUMBINGMECFtAMCAL CATEGORY CONTROL
'�' Archite t/Engineer. Lie.No:
„„ HUIL•DINGP-ERMITINFO '
,1 .,
Add ....
.. _ .Q7Y ,E[,ECTRIC PERMIT u'.FEE. i,
ress: •. PERMITISSUANCE ❑ . .O ❑
LICENSED CONTRACTOR'S DECLARATION `� ' -
Ihereby affirmthat lamlkensedunder prwislansofChapter 9(commune APPLIANCESSRESIDENTIAL JOB DESCKU'HON
Ingwlth In full
force and
affect. a!lhe Businemand Pm(ceNonaCede,and my
Itcense is ecfull form and erred. PAN[LS P
License Clam LICN �.
Date Contactor - -
ARCHITECTSDECLARATION 701-I WO AMPS
q0Z Iundcrstand my plsria shall be used npubOc rerorda OVER 1000 AMPS - SQ.Fr.FLOOR AREA S/SQ.Fr.
O
Fl Licensed 1'rofemLmal SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPGCIALCIlTCUIT/M15C AED I
7ox,��s . 1herebyafBrm that lamexempt from the Contractora License Law for the 11/��� 0 Pi
O p following reason:(Section 70315,Business and Professions Code:Any city or
FZ�cy countywhlchrcqulreeaper ttommtrun,alter,impmve,de=Ush,ormpalr �"P.METER ORPOLE INST, (� /J
7a any structure priortoitsiasuance,also requlresthe applicant forsuch permit to POWER DEVICES I`f�
V file S signed statement that he ls hocaud pursuant to the provision of the (�
3p� Contractor's License Law(Chapter 9(commencing with Stolon 7000)of Divi- gWUI{hg NC POOL ELECTRIC �� v
elon 3 of the Businessand Profemlon Code)orthat he t,exempt thercfromand ALUATION
Dal S the bast,for the alleged exemption. Any violation of Section NEILS by any I
AOUTLEISSWITCHFSFIKTURFS
applicant fora Nrrrdtaubjeds the applicant to a civil penalty of not more than /
n. dollst(5500). NEW RESIDENTIAL ELFGTA SQXT. STORIES TYPE CONSTRUCTION
�n a owner of the property,or my employees with wages m their wle
c epenutlon,wllldothe work and thestrucWre ls not Intended or offered for
O' e(Ser.7061,Business and Profession Code:The Communes License Law _
does not apply to an owner of property who builds orlmprovnthereon,and OCGGRONa RES,UNITS
,n• whodoessuch work himself or through his own employees,provided that such
improvementarenotintendedorofferadforule.ILhowevegthebulidingor TOTAL:
Improvement baold withinoneyearofcompletlon,the'owner-builderwlll have
tlurden of proving that he did not build or improve for purpose o(uk.). QTy, r,;�PLUMBING PERMhF IFEE'', FLOOD TDNE APN
j L as owner of the property,am exclusively contracting with licensed PERMITISSUANCE
contractors to construct the project(See.7014,Business and Professions Code: T
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN kVENT-WATER(FA)
Wilda or Improve thereto,n,and.who coact far such ptojern with a 's'
c,,00..t{Worts)licensed pursuant to the Contractor's License Law. FEE'SUMMARYBACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B k P C for this mason
aTT SIDE FEES
DRAINS FLOOR ROOF,AIE?A,COND. SAMTARY Y �N
Owner Date RECEIPT 11 '
WORIONAN I have a COMPENSATION DECLARATION - RlRE4 PER TRAP SCIIOOLTA% Y_ N
•, fi hereby afflmn that I have•ttrtiBcate of consent to pytheere,are - RECEIPT N
38W,Lab Workers'Compe�uatlonlnurantt oracertlficd copy Hereof(Sec. CAS EA.SYSFRM-I INCA OUTLETS PARK FEE _ Y_ N
Polis Lab C.)
Contract,
p RECEIPT N
Com an GAS FA.SYSFEM-0VERI(EA)
� Y BUILDING DIVISION FEES
Cerified copy t heed with the hed.
GREASE/INDUSIRL WASTE INTERCEPTOR PLANCI'IECK PEE
Certified copy ls filed with the city inspection dividers.
CERTIFICATE OF UEMPT]ON FROM WOR KERS' GREASE TRAP PAID
COMPENSATION gomINSURANCE . SEWER-SAMTARY-STORM FA.100FC. Date Remi t#
(Thi.¢union need nahe completed If the permit Is forces hundred dollars
(fT 00)oify that
Ittnlfy thaWATER IIENEd W/VENT/ELECTR' ENERGY FEE Y N
t In the performance,of the work for which this permit is Issued, r
I shall not employ any person In any manner se as to become subject to the WATER BYBTT:M/TREATING' '
Workers Compensation Laws of California.Data PAID
0 Z Applicant
Z O NOTICE TO APPLICANT:]f,oftr,making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQpT. Date Remi t#
should become subject to the Workers'Compensation provision of the LaborSSW
TOTAL:
N Code,you must forthwith comply with such provlslon or this permit shall be -3�Jl ILDINGI'E'
deemed revoked.
CE CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z Iherebyeff 'Cohat them is a construction lending agency for the perform- TO ELECTRIC FEE
7 ace,of the workfor which that permit is Issued(See.3097,CIv.C.) ELECTRIC EEE
(� O lender:Name - i
LL ~ Iendersnddm a QTc. MECHANICAL,PERMIT FEE MECHANICAL FEE
O W I cartlfythat l have read thbapplicati nand statethat the above Information
1 lsmrract.l agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} relating to building mmtruRion,and herebyauthodaercpresenoulvesofthis
city to enter upon the above-mentioned property for inspection purposes. ALTfRORADDIOMECH.
Z
(We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
V
against liabilities,judgment,metsand expense wh lch may In any wayaccme AIR HANDLING UMT(O 10,”CFM). - SUBTOTAL'
against said City In couscqu ence of the granting of this permit
AIR HANDLING UNIT(OVER I if"CRM) CONSTRUCTION TAX
mof Applicant/Contractor Date EXHAUSTIIOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE '
Will theappllcaut or(uture building occupant atom or handle hazardous HEATING UNIT(T0100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
fiealthand Safety Code Sedlon7S537(a)i HEATING UNIT(OVER 100,000 BTU) IPsea—
TOTA � `
❑Yes M No
Will the applicant orfuturc bulldingoccupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haurdous air contaminant as defined by the Bay Area Air
Quality Maragcment District? BOILER-COMPOHPORIW,OMBTU) n q
4 Ye F1 P A I D
No
have read the hn,a out materials requirement under Chapter 6.95 of BOILER-COMP(OVER100,000 BN)
the CaB ernia health k Safety Code,Sections 75505,75513 and 75531.I ' Qn
and natand that if the building deet not eu rmntly have a tenant,that it t,my NEW RISI DFNTTAL MECH. x7x�C SQ.Fr APR 1992
responsibility to notify the occupant of the requirement which=at he met
prior to bsuance of a Certificate of 0cm panty. Cl l v
v V `ayTL'I-111'"•
Owner or authorlsd agentDate ISSUED BY: Jal�9e�^9/R//AIT I _
IOTA L:
OFFICE QOPY