23242 (2) APPLICANT TO FILL IN INFORMATION WITHIN REDLINES — USE BALL POINT PEN ONLY
u
Bildin Pro'ed Identification PENd1T NO.
Building A44.:
23242
_ e� ► 6
fN ) A
T�I3 CITY OF CUPERTINO-BUILDINGDIVISION,
Contradn' ante: .. ,.7 Lk'o 3 APPLICATION I PERMIT �r.
BUILDINGELECTRICAL-PLUMBINGMECHAMCAL CA7TL;ORY CONTROLN
Architect/Engineer. Lic.No:
qlY.t,�. 1 " ,ELECTRIC PERM[Tt ,''PCE i '' -".BUILDING PERMIT;INFO,',
Address: ❑ ❑ ❑
PERMIT ISSUANCE. '
LICENSED CONTRACTOR'S DECLARATION IherebyttonIT(70thatlaivdor3 ofthe
provisions PreChapier9(commrn APPLIANCES-RESIDENTIALingwitJOB DESCRIPTION
time.1.In fon force of d adloon7 ofthe eusinessand Pro(eulons Code,and my
Licaeis Ins force and cite#. PANES .
License Class Lic.p
Date. Contrador UP TO 200AW3
ARCHITECTS DECLARATION 201-1(DO AMI'$ 'i i\ ^ '
X77 lundemtindm laroshallbeusedm bbcreeords. OVERI"AMPS. - _ IT.H100R' $/SQ,t7,
CC YP Po I..°•Qu.
y U Licensed Profemloral SIGNS ELECTRICAL 1 -',1 ('�
�6 ER
OWNER-R UILDER DECLARATION SPECIAL CIRCUIT/MISC u— r
F p. following reason. St on 7MI.mpt lBusiness
a nd Professions
rofessionslrendse Any
city orfor the TAMP.METER OR POLE INST. )E
ATE
anystmdurepdortoltslswance,al mquimstheappllcantforsuchpermltm
file a signed statement that he Is Ilmnsed pursuant to the provisions of the POWER DEVICES
Contrador`.Licenselaw(Chapmr9(commenciagwith Section 70M)of Divi- SWIMMING POOL ELECTRIC
sion 3 ofthe Buslnessand ProfeenoresCode orthat he I,exempt therefromand VALUATION
the bash for the alleged exemption. Any violation of Section 7LOM by say
06i
applicant fora permit subjectsthe applicant to a civil penattyolnat morethan OUTLETSSWITCHES-FIXTURES
a five hundred dollars($500)..� NEW RESIDENTIAL ELECTR SQ.FT.j.. M L as owner of the property,or my employees with wages as their sole 51'ORIES "TYPE CONSTRUCTION
C ¢ _compensation,wllldothe work and the structure is not intended or offered for
0 sale(Sec.7044,13ushessand Professions Code:The Contrador$License Law
oy$ does not apply to an owner of Property who builds or Improves thereon,and ,
whodoessuchworkhimselforthwghhisownemployees,provldedthatwch OCC.GROUP RF UNIT
Improvements are not Intended Orofferea forests.If,however thebuiiding or TOTAL:
improvement hsoid within oneyearofcompletion,the owner-bullderwili have
tn6irden of proving that he did not build or 4npmve for purpose of sale.). QTY, ''7 PLUMBING PERMITi-It� � FGE't FLOOn ZDNE TPN
u I,as owner of the property,am exclusively contracting with tkensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professiere Code:
The Contractor's Llmnse Law does not apply to an owner of property who ALTER-DRAIN VENT-WATER(FA)
builds or Improvss thereon, and who contracts for such projects with a _
on
,Il cmr(s)licensed Pursuant to the Contractor's License Law. FEE SUMMARY, ,
LJ I am exempt under Sec B k P C for this rcaaan BACK FLOW PROTECT.DEVICE
Owner Date DRAINS.FLOOR ROOF,AREA,COND. - SANITARY Y_ N•
r WORKMAN COMPENSATION DECLARATION •r RECEI•F N'
• 01 hereby affirm that I have a certificate of consent to self.Insure,or a FIXTURES'PEIR TRAPSCIiOOL'rAX Y - 'N_
certificate ofw.xkp s Compem.d..I`ssu`ance ora adified mpy themof(Sec. RECEIPT N
Moo lab CJ / 9Vx,s/)ry�p�IOI GAS FA.SYSTEM-1 INC.
40UTLE15 PARK F� Y_ N_
Poliq p `]lC1TOVl / J RECEIPT N
Com any GAS EA.SYSTEM-OVER4 LEA) BUILDING DIVISION FEES
�Certl ted copy is hereby th the city CREASE/INDUSTRL WASTE.INTERCEPTOR PLANCI'[ECK FEE
crtlfied copy is filed herebyithed.hay Inspection division. "
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID .
COMPENSATION INSURANCE ShWEIi SANIT '
Crhissectioneced not becompleted iftheperrut lsforomhundred dollars - ARYSTORMEA.200FT. Date Remit# '
(f100)orlensa WATER HEATER W/VENT/E,ECTB ENERGYFEE Y N
Icertifythat In the perfornance afthe work for which thisnn
pslt le issued, —
I shall not employ any person In any manner w an to become subject to the
worksriCompensation Law.Of California.Date PAID
SYSTEM/TREATING '
Z Applicant
.Z O NOTICETO APPLICANT.If.after making thisCertilicateof Ezemption,you NEW RESIDENTIAL PLMB. SQRT. Date Receipt#
Fshould bemrrcsubFd to the Workers'Compensation provisions ofthe Labor TOTAL:
W Code,you at forthwith comply with such pewiaioruor this permitshall be
LU j deemed revoked. BUIL12ING FEE
d CONSTRUCTION LENDING AGENCY SEISMIC PEE
I hereby affirm that there is amrutroction lendmgagency forthe perform- - ELECTRIC FEE
7 OZ znce ofthe workforwhichthh permit is Leaned(Sec.3097,Clv.C.) TOTAL:
0 _ lander'.Name - " i PLUMBING FEE
IL Lenaer`sAddre.. TLY. %MECHANICAL'PERMIT'' FEE t MECHANICALIGFEE B --y
O O l mrlrfythm l have read thisapplication and stmethat threbove Information
1 hoe ect.I agree to comply with all city and county ordIrarmsandstatelaws PERMRISSUANCE �� FEES PAID:
} N
relating to building covtrudion,and hereby authorize representatives Oflhls ,
(— Z
dtyto enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH. ,
— (We)agree to save,indemnify an a keep harmless the City of Cupertino - - Data Receipt#
against liabilities,judgments,costsand expenses which may In anywayareme AIR HANDLING UNIT(TO 10,000 CIM) - SUBTOTAL:
against said City in conscyunnce of the granting of this permit.
MR HANDLINGUNIT(OVER IQW0CEXU CONSTRUCTIONTAX
Signature of Applicant/Contractor Data EXHAUST HOOD(W/DUCT CONSTRUE;TIONTAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occu pant store or hand Is harardoua I HEATING UNIT(TO 100,0000 TU) es' Date
Rmei [#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the s
Health and Safely Code Sectlon2S532(a)7 HEATING UNIT(OVER 100,000 BTU) '� IOTA
0 Yes �No
Will the applicant orfutum building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit h..,doua air contaminants as dented by the Bay Area Air _
Qua Iity Management District? BOILER.COMP OtI'OR]OO,IXq BTU)
Y. � ❑❑No n A J D
4havereadlealth Safer mode,t�HSercons25rcnh5533 and 25534.
of BOILER-COMP(OVIR 100,000 BT1p If- Pi.
the Calilomla HOalih&Safety Code,SMloni 5505,25533 and 25534. 1 ,
underatited1b.kk4a building does not currently have a tenant,that it h my NEW RESIDENTIAL MECI. SQ.FF.
reJAN 3i '
po i ity to (ytheompantofthepppppp������qme
uirerrrrrr//////swhichmu be mo it 1992
pito Lssu ofa CertNate O(Ocm .
D.vner arwmnri as rnr Data CITY U- tit,.Ilvl .
ISSUED BY:
OFFICE COPY